Background/Purpose: Rheumatoid arthritis (RA) is a multi-organ inflammatory disorder associated with high cardiovascular morbidity and mortality. Cardiac involvements are typically clinically silent, only manifesting as heart failure after an extended subclinical phase. Myocardial abnormalities may arise from a number of distinct processes, including myocardial inflammation and/or myocardial fibrosis, any of which may be active in RA. We aimed to assess cardiac involvements using a cardiac magnetic resonance imaging (CMR) approach and to determine its association with disease characteristics and N-terminal pro-brain natriuretic peptide (NT-proBNP ) level in RA patients without cardiac symptoms.

Methods: Consecutive RA patients without cardiac symptoms were enrolled. RA patients with no history and/or clinical findings of systemic and pulmonary hypertension, coronary artery disease, valvular heart disease, atrial fibrillation, diabetes mellitus, and dyslipidemia underwent CMR. RA patients received conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) or biologic DMARDs (bDMARDs). Late gadolinium enhancement (LGE) was obtained for the assessment of myocardial fibrosis. Using Black-Blood T2-weighted image (T2-WI), myocardial inflammation could be assessed. We evaluated the prevalence of CMR abnormalities, and investigated possible associations of CMR abnormalities with RA disease characteristics, and NT-proBNP level.

Results: Sixty patients (mean age, 55.2 ± 1.3 years; 85% female) were enrolled. Thirty RA patients received csDMARDs [25, methotrexate (MTX) (8.7±2.1mg); 5, other drugs)] and 30 RA patients received bDMARDs [15, infliximab 3 mg/kg; 15, tocilizumab 8 mg/kg plus methotrexate (8.6±1.4 mg) ]. Twenty RA patients (33%) demonstrated myocardial abnormalities. High intensity on T2-WI was seen in seven RA patients (11%). LGE was found in 19 RA patients (32%), six of whom also demonstrated high intensity on T2-WI. Simplified Disease Activity Index (SDAI) scores were significantly higher in LGE-positive compared to LGE-negative (p=0.011). LGE was significantly associated with high NT-proBNP and SDAI (p=0.005, p=0.018, respectively). The use of bDMARDs was significantly associated with LGE-negative findings (p=0.0017). Other RA characteristics such as disease duration, autoantibody status, and cardiovascular risk factors were not significantly associated with myocardial abnormalities. After adjusting for confounding by age, RA duration, rheumatoid factor and bDMARDs, the association of LGE with SDAI remained significant (p=0.023), in which the SDAI scores were, on average, 10.9 units higher in LGE-positive than in LGE-negative. Receiver operating characteristic analysis showed NT-proBNP reliably detected myocardial abnormalities (area under the curve 0.856; 95% confidence interval, 0.833–0.904).

Conclusion: Subclinical myocardial abnormalities are common in RA patients without cardiac symptoms, associated with SDAI and NT-proBNP level. NT-proBNP level reliably detected the presence of cardiac involvements appeares to be useful markers to risk stratify RA patients.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/association-of-myocardial-abnormalities-with-n-terminal-pro-brain-natriuretic-peptide-and-disease-activity-in-rheumatoid-arthritis-without-cardiac-symptoms-assessed-by-cardiac-magnetic-resonance-imag/