THE HEART IN RHEUMATOID ARTHRITIS - AN ECHOCARDIOGRAPHIC STUDY.

Background: Rheumatoid arthritis (RA) is a chronic inflammatory disease of the joints. Joint pain, swelling and limited mobility of the joint are the most prominent features. Besides articular symptoms, RA can be associated with extra-articular features. Among those extra-articular features are cardiovascular diseases, including pericarditis, cardiomyopathy/ myocarditis, cardiac amyloidosis, coronary vasculitis, arrythmia, valve diseases and, most importantly, congestive heart failure and ischaemic heart disease. When compared with the general population, RA is associated with an increased mortality, the majority of which is originating from cardiovascular diseases. Objectives: To study cardiac manifestations in patients of rheumatoid arthritis by echocardiography with the objective of providing elements for earlier diagnosis and treatment. Material and Methods: The study was conducted in the Postgraduate Department of Medicine at S.M.H.S Hospital obtaining ethical clearance from the institutional ethical committee. The study was conducted from April 2016 to September 2017. A Total of 110 patients of RA attending Rheumatology OPD in SMHS Hospital in Srinagar, were taken into this study after obtaining informed consent. All patients were either previously or newly diagnosed cases of rheumatoid arthritis. New cases were investigated in the form of ESR, CRP, RF, ANTI-CCP for the diagnosis of RA as per ACR EULAR (2010) criteria. All those who met the ACR EULAR (2010) criteria for RA were screened for cardiac manifestations. Patients were examined clinically for cardiac signs and symptoms and patients were evaluated for cardiac manifestations by echocardiography. Results: Out of 110 studied patients 49% had heart involvement. Mitral regurgitation was the most common heart disease present in 20% of patients, followed by aortic regurgitation in 15.5% of patients, diastolic dysfunction in 14.5% of patients, tricuspid regurgitation in 11.8% of patients, PAH in 10.9% of patients, pericardial effusion in 9.1% of patients, systolic dysfunction in 6.3% of patients, cardiomyopathy (DCM) in 4.5% of patients, ischemic heart disease in 4.5% of patients, mitral stenosis in 0.9% and aortic stenosis in 0.9% of patients. The mean age at detection of heart disease in RA was 53 ?10.65 years, higher than mean age of studied RA patients (49.8?11.5). Analysing the pattern of distribution of age in RA patients with and without heart involvement, the heart involvement increased proportionately as the age advanced. Duration of illness in our study had a marked impact over the progression of heart involvement in patients of RA. Number of patients with heart disease increases with increase in duration of illness. Study showed that 9 (27.3%) patients had disease duration of ≤ 5 years, 23 (46.9%) patients had disease duration of 6-10 years, 16 (76.2%) patients had disease duration of 11-15 years, and 6 (85.7%) patients had disease duration of > 15 years of illness, with a statistically significant P value of P = 0.001 . Though females outnumbered males by a ratio of 3.6:1 as is characteristic of autoimmune disorder, once gender comparison of RA patients was done (Among these 110 patients, 24 (22%) subjects were male and 86 (78 %) subjects were female) there was no significant relation between gender and abnormal echocardiography findings in RA patients (p > 0.05). It was also observed in our study that RA patients with positive CRP mg/L (p =0.02), higher levels of RF IU/ml (p = 0.03) and higher levels of anti-CCP U/ml (P=0.01) were affected more than patients who had negative CRP mg/l, lower levels of RF IU/ml and anti-CCP U/ml. Conclusion: An observational study conducted to see cardiac involvement in patients of rheumatoid arthritis showed that 49% had cardiac involvement. Mitral regurgitation was the most common heart disease present in 20% of patients, followed by aortic regurgitation in 15.5% of patients, diastolic dysfunction in 14.5% of patients, tricuspid regurgitation in 11.8% of patients, PAH in 10.9% of patients, pericardial effusion in 9.1% of patients, systolic dysfunction in 6.3% of patients, cardiomyopathy (DCM) in 4.5% of patients, ischemic heart disease in 4.5% of patients, mitral stenosis in 0.9% and aortic stenosis in 0.9% of patients.