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Rheum Dis Clin North Am [journal]
- Cardiovascular rheumatic diseases. Preface. [Journal Article]
- Rheum Dis Clin North Am 2014 Feb; 40(1):xi-xii.
- Gout and the heart. [Journal Article]
- Rheum Dis Clin North Am 2014 Feb; 40(1):125-43.
The association between gout and cardiovascular diseases has been noted for centuries but was not subjected to rigorous epidemiologic studies until recently. The published literature is almost unanimous in the strength and consistency of this association. However, the impact of gout over and above that conferred by hyperuricemia and other risk factors of cardiovascular disease has not been well studied. Future studies are expected to shed light on the pathophysiologic basis of this association.
- Pulmonary arterial hypertension related to connective tissue disease: a review. [Journal Article]
- Rheum Dis Clin North Am 2014 Feb; 40(1):103-24.
PAH associated with connective tissue diseases is associated with significant functional impairment and morbidity, and carries with it a poor prognosis. The mortality is as high as 10% to 15% in the first year after diagnosis; making it a devastating disease. The availability of ever-increasing numbers of treatment options in the recent era have improved survival in this patient population and have made early and accurate diagnosis a more important goal. According to the Registry to Evaluate Early and Long-Term Pulmonary Arterial Hypertension Disease Management (REVEAL), 1-year, 3-year, 5-year, and 7-year survival rates from time of diagnostic right-sided heart catheterization in patients with PAH were found to be 85%, 68%, 57%, and 49%, respectively, which is a considerable improvement since the National Institutes of Health registry 2 decades previously. In a study by Condliffe and colleagues, survival rates in patients with SSC-associated PAH have improved to 78%at 1 year and 47% at 3 years. Patients with SLE-related PAH have a much higher survival rate of up to 75% at 3 years. Proper screening, early diagnosis, and early treatment can have a significant impact in reducing morbidity and mortality. A small study to assess outcomes in patients with asymptomatic CTD found to have exercise induced PAH suggest that bosentan may be safe and effective in improving the hemodynamics and outcomes in these patients. This study included only 10 patients, and additional randomized trials with larger numbers of subjects are needed to affirm this hypothesis. Studies are under way to find additional therapeutic modalities in the form of PDGF receptor blockers, VEGF blockers, tyrosine kinase inhibitors, endothelial dysfunction inhibitors, multikinase inhibitor of Raf-1, serotonin receptor antagonists,and rho kinase inhibitors. Despite these, clinical suspicion, early diagnosis, early
- Systemic sclerosis and the heart. [Journal Article]
- Rheum Dis Clin North Am 2014 Feb; 40(1):87-102.
Heart disease, either clinically apparent or silent, is a frequent complication of systemic sclerosis (SSc, scleroderma) and may affect both patients with diffuse cutaneous and limited cutaneous SSc. The availability of more sensitive modalities has led to an increased awareness of scleroderma heart disease, which often involves the pericardium, myocardium, and cardiac conduction system. This awareness of cardiac involvement requires attention and interventions led by internists, cardiologists, and rheumatologists. Although no specific therapy exists for scleroderma heart disease, early recognition of the presence and type of scleroderma heart disease may lead to more effective management of patients with scleroderma.
- The heart and pediatric rheumatology. [Journal Article]
- Rheum Dis Clin North Am 2014 Feb; 40(1):61-85.
Recent advances in Kawasaki disease have included attempts to define genes involved in its pathogenesis. There have been recent advances in the studies of rheumatic carditis, leading to a better understanding of the mechanism of the disease. Histologic evaluation of patients with neonatal lupus erythematosus has revealed fibrosis with collagen deposition and calcification of the atrioventricular node. Therapy for cardiac involvement in systemic juvenile idiopathic arthritis should involve treatment of the underlying disease and systemic inflammatory state, and typically includes nonsteroidal antiinflammatory drugs, corticosteroids, disease-modifying drugs, and biologic therapies targeting tumor necrosis factor-alpha, interleukin-1, and interleukin-6.
- Cardiac manifestations of systemic lupus erythematosus. [Journal Article]
- Rheum Dis Clin North Am 2014 Feb; 40(1):51-60.
The heart is one of the most frequently affected organs in SLE. Any part of the heart can be affected, including the pericardium, myocardium, coronary arteries, valves, and the conduction system. In addition to pericarditis and myocarditis, a high incidence of CAD has become increasingly recognized as a cause of mortality, especially in older adult patients and those with long-standing SLE. Many unanswered questions remain in terms of understanding the pathogenesis of cardiac manifestations of SLE. It is not currently possible to predict the patients who are at greatest risk for the various types of cardiac involvement. However, with the rapid advancement of basic science and translational research approaches, it is now becoming easier to identify specific mutations associated with SLE. A better understanding of these genetic factors may eventually allow clinicians to categorize and predict the patients who are at risk for specific cardiac manifestations of SLE.
