Chronic Heart Failure in Rheumatoid Arthritis Patients (Part III): Effects of Antirheumatic Drugs

Chronic autoimmune inflammation is one of the leading risk factors for the development of chronic heart failure (CHF) in rheumatoid arthritis (RA). The purpose of the review is to analyze the results of investigations on the effects of conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs), biological disease-modifying anti-rheumatic drugs (bDMARDs), and targeted csDMARDs on cardiac function and the risk of developing CHF in patients with RA. Methotrexate may reduce the CHF risk and have a positive effect on the course of this condition in patients with RA. Despite the data on the presence of leflunomide effects that impede myocardial remodeling, there is no evidence of the role of the drug in the prevention of CHF in RA patients. Hydroxychloroquine may contribute to the prevention of CHF, but the risk of developing severe cardiotoxicity should be considered when taking the drug for a long time. Most studies have not revealed the negative effect of tumor necrosis factor inhibitors on the prevalence and incidence of new cases of CHF in RA patients, and an improvement in the structure and function of the heart during therapy has been shown. Inhibitors of interleukin (IL) -1, inhibitors of IL-6, inhibitors of T-cell co-stimulation, anti-B-cell therapy, targeted csDMARDs do not increase the risk of CHF and may have cardioprotective effects, including slowing the progression of left ventricle myocardial dysfunction. Due to the high risk of CHF and CHF-associated mortality in RA patients, early diagnosis of cardiac dysfunction, development of a prevention and treatment strategies are needed, including high-quality prospective studies to assess the effect of anti-rheumatic therapy on myocardial function, risk of developing and decompensation of CHF in RA patients. It is possible that some drugs may possess protective effects on cardiomyocytes so they could become the first-line drugs in patients with CHF or the risk of its development.

Chronic Heart Failure in Rheumatoid Arthritis Patients (Part II): Difficulties of Diagnosis

Rheumatoid arthritis (RA) is characterized by a twofold increase in morbidity and mortality due to chronic heart failure (CHF). At the same time, the prevalence of CHF among RA patients is significantly underestimated. The aim of the review was to analyze the results of the main studies on the features of the clinical presentation of heart failure (HF) in RA patients, the role of visualization techniques and biomarkers in the diagnosis of HF and preclinical dysfunction of the myocardium. HF in patients with RA is characterized by a predominance of HF with a preserved left ventricular ejection fraction (LVEF). The use of clinical diagnostic criteria in RA patients can lead to both over- or underdiagnosis of CHF. Systolic dysfunction estimated by LVEF is rare in RA and does not reflect the real frequency of myocardial dysfunction. Echocardiography (ECHO-CG) with tissue Doppler echocardiography (TDE) and visualization of myocardial deformation, magnetic resonance imaging (MRI) of the heart in RA patients revealed a high frequency of HF with preserved ejection fraction, left ventricular remodeling and hypertrophy, pre-clinical systolic and diastolic dysfunction. Determination of natriuretic peptides is useful for verifying the diagnosis of HF and estimating the prognosis in this cohort, despite the possible decrease in the sensitivity and specificity of these indicators in RA patients. The review discusses the advantages of MRI of the heart, including quantitative T1 and T2 regimens, in the diagnosis of myocarditis, myocardial fibrosis, and myocardial perfusion disorders in RA patients. In order to verify the diagnosis of heart failure and detect pre-clinical myocardial dysfunction in RA patients, the determination of natriuretic peptides concentration should become part of the routine examination, beginning with the debut of the disease, along with the collection of a cardiological history, physical examination, ECHO-CT with TDE, and visualization of myocardial deformation. Evaluation of the quantitative characteristics of tissue according to MRI of the heart could improve the diagnosis of myocardial damage.

[Specific features of hypertension in patients with systemic lupus erythematosus]

AIM

To study the specific features of the development and course of hypertension in patients with systemic lupus erythematosus (SLE).

SUBJECTS AND METHODS

A total of 106 age- and sex-matched patients, including 47 with SLE and 55 with hypertensive disease (HD), were examined. In all the patients, plasma renin levels were determined; serum von Willebrand factor antigen concentrations were estimated; desquamated endothelial cell counts were calculated; and 24-hour blood pressure (BP) monitoring (BPM) and Doppler ultrasound of carotid arteries performed.

RESULTS

In the patients with SLE and hypertension compared to those with HD, the mean diastolic BP (DBP) was 86.5 (79.5-93.5) mm Hg versus 80.5 (77-90) mm Hg (daytime) and 78 (69-91.5) mm Hg versus 72.5 (64-78) mm Hg (nighttime) (p < 0.05), and there was also a decrease in daily DBP index (5 [0.5-15]% versus 11 [7.5-18]% (p < 0.02)). The plasma renin levels were 1.67 (0.78-2.47) and 0.49 (0.25-0.81) ng/ml/h in the patients with SLE and in those with HD, respectively, p = 0.04 and 0.42 (0.36-0.47) ng/ml/h in the control group (p = 0.0001). An atherosclerotic vascular lesion was found in 52 and 32% of the patients with SLE and those with HD, respectively. The von Willebrand factor antigen levels were 1.63 (0.81-3.36) and 0.29 (0.23-2.8) IU/ml in these patients, respectively (p = 0.04). The plasma circulating endothelial cell counts were also significantly higher in the patients with SLE and hypertension than in those with HD (8 [7-10] x 10(4)/l and 5 [3-8] x 10(4)/l (p < 0.01).

CONCLUSION

The patients with SLE and hypertension show a high rate of its hyper-renin states, a propensity for nocturnal hypertension, an increase in DBP, and obvious vascular endothelial regulatory dysfunction.