ЖУРНАЛ КАРДИОРЕСПИРАТОРНЫХ ИССЛЕДОВАНИЙ | JOURNAL OF CARDIORESPIRATORY RESEARCH
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Хусаинова Мунира Алишеровна
Самаркандский Государственный Медицинский Институт
Ассистент кафедры пропедевтики внутренних болезней,
Самарканд, Узбекистан
ХРОНИЧЕСКАЯ СЕРДЕЧНАЯ НЕДОСТАТОЧНОСТЬ У БОЛЬНЫХ РАННИМ РЕВМАТОИДНЫМ АРТРИТОМ
For citation:
Khusainova M.A. Сhronic heart failure in patients with early rheumatoid arthritis. Journal of cardiorespiratory research. 2021, vol. 2,
issue 4, pp.67-69
http://dx.doi.org/10.26739/2181-0974-2021-4-15
АННОТАЦИЯ
Ревматоидный артрит - системное воспалительное заболевание соединительной ткани с преимущественным поражением мелких
суставов по типу эрозивно-деструктивного полиартрита неясной этиологии со сложным аутоиммунным патогенезом. Заболевание
характеризуется высокой инвалидизацией (70%), которая наступает довольно рано. Основными причинами смерти от этого заболевания
являются инфекционные осложнения и почечная недостаточность. Ревматоидный артрит широко распространен во всем мире, и все
этнические группы подвержены ему. Хроническая сердечная недостаточность - клинический синдром при некоторых заболеваниях,
сопровождающийся характерными симптомами (одышка, снижение физической активности, усталость, отеки и т.д.), связанными с
недостаточной перфузией органов и тканей в состоянии покоя или во время физической нагрузки, сопровождающимися задержкой
жидкости в организме и ее накоплением в мягких тканях.
Ключевые слова
: ревматоидный артрит, хроническая сердечная недостаточность, фракция выброса, левый желудочек.
Khusainova Munira Alisherovna
Samarkand State Medical Institute
Assistant of the Department of Propaedeutics of
Internal Diseases, Samarkand, Uzbekistan
CHRONIC HEART FAILURE IN PATIENTS WITH EARLY RHEUMATOID ARTHRITIS
ANNOTATION
Rheumatoid arthritis is a systemic inflammatory disease of connective tissue with a predominant lesion of small joints by the type of erosive-
destructive polyarthritis of unclear etiology with a complex autoimmune pathogenesis. The disease is characterized by high disability (70%), which
occurs quite early. The main causes of death from the disease are infectious complications and renal failure. Rheumatoid arthritis is widespread all
over the world and all ethnic groups are susceptible to it. Chronic heart failure is a clinical syndrome in some diseases, accompanied by characteristic
symptoms (shortness of breath, decreased physical activity, fatigue, edema, etc.) associated with inadequate perfusion of organs and tissues at rest
or during exercise, accompanied by fluid retention in the div and its accumulation in soft tissues.
Keywords:
Rheumatoid arthritis, chronic heart failure, ejection fraction, left ventricle
Khusainova Munira Alisherovna
Samarqand Davlat Tibbiyot Instituti
Ichki kasalliklar propedevtikasi kafedrasi assistenti,
Samarqand, O'zbekiston
ERTA REVMATOID ARTRITI BO'LGAN BEMORLARDA SURUNKALI YURAK YETISHMOVCHILIGI
ANNOTATSIYA
Revmatoid artrit – etiologiyasi noma'lum murakkab autoimmun patogenezli eroziv-destruktiv poliartrit tipida kichik bo'g'imlarning zararlanishi
ustunligi bilan kechuvchi biriktiruvchi to'qimaning tizimli yallig'lanish kasalligi. Kasallik ko'p hollarda erta nogironlikka olib keladi (70%).
Kasallik tufayli o'limning asosiy sabablari infeksion asoratlar va buyrak yetishmovchiligidir. Revmatoid artrit butun dunyoda keng tarqalgan va
barcha etnik guruhlar bu kasallikka moyil. Surunkali yurak yetishmovchiligi ba'zi kasalliklarda klinik sindrom bo'lib, nafas qisishi, jismoniy
faoliyatning pasayishi, charchoq, shish asosiy xarakterli belgilar hisoblanadi. Organizm yumshoq to’qimalarida suyuqlik to'planishi bilan birga
kechadi.
Kalit so'zlar
: revmatoid artrit, surunkali yurak yetishmovchiligi, chap qorincha.
