Background Patients with rheumatoid arthritis (RA) are more likey to have diastolic dysfunction and this finding may explain the higher risk of heart failure and pulmonary hypertension in this population1. These features could be specially relevant in patients with long-term evolution of the disease in which the influence of the biological treatment is unknown.
Objectives To study the prevalence and the degree of diastolic function (DF) and pulmonary hypertension (PH) in long-standing AR patients on biological therapy.
Methods Retrospective study of long-standing AR patients on biological therapy (16% abatacept, 16% adalimumab, 18% etanercept, 2% golimumab, 8% infliximab, 20% rituximab and 20% tocilizumab) with unknown cardiac disease and with a transthoracic echocadiographic study available. Clinical and echocardiographics measurements of DF were obtained with transmitral E and A wave ratio with the following patterns in order of increasing impairment of DF: normal, impaired relaxation, pseudonormal and restrictive. A normal DF was considered in the presence of either normal or altered relaxation in patients >45 years. DF was also measured with tissue Doppler (E/e' ratio at the level of the septal annulus) being abnormal a ratio >15. The degree of pulmonary pressure was estimated using the tricuspid regurgitation velocity and PH was graded as follows: mild (30-39mmHg), moderate (40-49 mmHg) and severe (≥50mmHg).
Results Fifty patients were included, age 59±13 years, 78% females. Seventy-two percent had hypertension and 16% diabetes. Median disease evolution was 12 [6-18] years. With respect to E/A ratio, 74% patients had normal DF. In 7 patients (14%) there was a pseudonormal pattern (with an attributable cause in all of them: atrial fibrillation, ischemic heart disease and age >75 years). With respect to E/e' ratio, mean value was 10.2±4.6 and 20% had E/e' >15. These patients were older (67.5±8.1 vs 57.6±13.9 years, p=0.036) and had higher antiCCP levels (median 340 vs 31.5, p=0.016) without statistically significant differences in the time of evolution of the disease and in other clinical characteristics. We found pulmonary hypertension in 42% of patients, 86% mild and only 14% moderate (3 patients, with ischemic heart disease and/or age >70 years). The presence of pulmonary hypertension was associated to age (65.5±8.9 vs 57.2±14.4 years, p=0.05) and E/e' values (12.9 vs 9.2, p=0.011)
Conclusions In our population of long-standing AR on biological therapy, the presence of impaired DF is uncommon and is associated to age, comorbidity and higher levels of anti-CCP, whereas pulmonary hypertension is mainly mild reflecting the age and the inherent diastolic dysfunction in these elderly patients
Aslam F, Bandeali SJ, Khan NA, Alam M. Diastolic dysfunction in rheumatoid arthritis: a meta-analysis and systematic review. Arthritis Care Res (Hoboken). 2013 Apr;65(4):534-43
Disclosure of Interest None declared