- Cardiovascular disease in rheumatoid arthritis. [Journal Article]
- Rheum Dis Clin North Am 2014 Feb; 40(1):27-49.
RA can manifest in a variety of cardiac complications, including pericarditis, valvular disease, cardiomyopathy, and amyloidosis. Subclinical involvement is higher than anticipated. CVD is also prevalent in patients with RA, with onset in early disease. Several disease-specific risk factors, like seropositivity, disease activity, and medications, are implicated in the pathogenesis of CVD in RA. Cardiovascular risk assessment in RA varies from the general population. Some traditional risk factors like BMI and lipid levels apply differently to the RA population. Statins are useful in managing dyslipidemia in RA. There is good evidence to support cardiovascular risk reduction with methotrexate and TNF-I use if good disease control is achieved.
- The heart in vasculitis. [Journal Article]
- Rheum Dis Clin North Am 2014 Feb; 40(1):11-26.
All primary vasculitides can target the heart, but this complication is more frequent in TAK, PAN, and EGPA. Although pericarditis is seen in virtually all forms of vasculitis, it rarely becomes a significant clinical problem. Myocarditis is more prevalent in EGPA and TAK, and coronary angiitis is most common in TAK, PAN, and BD. In addition, AI is a classic complication of TAK-induced aortitis, and intracavitary cardiac thrombus formation mainly affects patients with BD. Myocarditis, coronary arteritis, and valvular disease can lead to congestive heart failure and represent poor prognostic factors that require aggressive therapy. Imaging and pathology studies have found that subclinical involvement is common (e.g., TAK, PAN, EGPA, GPA, and BD). Management differs depending on the cardiac structure involved and the activity of the disease.Although pericarditis can be treated with NSAIDs, colchicine, or-low dose prednisone, myocarditis and coronary vasculitis require high doses of CS and frequently cytotoxic agents. Valvular lesions, coronary arteriopathy, and ventricular thrombosis often need surgical intervention. In the face of active disease, clinical judgment is important to help weigh the risks and benefits of delaying surgery versus operating in possibly inflamed tissues. As in other rheumatic diseases, risks factors for atherosclerosis (eg, hypertension, dyslipidemia) should be identified and corrected. Finally, heart failure–and ischemia-targeted therapies are important components of the treatment strategy when indicated.
- The heart in inflammatory myopathies. [Journal Article]
- Rheum Dis Clin North Am 2014 Feb; 40(1):1-10.
Systemic autoimmune diseases are becoming increasingly linked to accelerated risks of cardiovascular disease and events. What is apparent from the above review is that the IIM are not an exception to this growing pattern. Although not always clinically apparent, there seems to be a large percentage of patients who have subclinical CV involvement. Many of the traditional risk factors for CAD, such as hypertension and hyperlipidemia, are associated with developing cardiac involvement in patients with IIM. At this time, it is unclear how much of the atherosclerotic CV morbidity and mortality in IIM patients is driven by traditional CV risk factors versus the effects of chronic systemic inflammation from the underlying IIM. The effects of immunosuppression on cardiac disease and events in IIM patients requires further investigation in carefully controlled studies. IIM patients with cardiac involvement are at increased risk for overall mortality when compared with IIM patients without CV disease. The risk of severe cardiac and vascular disease complications seems to be higher than that of the general population. Treatments can be focused on preventing traditional cardiovascular risk factors including avoidance of corticosteroids when possible, although this task remains challenging in IIM as is true of other rheumatic diseases. Once complications do develop, they should be managed similarly to patients without IIM. The use of statins for hyperlipidemia and atherosclerosis in IIM is an area that is in need of further investigation, although initial work suggests that their use is not uncommon by IIM specialists. Further work is needed to determine whether aggressive immunosuppressive treatment of patients with subclinical cardiac disease will lead to better outcomes. Work is also needed in the area of better laboratory, imaging, and serologic testing to identify patients at risk for the worst cardiovascular complications. At this point, based on the body of evidence reviewed here and elsewhere, it is imperative that physicians treating IIM patients performa routine cardiovascular risk assessment at the onset of diagnosis. Appropriate diagnostic and monitoring studies should be performed on those patients who screening history or examination is suggestive of cardiac involvement.
- Rheumatic Disease Clinics of North America. Pediatric rheumatology. Preface. [Introductory Journal Article]
- Rheum Dis Clin North Am 2013 Nov; 39(4):xvii-xviii.