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Universitatea de Medicina si Farmacia “Iuliu Hatieganu” Cluj-Napoca
Aspecte ale afectarii cardiovasculare
la pacientii cu poliartrita reumatoida
Gabriel Gusetu
Rheumatoid arthritis
Aggressive, potentially debilitating disease
Average life expectancy shortened by 5-15 years.
Early and appropriate treatment – improvement and /
or control of disease
Cardiovascular involvement in RA
- different presentations, some clinically obvious and
others not
- cardiovascular involvement plays a significant role in
this diminished life expectancy in RA patients;
contributing factors include:
- homocysteine levels,
- lipid profiles,
- sedentary lifestyle,
- silent coronary artery disease,
- vasculitis
Cardiovascular involvement in RA
Pericarditis
- the most common manifestation of RA in the heart
- autopsy studies reveal up to 30% of patients with
pericarditis,
- echocardiography studies: 50% of the patients to be
affected,
- only 3% experience clinical symptoms
- be alert to rare instances of pericardial tamponade and
constrictive pericarditis
Cardiovascular involvement in RA
Myocarditis
Nonspecific myocardial inflammation occurr
in ~ 1-15 %
Rheumatoid nodules of varying sizes or
miocardial fibrosis may occur and can be
responsible for conduction abnormalities.
Cardiovascular involvement in RA
Endocarditis
- Necrotizing granulomas similar to rheumatoid nodules
in the aortic and mitral valves
- Asymptomatic or lead to valvular dysfunction
Coronary Vasculitis
- rare
- when present, (in the setting of systemic vasculitis), it
may be asymptomatic,
- rare cases of coronary vasculitis leading to myocardial
infarction have been reported
Pathophysiology of inflammation in RA
Current Treatment
Targets
Rheumatoid
Factors,
anti-CCP
B cell
Immune complexes
Complement
T cell
IFN- &
Neutrophil
Antigenpresenting
cells
B cell or
macrophage
Pannus
other
cytokines
Synoviocytes
Macrophage
Mast cell
TNF
Chondrocytes
IL-1
Osteoclast
Articular
cartilage
Production of collagenase and other
neutral proteases
Bone
Adapted from Arend WP, Dayer JM. Arthritis Rheum. 1990;33:305–15
Biologic DMARD’s –
Genetically Engineered Targeted Molecules
Similar or Identical to Naturally Occurring Molecules
TNFα antagonists:
Interleukin-1 antagonist
Anakinra (Kineret)
Suppress T-Cell activation
Adalimumab (Humira)
Etanercept (Enbrel)
Infliximab (Remicade)
Abatacept (Orencia)
Anti B-Cell monoclonal antibody
Rituximab (Rituxan)
Safety Considerations
with Biologic DMARD’s
Serious Infections
Opportunistic infections (TB)
Malignancies/lymphoma
Demyelination
Hematologic abnormalities
Administration reactions
Congestive heart failure
Hepatic
Autoantibodies and drug
induced lupus
Vaccination
Biologics: Relative Contraindications
Active Hepatitis B Infection
Active serious infections
Chronic or recurrent infections
Current neoplasia
History of TB or positive PPD (untreated)
Congestive heart failure (Class III or IV)
TNFα – antagonists :
cardiovascular side effects
TNFα – proved direct effect in pathogenesis and
progression of HF
FDA (2001): worsening HF NYHA III, IV class
TNFα – antagonists :
cardiovascular side effects
Recent trials - non-significant progression of HF
“ The most interesting analysis in this study suggests that
effective antirheumatic treatment, with traditional diseasemodifying antirheumatic drugs (DMARDs), glucocorticoids, or
anti-TNF biologics, reduces the risk of cardiovascular disease in
rheumatoid arthritis. Some methodological issues are discussed,
however, and confirmatory studies are suggested.”
Arthritis Research & Therapy 2008, 10:105
Method. […. ] to investigate the influence of disease-related and
treatment specific risk factors on the incidence or worsening of
heart failure.
Results. […….] A residual nonsignificant risk related to
treatment with TNF inhibitors remained (adjusted HR 1.66 [95%
confidence interval 0.67–4.1], P 0.28). This residual risk was
balanced by the efficacy of the anti-TNF treatment.
Conclusion. The findings of this study indicate that TNF inhibitor
treatment that effectively reduces the inflammatory activity of RA
is more likely to be beneficial than harmful with regard to the risk
of heart failure, […]
J.Listing et al. Arthritis & Rheumatism Vol. 58, No. 3, March 2008
LOT I - Bolnavi cu PAR care primesc terapie
biologica si terapie standard
LOT II - Bolnavi cu PAR care nu primesc terapie
biologica
Evaluare periodica (0, 6, 12, 18, 24, 30 luni)
Clinic
Factori de risc cardiovasculari
Ecocardiografic, Nt pro-BNP
EKG (standard, monitorizare Holter)
Is indeed RA
A particular risk factor for women ?
Lori Mosca et al. Circulation. 2007;115:1481-15
Lori Mosca et al. Circulation. 2011;123:1243-12
LOT I Femei cu PAR
LOT II Barbati cu PAR
LOT III Femei cu factori de risc CV
Evaluare la 2.5 ani
Clinic
Factori de risc cardiovascular cunoscuti
Ecocardiografie
EKG, Testare de stress
Coronarografie, acolo unde se ridica suspiciunea de
angina
Va multumesc