Heart involvement in Rheumatoid Arthritis: Systematic review and meta-analysis

Abstract

Objective

The aim of our study was to conduct a systematic review with meta-analysis of the current case–control studies about the valvular and pericardial involvement in patients with Rheumatoid Arthritis (RA), asymptomatic for cardiovascular diseases.

Methods

Case–control studies were identified by searching PubMed (1975–2010) and the Cochrane Central Register of Controlled Trials (CENTRAL) (1975–2010). Participants were adult patients with RA asymptomatic for cardiovascular diseases, and the outcome measure was the presence of cardiac involvement.

Results

Quantitative synthesis included 10 relevant studies out of 2326 bibliographic citations that had been found. RA resulted significantly associated to pericardial effusion (OR 10.7; 95% CI 5.0–23.0), valvular nodules (OR 12.5; 95% CI 2.8–55.4), tricuspidal valve insufficiency (OR 5.3; 95% CI 2.4–11.6), aortic valve stenosis (OR 5.2; 95% CI 1.1–24.1), mitral valve insufficiency (OR 3.4; 95% CI 1.7–6.7), aortic valve insufficiency (OR 1.7; 95% CI 1.0–2.7), combined valvular alterations (OR 4.3; 95% CI 2.3–8.0), mitral valve thickening and/or calcification (OR 5.0; 95% CI 2.0–12.7), aortic valve thickening and/or calcification (OR 4.4; 95% CI 1.1–17.4), valvular thickening and/or calcification (OR 4.8; 95% CI 2.2–10.5), and mitral valve prolapse (OR 2.2; 95% CI 1.2–4.0).

Conclusions

Our systematic review pointed out the strength and the grade of both pericardial and cardiac valvular involvement in RA patients. Our findings underscore the importance of an echocardiographic assessment at least in clinical research when RA patients are involved. Moreover, further research is needed to understand the possible relationship of our findings and the increased cardiovascular mortality.

Introduction

Rheumatoid Arthritis (RA) is a chronic inflammatory disease that affects joints causing deformities, severe disability and premature mortality [1], [2]. This disease has a high social and economic burden. Indeed, about 1.3 million adults are affected by RA in the United States [3]. The world prevalence of RA might be around 0.3–1.2% [4]. Recently the Swedish patients register [5] has shown a RA cumulative prevalence of 0.77% (women 1.16% men 0.44%) confirming above mentioned assumptions. In this disease, the synovial membrane is the main target, although extra-articular manifestations can be found including the cardiac ones. Pericarditis is the cardiac manifestation most readily recognized, but myocardial disease, coronary vasculitis, diastolic dysfunction, accelerated atherosclerosis and valvular lesions of the heart have also been reported [6]. The premature mortality among patients with RA is frequently due to cardiovascular disease [7], primarily ischemic heart disease [8] and congestive heart failure [9]. A recent meta-analysis of our team showed that rheumatoid patients have a higher left ventricular mass than controls [10]. Moreover, in rheumatoid patients without overt cardiovascular disease, we previously reported pericardial, valvular, and aortic root involvement that we clinically defined as “silent rheumatoid heart disease” [11]. Recently, Yiu et al. [12] have found out a significant association between Rheumatoid Arthritis and valvular calcifications. This study used multidetector computed tomography and has also pointed out that the presence of mitral valve calcification independently predicted the occurrence of premature atherosclerosis. On the other hand, several echocardiographic studies have been published in the last two decades on this issue. So that, summarizing evidence from all these studies may be useful to understand the effect of the disease on cardiac structures of rheumatoid patients almost partially in the pre-biological era.

The aim of our study was to perform a systematic review and meta-analysis of the current case–control studies based on echocardiographic assessment of valvular and pericardial involvement in patients with RA.