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CHAPTER SUMMARY AND CENTRAL ILLUSTRATION

Chapter Summary

This chapter covers the most common rheumatologic diseases encountered by cardiovascular clinicians, including connective tissue diseases, vasculitis, and crystalline arthritis. An overview of clinical presentations, diagnostic work-ups, and recommended treatments is provided, with special attention paid to the cardiovascular manifestations of these conditions. Increased levels of inflammation in rheumatologic patients are a primary driver of their symptoms and play a large role in the development of associated cardiovascular disease (see Fuster and Hurst’s Central Illustration). Because of the systemic nature of rheumatologic illnesses, inflammation can be seen throughout the heart and its pericardial lining, as well as in various-sized blood vessels. Over time, this inflammation can lead to fibrosis, infiltrative disease, and cardiovascular dysfunction. Underlying inflammation also creates a hypercoagulable state, putting these patients at risk of thromboembolic events. Additionally, increased inflammation may be a significant risk factor for developing accelerated atherosclerosis and future cardiovascular disease. Early recognition and treatment of the underlying inflammatory process is vital for cardiovascular health.

eFig 76-01 Chapter 76: Rheumatologic Disease and the Cardiovascular System

INTRODUCTION

Rheumatologic diseases are notable for their widespread, multisystem involvement. The cardiovascular system plays a critical role in these diseases and can greatly impact the morbidity and mortality of patients living with rheumatologic conditions. The cardiovascular manifestations seen in rheumatologic diseases are wide-ranging in terms of their severity, when in the disease process they occur, and what aspects of the cardiovascular system they affect. There are three ways in which rheumatologic diseases affect the cardiovascular system: First, inflammation in the pericardium, myocardium, or vasculature, akin to that found in synovial tissue that causes the hallmark articular manifestations of many of these diseases; second, fibrosis or infiltration of the heart resulting in conduction abnormalities; and third, hypercoagulability that can lead to thrombotic events causing limb ischemia, stroke, and myocardial infarction (MI).

Even when there is no direct damage on the cardiovascular system, the heightened proinflammatory milieu that exists in these conditions may be a significant risk factor for atherosclerosis and cardiovascular disease (CVD). Elevated inflammatory markers such as CRP and IL-6 have been associated with increased risk for ischemic stroke and coronary heart disease (CAD).1 Other markers of inflammation such as elevated erythrocyte sedimentation rate, tumor necrosis factor (TNF) alpha, and transforming growth factor (TGF) beta have also been linked with heightened risk of developing atherosclerosis.1 Given the observed relationship between an elevated inflammatory state and cardiac disease, it is important that these rheumatologic diseases are recognized promptly and treated appropriately, in order to control inflammation and potentially mitigate deleterious effects on the cardiovascular system.

Patients with rheumatologic conditions frequently face a lengthy delay to diagnosis2 and may seek out various doctors and specialists before the correct diagnosis is made. At times, the first presenting symptom ...

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