Rheumatoid Arthritis and Congestive Heart Failure

Patient Expert

As mentioned in a previous post, Rheumatoid Arthritis and Heart Disease, patients with RA have a significantly increased risk of heart attack and stroke and a shorter life expectancy as compared to the general population.   Rheumatoid arthritis may cause the the outer lining of the heart to swell (pericarditis) and cause heart complications. Inflammation of the heart muscle, called myocarditis, can also develop. Both of these conditions can lead to congestive heart failure (weakening of the heart's pumping ability) which is more common among people with rheumatoid arthritis.

What is Congestive Heart Failure (also known simply as Heart Failure)?

The National Heart Lung and Blood Institute (NHLBI) shares key points related to heart failure:

*****   Heart failure is a condition in which your heart can't pump blood the way it should. In some cases, the heart can't fill with enough blood. In other cases, the heart can't send blood to the rest of the body with enough force. Some people have both problems.

***** "Heart failure" doesn't mean that your heart has stopped or is about to stop working. However, it's a serious condition that requires medical care.

***** The leading causes of heart failure are diseases that damage the heart. These include coronary artery disease, high blood pressure, and diabetes. Heart failure develops over time as the pumping action of the heart grows weaker.

***** Heart failure is a common condition. About 5 million people in the United States have heart failure, and it results in about 300,000 deaths each year. Heart failure is more common in people who are 65 or older, African American, or overweight or obese. Men have a higher rate of heart failure than women.

***** Common signs and symptoms of heart failure are shortness of breath or trouble breathing, fatigue (feeling tired), and swelling in the ankles, feet, legs, abdomen, and, rarely, the veins in the neck. All of these symptoms are due to fluid buildup in your body.

What is the risk of Congestive Heart Failure in patients with RA? Researchers at the Mayo Clinic have observed that patients with RA have** twice the risk** of developing congestive heart failure as compared with persons without rheumatoid arthritis.   The excess risk stayed elevated even after researchers adjusted for common cardiovascular risk factors (i.e., hypertension, smoking, diabetes) and ischemic heart disease.   Most interesting is that the risk of congestive heart failure is higher in RA patients who are RF-positive than in those who are RF-seronegative.   This increased risk may be present at the earliest stages of the disease and may occur in the absence of obvious cardiovascular risk factors or ischemic heart disease.   See "The Risk of Congestive Heart Failure in Rheumatoid Arthritis: A Population-Based Study Over 46 Years."

In a more recent study, the Mayo Clinic researchers found that RA patients with heart failure appear to have a more subtle presentation, with a lower frequency of typical heart failure symptoms and signs, as compared with non-RA patients with heart failure.   Mortality in the first year following heart failure is also higher in RA patients.   Their data suggests that new ways of screening for early left ventricular dysfunction in patients with RA should be investigated in order to optimize survival rates.   See "The Presentation and Outcome of Heart Failure in Patients With Rheumatoid Arthritis Differs From That in the General Population."

Do anti-TNF medications promote or prevent Heart Failure in RA patients?

Doctors at Johns Hopkins note that all patients receiving a TNF inhibitor should be carefully and continuously monitored for signs of infection. And that Infliximab (Remicade) is not recommended for use in patients with congestive heart failure or with demyelinating disease.   In previous studies of anti-TNF medications as used to treat congestive heart failure, it was found that patients had a poor outcome and studies were halted.

However, researchers in Germany have determined that if treatment with anti-TNF medications is effective in reducing the inflammatory activity of rheumatoid arthritis, then they are more likely to be beneficial than harmful with regard to the risk of heart failure.   The same researchers also note that treatment with COX-2 inhibitors (such as Celebrex) or glucocorticoids may contribute to the increased risk of heart failure in RA patients, although that was not a focus in their study.   Screening for cardiac risk factors and effective treatment of both RA and cardiovascular disease are essential.   See "Does Tumor Necrosis Factor Inhibition Promote or Prevent Heart Failure in Patients With Rheumatoid Arthritis?"

In a 2008 editorial in the journal Arthritis & Rheumatism, Sherine Gabriel of the Mayo Clinic addresses some of the complexities of the question posed above.   Gabriel points out that results of the analysis were highly nonsignificant both for new heart failure cases and for new or worsening heart failure combined.   While the estimated hazard rates suggest that the overall risk may be reduced by 30-35%, this analysis also indicates that the risk may be increased by as much as 84% which certainly does not support the "more likely to be beneficial than harmful" statement.

Gabriel also points out that since the halted trials of using TNF inhibitors to treat congestive heart failure (referenced above), the Food and Drug Administration (FDA) has received numerous reports of cases of new and/or worsening heart failure in patients with RA and/or Crohn's disease treated with TNF inhibitors. A recent analysis demonstrated a nearly 3-fold increase in drug-related serious adverse events (including mortality) reported to the FDA from 1999 through 2005, and it was noted that TNF inhibitors were among the 15 most frequently named offending drugs.   See "Tumor Necrosis Factor Inhibition: A Part of the Solution or a Part of the Problem of Heart Failure in Rheumatoid Arthritis?"
What can you do if you have early symptoms of Heart Failure?

More key points from NHLBI regarding heart failure:

***** Your doctor will diagnose heart failure based on your medical and family histories, a physical exam, and tests. He or she must rule out other causes for symptoms and find out whether you have a disease or condition that's causing heart failure. He or she also will check whether your heart is damaged and how well it pumps blood.

***** Heart failure treatment may include lifestyle measures, medicines, ongoing care, and using a medical device or having surgery. The sooner you start treatment, the better off you're likely to be.

***** You can take steps to prevent heart failure by having a healthy lifestyle, preventing and treating conditions that can lead to heart failure, and taking medicines as your doctor prescribes.

***** Heart failure can't be cured. You will likely need to take medicine and follow a treatment plan for the rest of your life. Despite treatment, your symptoms may get worse over time. Following your treatment plan, taking steps to prevent heart failure from getting worse, and planning ahead can help you stay healthier longer.

***** Researchers are finding and testing new treatments for heart failure. These treatments offer hope for the future. Talk to your doctor about whether research studies may benefit you.

For More Information: Myocardial dysfunction in rheumatoid arthritis: epidemiology and pathogenesis. Giles JT, Fernandes V, et al. Arthritis Research & Therapy 2005, 7:195-207.

Glucocorticoids and Cardiovascular Events in Rheumatoid Arthritis: A Population-Based Cohort Study. Davis JM III, Maradit-Kremers H, et al. Arthritis & Rheumatism 2007, 56(3):820-830.

Heart failure among younger rheumatoid arthritis and Crohn's patients exposed to TNF-{alpha} antagonists.   Curtis JR, Kramer JM, Martin C, et al.   Rheumatology 2007, 46(11):1688-1693.

More information regarding Congestive Heart Failure can be found here at HealthCentral.