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Heart failure and left ventricular dysfunction in rheumatoid arthritis

Katherine P Liao, MD, MPH
Paul B Yu, MD, PhD, FAHA
Section Editor
Ravinder N Maini, BA, MB BChir, FRCP, FMedSci, FRS
Deputy Editor
Paul L Romain, MD


Heart failure (HF) is a common clinical syndrome that can result from a variety of structural or functional cardiac disorders. There is an increased incidence of HF in patients with rheumatoid arthritis (RA) compared with the general population, and HF may contribute to the shortened life expectancy observed in RA. In addition to symptomatic HF, asymptomatic left ventricular (LV) systolic dysfunction, defined by a reduced LV ejection fraction, is also more prevalent among patients with RA. Attempts to eliminate the risk of HF in patients with RA may significantly improve their survival.

Issues related to HF in patients with RA will be reviewed here. Other cardiac manifestations of RA and the issue of HF as a complication of targeted therapy directed against tumor necrosis factor (TNF)-alpha are presented separately. (See "Coronary artery disease in rheumatoid arthritis: Implications for prevention and management" and "Overview of the systemic and nonarticular manifestations of rheumatoid arthritis", section on 'Cardiac disease' and "Tumor necrosis factor-alpha inhibitors: An overview of adverse effects", section on 'Heart failure'.)


Population-based studies — There are growing numbers of population-based estimates of the incidence, prevalence, and prognosis of heart failure (HF) in rheumatoid arthritis (RA) [1]. Data suggest that the incidence of HF in patients with RA is increased compared with a population of similar age and sex distribution without RA [2-5].

One study involved 575 patients with RA and 583 patients without RA [2,4]; the incidence of HF was significantly higher among patients with RA after adjustment for age, sex, known cardiovascular risk factors, and the presence of ischemic heart disease (1.99 versus 1.16 cases per 100 person-years, respectively).

In a second series, 603 patients with RA were compared with 603 controls without RA [3]. The cumulative incidence of HF but not ischemic heart disease was significantly higher in those with RA (37 versus 28 percent, at 30 years of follow-up).