ЖУРНАЛ КАРДИОРЕСПИРАТОРНЫХ ИССЛЕДОВАНИЙ | JOURNAL OF CARDIORESPIRATORY RESEARCH
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The prevalence is 0.5-1% (up to 5% in the elderly) in developed
countries. From 5 to 50 people per 100,000 population get sick every
year. The average age of onset of the disease is 40-50 years for women
and slightly more for men. Women get sick 3-5 times more often than
men.
The total mortality of patients with any CHF is 6% per year. A
distinctive feature of a patient with HF is comorbidity, so 60% have
coronary heart disease, 36% have atrial fibrillation, 34% have type 2
diabetes mellitus, 36% have chronic kidney disease, 43% have a history
of myocardial infarction.
Rheumatoid arthritis (RA) is characterized by a twofold increase in
morbidity and mortality associated with chronic heart failure (CHF). At
the same time, the prevalence of CHF among RA patients is
significantly underestimated.
In RA, CHF with a preserved ejection fraction (LV) of the left
ventricle (LV) prevails. The use of clinical diagnostic criteria can lead
to hyper- or underdiagnosis of CHF in RA patients. Systolic dysfunction
assessed by LVEF is rarely detected in RA and does not reflect the
actual frequency of myocardial dysfunction. Echocardiography
(ECHO-KG) with tissue Dopplerography (TDG) and visualization of
myocardial deformity, magnetic resonance imaging (MRI) of the heart
in RA revealed a high frequency of CHF with preserved LV LV, LV
remodeling and hypertrophy, preclinical systolic and diastolic
dysfunction. The main causes of premature mortality from
cardiovascular
diseases
are
progressive
atherosclerosis,
the
development of chronic heart failure (CHF), sudden cardiac death.
However, a 10-year prospective observational study revealed that
achieving low RA disease activity led to a 35% reduction in
cardiovascular risk (acute coronary syndrome, cerebral stroke/transient
ischemic attack, peripheral artery disease, CHF).
Material and methods
CHF was detected in 24 (33%) patients with early RA. 22 patients
were included in this study. Two patients dropped out due to the lack of
echocardiography (EchoCG) data in dynamics. Most patients were
women – 17 (77%). All patients were examined by a cardiologist, daily
monitoring of electrocardiogram and blood pressure (BP), EchoCG,
duplex scanning of carotid arteries was performed. According to the
recommendations of the Uzbekistan Society of Cardiology, an
assessment of traditional risk factors for cardiovascular diseases was
carried out. The diagnosis of CHF was verified in accordance with the
recommendations the diagnosis and treatment of chronic heart failure
society of specialists in heart failure when the patient has four key
criteria: characteristic symptoms and/or signs of heart failure
(shortness of breath, fatigue, limited physical activity, swelling of the
ankles), objective signs of heart dysfunction according to
Echocardiography with tissue Doppler and the level of Pro-brain
natriuretic peptide b-type (N-terminal propeptide (NT-proBNP), more
than 125 PG/ml). In addition, electrocardiography and lung radiography
were performed. The 6-minute walk test was not performed due to
limited mobility of patients with RA.
Echocardiographic examination was performed according to the
recommendations of the American Society of Echocardiography
(American Society of Echocardiography - ASE). Diastolic dysfunction
was determined in accordance with the Recommendations for
determining the diastolic function of the left ventricle (LV). According
to the principles of the "treatment to goal" strategy, all patients were
initiated methotrexate (MT) therapy with a rapid increase in the dose to
30 mg per week subcutaneously. With insufficient efficiency of MT
through For 3 months, a genetically engineered biological drug (GIBP),
mainly an inhibitor of tumor necrosis factor-alpha (TNF-α), was added
to therapy. The dynamics of the surveyed 22 patients with RA, a
complex of examinations like the primary one was carried out. After 18
months in remission and low activity of the disease there were 10 (45%)
patients, of which 6 (60%) patients underwent MT therapy in
combination with GIBP (adalimumab, certolizumab pegol). At the time
of inclusion in the study, nonsteroidal anti-inflammatory drugs were
taken 8 (36%) patients with early RA. Cardioprotective drugs were
regularly taken by 22 (100%) patients. At the outpatient stage,
cardioprotective therapy did not change.
Results
Initially, 21 (95%) patients had CHF with preserved ejection
fraction (EF), and 1 patient had CHF with reduced EF. 6 (27%) patients
had functional class I (FC) according to NYHA (New York Heart
Association Functional Classification – Classification of the New York
Cardiological Association), 15 (68%) - FC II, 1 (5%) – FC III. After 18
months, she was observed positive dynamics in the form of
improvement of clinical symptoms (decreased severity of dyspnea,
peripheral edema), echocardiographic indicators (decrease in the size of
the left atrium and its index of end-systolic volume, IVRT (isovolumic
relaxation time - isovolumic relaxation time), LV diastolic function.
