الفهرس Only 14 pages are availabe for public view
 |  | from | 150 |  |  |
| | | from | 150 | | |
Abstract
Rheumatoid arthritis is a chronic, debilitating disease in which articular inflammation and joint destruction are accompanied by systemic manifestations, together with extra-articular organs involvement. Most mortality studies in patients with rheumatoid arthritis published since 1950 have shown an increased mortality from cardiovascular diseases. In the 80s and early 90s some investigators pointed that cardiovascular death was increased in patients with rheumatoid arthritis. More recent studies have confirmed that cardiovascular disease is the most common cause of mortality in RA, with a relative risk of about two compared with age matched control. Moreover the cardiovascular events occur approximately a decade earlier than in the general population.
As the RA suffers are dealing with significant pain and stress, therefore cardiovascular disease assessment and prevention may be delayed, and not diagnosed until fatal events occur.
In 2009 Van Halm and his colleagues concluded that the prevalence of cardiovascular diseases in RA is increased to an extent that it is at least comparable to that of diabetes type 2. The aim of this study was to study the possibility of cardiac involvement in Egyptian patients with rheumatoid arthritis. The study was conducted on 40 patients with RA diagnosed according to ACR 1987 criteria, and were recruited from the outpatient clinics of Physical medicine, and Rheumatology department in the Main and El Hadra University Hospitals. Patients with diabetes mellitus, hperlipidaemia, cardiovascular disease preceding the RA, history of receiving selective COX2 inhibitors, and smoker were excluded from the study, in a trial to shut out the well known traditional cardiovascular risk factors. A careful history was taken, and all patients had rheumatological assessment including the 28 joint disease activity score (DAS28), and the Health Assessment Questionnaire Disability Index (HAQ-DI). The cardiac assessment included the clinical examination, the standard 12-lead resting ECG, and echocardiographic study. The laboratory evaluation included the erythrocyte sedimentation rate, C-reactive protein, rheumatoid factor, and N- terminal Brain natriuretic peptide. The N- terminal Brain natriuretic peptide (NT pro-BNP) is a peptide hormone released into the circulation in response to increased myocardial stretch and wall tension, and it is acting as general indicator of cardiac structural disease.
Most of the studied patients were females (38 ♀ versus 2 ♂), aged from 20 to 71 years, and with a disease duration ranging from 1 to 40 years. Thirteen patients were not compliant to medical treatment, 31 patients received corticosteroids, methotrexate as the only DMARDs in 22 patients, 5 patients had combined DMARDs, and only 1 patient received biological therapy. At the time of examination 5 patients were in a clinical remission, 2 had low disease activity score, 6 were with a moderate disease activity, and the remaining 27 had high disease activity score at the time of examination according to DAS28. Eight patients showed clinically apparent extra-articular manifestations of them 6 had rheumatoid nodules, and the remaining 2 had vasculitic peripheral neuropathy.
Regarding the laboratory evaluation of the studied subjects, the CRP and NT pro-BNP were statistically significant higher in the patients group when compared to the control group. when the studied patients were grouped according to the resting CRP level, group (A) with CRP< 6 mg / dl (low grade systemic inflammation) and group(B) with c RP ≥ 6mg/l (high grade systemic inflammation) there was a statistically significant difference between both groups regarding some echocardiographic parameters, and moreover by correlation study there was a positive significant correlation between the CRP level and the systolic pulmonary artery pressure, and the presence of diastolic dysfunction.
A positive significant correlation was found between the disease activity measured by DAS28 and the level of NT pro-BNP, and no statistically significant correlation could be found between the duration of RA process and the level of NT pro-BNP. Using a cut off point of 126 pg/ml the sensitivity and specificity of NT pro-BNP for detection of diastolic dysfunction was 65.2% and 90.9% respectively, the area under the ROC curve= 76.9%, positive predictive value= 57, and negative predictive value= 86.2.
The detected ECG changes in this series were atrial fibrillation in 1 patient and ST segment depression in 3 patients.
Various echocardiographic findings were found in the studied patients, left atrial dilatation in 2 patients, mild aortic regurgitation in 3 patients, systolic dysfunction in 2 patients, 10 patients had pulmonary hypertension, and 23 patients showed left ventricular diastolic dysfunction. Because primary diastolic dysfunction is an important cause of heart failure, as it often is a silent alteration preceding systolic dysfunction; knowledge of this complication in patients with rheumatoid arthritis without clinically evident cardiac disease may be important to improve patient’s survival.
When the studied patients with rheumatoid arthritis were grouped according to the presence or absence of left ventricular diastolic dysfunction to assess whether patients with left ventricular diastolic dysfunction had some peculiarities that might help identify these patients. There were no statistically significant differences in the age of the studied patients at the time of the study, the duration of the disease process, and HAQ-DI between the patients with and without left ventricular diastolic dysfunction. There were statistically significant differences between both groups regarding the DAS28, level of CRP, level of NT pro-BNP, and the systolic pulmonary artery pressure.
Left ventricular diastolic dysfunction occurred in 76.9% of the patients who were not compliant to medical treatment, and no difference were found in the cumulative dose of corticosteroids among patients with and without left ventricular diastolic dysfunction, and the last observation that extra-articular manifestations were more common among rheumatoid patients with left ventricular diastolic dysfunction .