Clinical features of the course of ischemic heart disease in patients with rheumatoid arthritis

The dissertation is devoted to the study of the clinical features of the course of coronary heart disease (CHD) in patients with rheumatoid arthritis (RA). The work examines the relationship between chronic autoimmune inflammation in RA and the development of atherosclerotic vascular damage and cardiovascular complications, which contribute significantly to the mortality of this patient group. Particular attention is paid to the prevalence and character of CHD risk factors, lipid metabolism disturbances, silent myocardial ischemia, arrhythmias, and the morphofunctional state of the heart in RA patients depending on the duration, activity and form of the disease.

The study carries out a comparative analysis of the prevalence of risk factors and angina pectoris syndrome in RA patients, in patients with osteoarthritis, and in individuals with CHD without pathology of the musculoskeletal system. The influence of disease-modifying and anti-inflammatory therapy on the development and course of CHD is evaluated. The obtained data are aimed at improving the early detection of cardiovascular disorders and optimizing the management of RA patients with concomitant coronary heart disease.

Relevance of the problem. In most countries of the world, rheumatoid arthritis (RA) is a pressing medical and social problem due to its high prevalence, involvement of individuals of various age groups, the progressive nature of the disease, and the high level of disability and mortality [78, 117, 297]. According to a number of authors, the prevalence of RA in the population is about 1% [3, 54, 72, 99].

It is known that the chronic autoimmune process underlying the pathogenesis of RA leads to an increased risk of associated cardiovascular pathology, primarily related to atherosclerotic vascular damage [177, 278]. Epidemiological studies have shown a growing impact of cardiac pathology, including coronary heart disease (CHD), on the mortality of RA patients [197, 198, 283, 293].

Certain parallels have been established between the pathogenetic mechanisms in RA and atherosclerosis [34, 177, 211]. It has been shown that the formation of an unstable atherosclerotic plaque is accompanied by a Th1-type immune response, elevated levels of pro-inflammatory cytokines TNF-α, IL-1 and IL-6, and overexpression of cellular adhesion molecules, which brings atherosclerotic vascular damage closer to classical Th1-dependent autoimmune diseases and primarily to RA [211].

At present, there is no consensus on the role of traditional cardiovascular risk factors, as well as on the use of disease-modifying and anti-inflammatory therapy, in the development of CHD in patients with RA [114, 116, 128, 181, 276, 280].

Data are available on the state of lipid metabolism in RA patients; however, evidence on disturbances of the blood lipid profile in RA patients with concomitant CHD is insufficient [5, 262].

In the available literature we have found only isolated studies addressing the clinical aspects of the combination of RA and concomitant cardiovascular pathology [81, 182], indicating a possible subclinical course of CHD in RA patients; however, the problem of silent myocardial ischemia (SMI) in this category of patients has not been studied.

Thus, despite the established fact of an increased risk of cardiovascular diseases in patients with RA, the features of the course of CHD in this group of patients require further investigation.

Aim of the study. To investigate the clinical features of the course of coronary heart disease in patients with rheumatoid arthritis.

Objectives of the study:

1. To conduct a comparative study of the prevalence of the leading CHD risk factors, as well as of angina pectoris syndrome, in patients with rheumatoid arthritis and osteoarthritis under conditions of a screening examination.

2. To investigate lipid metabolism disturbances in patients with rheumatoid arthritis and CHD.

3. To determine the prevalence and severity of silent myocardial ischemia, as well as the frequency and character of cardiac rhythm disturbances, in patients with rheumatoid arthritis and CHD.

4. To evaluate the morphofunctional state of the heart in patients with rheumatoid arthritis and CHD.

5. To identify the clinical features of the course of CHD in patients with rheumatoid arthritis depending on the duration, degree of activity and form of the disease.

6. To evaluate the influence of disease-modifying and anti-inflammatory therapy on the course of CHD in patients with rheumatoid arthritis.

Main statements put forward for defense:

1. In the majority of patients with rheumatoid arthritis, coronary heart disease is characterized by a low frequency of angina pectoris syndrome, in contrast to CHD in patients with osteoarthritis (OA) and in patients with CHD without pathology of the musculoskeletal system.

2. The severity and duration of ischemic changes in RA patients with CHD depend on the presence of systemic manifestations, the duration of the disease and the age of the patient, while the frequency of detected rhythm disturbances depends on the age of the patient and the degree of RA activity.

3. The leading traditional CHD risk factors in RA patients are arterial hypertension, hypercholesterolemia and age over 55 years; however, the prevalence of these risk factors is lower than in patients with OA. Dyslipoproteinemia in RA patients with concomitant CHD is also detected less frequently than in OA patients with CHD and in patients with CHD.

Scientific novelty.

As a result of the study, it was shown for the first time that the leading classical risk factors (arterial hypertension, hypercholesterolemia, obesity) play a greater role in the development of atherosclerotic vascular damage in OA patients than in RA patients. A lower prevalence of dyslipoproteinemia in RA patients with CHD was demonstrated compared with OA patients with CHD and with CHD patients.

A higher frequency and greater severity of silent myocardial ischemia were established in RA patients with CHD compared with CHD patients.

Features of ischemic changes and cardiac rhythm disturbances were identified in RA patients with CHD depending on the duration, degree of activity and presence of systemic manifestations, as well as the age of the patients.

Practical significance of the work.

In view of the high frequency of silent myocardial ischemia and cardiac rhythm disturbances in RA patients with CHD and the low physical activity of this group of patients, the significance of evaluating ischemic changes by means of Holter ECG monitoring was demonstrated. Taking into account the features of the course of CHD in RA patients, indications were proposed for 24-hour ECG monitoring in RA patients. Given the high prevalence of left ventricular diastolic dysfunction in RA patients with CHD, the importance of assessing transmitral blood flow for the early detection of heart failure was shown.

Implementation of the results.

The results of the study have been implemented in the practical work of the therapeutic departments of the Saint Petersburg Medical Association of Leningrad Oblast (SPb MALO) and the rheumatology department of the Leningrad Oblast Clinical Hospital. The findings of the dissertation have been incorporated into the teaching process of the Department of Therapy No. 1 named after E.E. Eichwald.

Approval of the work.

The results of the work were reported and discussed at the conference of young scientists "Topical Issues of Clinical and Experimental Medicine — 2002" (2002, Saint Petersburg), the conference of young scientists "Topical Issues of Clinical and Experimental Medicine — 2003" (2003, Saint Petersburg), the scientific conference of young rheumatologists (2002, Moscow), the III All-Russian Conference "Modern Possibilities of Holter Monitoring" (2002, Saint Petersburg), the I Northwestern Scientific and Practical Conference on Rheumatology (2001, Saint Petersburg), and the II Northwestern Scientific and Practical Conference on Rheumatology (2002, Petrozavodsk).

Publications. On the topic of the dissertation, 10 works have been published.