There was no decompensation of CHF. Initially, target blood pressure
levels were achieved in 12 patients (55%). After 18 months, 13 (59%)
patients had systolic and diastolic blood pressure levels in the target
range.
LV myocardial diastolic function was normalized in 7 (32%)
patients. In all cases, the target blood pressure level, remission (n=5)
and low disease activity (n=2) were achieved. Patients with RA and
CHF with normalized LV diastolic function were more likely to receive
combination therapy with MT and GIBP - 5 (71%) than monotherapy
with MT.
In patients with RA and CHF, the level of NT-proBNP decreased
from 192.2 [151.4; 266.4] to 114.0 [90.4; 163.4] pg/ml, normalization
of its level was detected in 16 out of 22 (73%) patients against the
background of achieving remission or low RA activity. Patients with
persistent elevated NT proBNP values had moderate or high disease
activity.
Clinical manifestations of CHF regressed in 5 (22%) of 22 patients,
LV diastolic function and the level of NT-proBNP normalized.
Discussion
Our study for the first time showed positive dynamics of clinical
manifestations of CHF, LV diastolic dysfunction and NT-proBNP
levels in patients with early RA and CHF on the background of
antirheumatic therapy according to the strategy "treatment to goal
achievement" during 18 months of follow-up.
Unlike patients with CHF in the general population, patients with
RA suffer mainly CHF with preserved PV, which is caused by systemic
inflammation and endothelial dysfunction. As is known, the leading
factor in the pathogenesis of RA is the circulation of pro-inflammatory
cytokines with the development of inflammation in the joints. It is also
proved that increased secretion of TNF-α, interleukin 1 (IL-1), IL-6, IL-
18, chemokines affect the development of CHF, mainly with preserved
PV. In RA, a high level of TNF-α not only causes the destruction of
joints, but also acts systemically, affecting the work of the heart and
contributing to the development of ventricular dysfunction of the heart.
The positive effect of antirheumatic therapy on the course of CHF
in patients with early RA may be due to the blockade of the "cytokine
storm". Several experimental studies have demonstrated that cytokines
can modulate myocardial function through various mechanisms,
including stimulation of hypertrophy and fibrosis by direct action on
cardiomyocytes and fibroblasts, impaired myocardial contractility,
affecting intracellular calcium transport and signal transduction via
beta-adrenergic receptors, induction of apoptosis and stimulation of
genes involved in myocardial remodeling.
Positive results of the use of MT in patients with RA and CHF were
obtained. Methotrexate is recognized as the gold standard of treatment
of RA, due to its immunosuppressive properties, it leads to a decrease
in destructive processes in the bones, slowing down the atherosclerotic
process and reducing the risk of cardiovascular complications. Against
the background of MT therapy, there was a decrease in the risk of all
cardiovascular complications and heart attack myocardium in RA
patients by 28 and 19%, respectively. According to the results of a study
conducted by K. Gong et al., in patients with CHF without RA on the
background of therapy MT and reduction of proinflammatory cytokines
in the blood showed an improvement in FC by NYHA and a test with a
6-minute walk.
Previously, attempts were made to use GIBP for the treatment of
CHF in patients without RA. However, the use of TNF-α inhibitors in
this cohort of patients led to an increase in CHF decompensation and
mortality. It is worth noting that in the above studies, the doses of
ЖУРНАЛ КАРДИОРЕСПИРАТОРНЫХ ИССЛЕДОВАНИЙ | JOURNAL OF CARDIORESPIRATORY RESEARCH
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etanercept and infliximab were higher than those recommended for use
in RA patients.
In our study, the normalization of diastolic function was influenced
not only by remission and low activity of the disease, but also by the
achievement of the target blood pressure level. LV diastolic function
was normalized only in patients with target blood pressure levels. It is
well known that with an increase in blood pressure, the load on the LV
myocardium increases, accompanied by cardiomyocyte hypertrophy, as
well as an increase in collagen content and fibrosis, followed by
myocardial remodeling, apoptosis of its cells and violation of systolic
and diastolic LV function.
Conclusion
In patients with early RA with CHF, there is an improvement in the
clinical course of CHF, LV diastolic function, as well as a decrease in
the level of NTproBNP against the background of antirheumatic therapy
carried out according to the "treatment to goal" strategy.
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