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Literature review current through: Nov 2017. | This topic last updated: Dec 07, 2016.
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  1. Voskuyl AE. The heart and cardiovascular manifestations in rheumatoid arthritis. Rheumatology (Oxford) 2006; 45 Suppl 4:iv4.
  2. Nicola PJ, Maradit-Kremers H, Roger VL, et al. The risk of congestive heart failure in rheumatoid arthritis: a population-based study over 46 years. Arthritis Rheum 2005; 52:412.
  3. Nicola PJ, Crowson CS, Maradit-Kremers H, et al. Contribution of congestive heart failure and ischemic heart disease to excess mortality in rheumatoid arthritis. Arthritis Rheum 2006; 54:60.
  4. Crowson CS, Nicola PJ, Kremers HM, et al. How much of the increased incidence of heart failure in rheumatoid arthritis is attributable to traditional cardiovascular risk factors and ischemic heart disease? Arthritis Rheum 2005; 52:3039.
  5. Davis JM 3rd, Maradit Kremers H, Crowson CS, et al. Glucocorticoids and cardiovascular events in rheumatoid arthritis: a population-based cohort study. Arthritis Rheum 2007; 56:820.
  6. Pujades-Rodriguez M, Duyx B, Thomas SL, et al. Rheumatoid Arthritis and Incidence of Twelve Initial Presentations of Cardiovascular Disease: A Population Record-Linkage Cohort Study in England. PLoS One 2016; 11:e0151245.
  7. Bhatia GS, Sosin MD, Patel JV, et al. Left ventricular systolic dysfunction in rheumatoid disease: an unrecognized burden? J Am Coll Cardiol 2006; 47:1169.
  8. Schau T, Gottwald M, Arbach O, et al. Increased Prevalence of Diastolic Heart Failure in Patients with Rheumatoid Arthritis Correlates with Active Disease, but Not with Treatment Type. J Rheumatol 2015; 42:2029.
  9. Seyfeli E, Guler H, Akoglu S, et al. Right ventricular diastolic abnormalities in rheumatoid arthritis and its relationship with left ventricular and pulmonary involvement. A tissue Doppler echocardiographic study. Int J Cardiovasc Imaging 2006; 22:745.
  10. Montecucco C, Gobbi G, Perlini S, et al. Impaired diastolic function in active rheumatoid arthritis. Relationship with disease duration. Clin Exp Rheumatol 1999; 17:407.
  11. Corrao S, Sallì L, Arnone S, et al. Echo-Doppler left ventricular filling abnormalities in patients with rheumatoid arthritis without clinically evident cardiovascular disease. Eur J Clin Invest 1996; 26:293.
  12. Di Franco M, Paradiso M, Mammarella A, et al. Diastolic function abnormalities in rheumatoid arthritis. Evaluation By echo Doppler transmitral flow and pulmonary venous flow: relation with duration of disease. Ann Rheum Dis 2000; 59:227.
  13. Gonzalez-Juanatey C, Testa A, Garcia-Castelo A, et al. Echocardiographic and Doppler findings in long-term treated rheumatoid arthritis patients without clinically evident cardiovascular disease. Semin Arthritis Rheum 2004; 33:231.
  14. Rudominer RL, Roman MJ, Devereux RB, et al. Independent association of rheumatoid arthritis with increased left ventricular mass but not with reduced ejection fraction. Arthritis Rheum 2009; 60:22.
  15. Giles JT, Malayeri AA, Fernandes V, et al. Left ventricular structure and function in patients with rheumatoid arthritis, as assessed by cardiac magnetic resonance imaging. Arthritis Rheum 2010; 62:940.
  16. Mutru O, Laakso M, Isomäki H, Koota K. Cardiovascular mortality in patients with rheumatoid arthritis. Cardiology 1989; 76:71.
  17. Gonzalez A, Maradit Kremers H, Crowson CS, et al. Do cardiovascular risk factors confer the same risk for cardiovascular outcomes in rheumatoid arthritis patients as in non-rheumatoid arthritis patients? Ann Rheum Dis 2008; 67:64.
  18. Maradit-Kremers H, Nicola PJ, Crowson CS, et al. Raised erythrocyte sedimentation rate signals heart failure in patients with rheumatoid arthritis. Ann Rheum Dis 2007; 66:76.
  19. Cole J, Busti A, Kazi S. The incidence of new onset congestive heart failure and heart failure exacerbation in Veteran's Affairs patients receiving tumor necrosis factor alpha antagonists. Rheumatol Int 2007; 27:369.
  20. Solomon DH, Rassen JA, Kuriya B, et al. Heart failure risk among patients with rheumatoid arthritis starting a TNF antagonist. Ann Rheum Dis 2013; 72:1813.
  21. Whelton A, Lefkowith JL, West CR, Verburg KM. Cardiorenal effects of celecoxib as compared with the nonsteroidal anti-inflammatory drugs diclofenac and ibuprofen. Kidney Int 2006; 70:1495.
  22. Wei L, MacDonald TM, Walker BR. Taking glucocorticoids by prescription is associated with subsequent cardiovascular disease. Ann Intern Med 2004; 141:764.
  23. Souverein PC, Berard A, Van Staa TP, et al. Use of oral glucocorticoids and risk of cardiovascular and cerebrovascular disease in a population based case-control study. Heart 2004; 90:859.
  24. Van Doornum S, McColl G, Wicks IP. Accelerated atherosclerosis: an extraarticular feature of rheumatoid arthritis? Arthritis Rheum 2002; 46:862.
  25. Davis JM 3rd, Roger VL, Crowson CS, et al. The presentation and outcome of heart failure in patients with rheumatoid arthritis differs from that in the general population. Arthritis Rheum 2008; 58:2603.
  26. Bernatsky S, Hudson M, Suissa S. Anti-rheumatic drug use and risk of hospitalization for congestive heart failure in rheumatoid arthritis. Rheumatology (Oxford) 2005; 44:677.
  27. Wolfe F, Michaud K. Heart failure in rheumatoid arthritis: rates, predictors, and the effect of anti-tumor necrosis factor therapy. Am J Med 2004; 116:305.
  28. Peters MJ, Welsh P, McInnes IB, et al. Tumour necrosis factor {alpha} blockade reduces circulating N-terminal pro-brain natriuretic peptide levels in patients with active rheumatoid arthritis: results from a prospective cohort study. Ann Rheum Dis 2010; 69:1281.