Background/Purpose: Patients with rheumatoid arthritis (RA) are known to have an increased risk of cardiovascular disease, particularly atherosclerosis and heart failure.  However, little is known about the occurrence of valvular heart disease (VHD) in RA. The purpose of our study was to investigate the occurrence of VHD among patients with RA compared to the general population.

Methods: A population based inception cohort of residents of a geographically well-defined area with adult onset RA who met 1987 ACR criteria in 1998-2007 and a comparison cohort of age and sex matched non-RA subjects from the same population base were assembled and followed until death, migration or the present. Echocardiograms were reviewed to determine the occurrence of VHD as defined by the 2014 ACC/AHA guidelines.  Cumulative incidence of VHD adjusted for the competing risk of death was estimated.

Results: The study included 379 patients with RA and 379 non-RA subjects (mean age 55.1 [SD 15.2] years, 69% women in both cohorts). Among these cohort of patients, 117 patients with RA and 89 non-RA subjects had at least 1 echocardiogram performed after incidence/index date. The prevalence of VHD was similar in the RA and non-RA cohorts at RA incidence/index date(2% versus 3%; P=0.82). The cumulative incidence (± SE) of any valve disease during follow up  was  higher among patients with RA compared to non-RA subjects(26% ± 2.5% versus 16.9% ± 2.1% at 10 years; P=0.013). The difference persisted after adjustment for age, sex, and calendar year of RA incidence/index date (hazard ratio[HR]:1.49; 95%CI: 1.11,1.99). Among all valve diseases, the cumulative incidence of any grade of mitral regurgitation (MR) (24.6% ± 2.4% versus 15.6% ± 2.0% at 10 years; p=0.015) and tricuspid regurgitation (TR) (23.1% ± 2.4% versus 16.3% ± 2.1%; p=0.045) were significantly higher in patients with RA compared to non-RA subjects. The cumulative incidence of  at least moderate MR (4.3% ± 1.2% versus 3.0% ±  0.9%; p=0.95) and at least moderate TR (6.6%  ±  1.5% versus 3.7%  ±  1.1%; p=0.23) were not significantly different between RA and non-RA. Risk factors for valve disease occurrence in patients with RA included age (HR 2.08 per 10 year increase; 95% CI: 1.79, 2.42), atrial fibrillation (HR 2.67: 95%CI: 1.63, 4.37), stroke (HR 2.45; 95%CI: 1.41, 4.26), coronary heart disease (HR: 2.25; 95%CI: 1.45, 3.49). Joint erosions were associated with reduced risk of valvular disease (HR 0.67, 95% CI 0.45, 0.99).  Rheumatoid nodules, joint surgery, elevated ESR in first year of diagnosis, DMARDs, and biologics were not associated with risk of valve disease. Risk factors for at least moderate valve disease included atrial fibrillation and stroke as well as severe extra-articular manifestations (HR 4.22; 95%CI: 1.64, 10.86).

Conclusion: Although VHD has not been considered to be a major cardiac manifestation of RA, our current study has revealed a higher than anticipated incidence of asymptomatic valvular involvement. MR and TR incidence is more common than any other valve diseases.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/occurrence-of-valvular-heart-disease-in-rheumatoid-arthritis-a-population-based-study/