From the Guidelines
I would refer a patient with a history of autoimmune inflammatory disorders to cardiology because these conditions significantly increase cardiovascular risk, as evidenced by the 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA guideline for the management of patients with chronic coronary disease 1. Autoimmune disorders like rheumatoid arthritis, systemic lupus erythematosus, and psoriatic arthritis create chronic systemic inflammation that accelerates atherosclerosis and can damage heart structures directly. These patients have a higher risk of cardiovascular events compared to the general population, with some studies suggesting a 1.5-2 times increased risk 1. Additionally, medications commonly used to treat autoimmune conditions, such as corticosteroids (prednisone), certain DMARDs, and NSAIDs, may have cardiovascular side effects including fluid retention, hypertension, and increased thrombotic risk. A cardiology evaluation would typically include:
- A comprehensive cardiovascular risk assessment
- Baseline ECG
- Echocardiogram to assess cardiac structure and function
- Possibly stress testing or coronary calcium scoring depending on risk factors, as recommended by the American Heart Association 1. The cardiologist can help develop a tailored cardiovascular risk management plan that considers both the patient's autoimmune condition and their cardiac health, potentially including medications like statins, antihypertensives, or low-dose aspirin when appropriate, while avoiding treatments that might exacerbate their autoimmune condition. It is essential to prioritize adequate control of disease activity with steroid-sparing agents to lower cardiovascular risk, as suggested by the 2023 guideline 1. By referring the patient to cardiology, we can ensure that their cardiovascular risk is properly assessed and managed, ultimately improving their quality of life and reducing their risk of morbidity and mortality.
From the Research
Referral to Cardiology for Patients with Autoimmune Inflammatory Disorders
Referring a patient to cardiology if they have a history of autoimmune inflammatory disorders is crucial due to the increased risk of cardiovascular disease associated with these conditions. The key factors contributing to this risk include:
- Aberrant leukocyte function and pro-inflammatory cytokines, which result in vascular dysfunction, impaired resolution of inflammation, and promotion of chronic inflammation 2
- Loss of tolerance to self-antigens and the generation of autoantibodies, which are implicated in the maladaptive inflammatory response during atherosclerotic cardiovascular disease 2
- Traditional cardiovascular risk factors, such as dyslipidaemia and hypertension, which alone do not explain the increased risk of cardiovascular disease associated with autoimmune diseases, but contribute to the excess cardiovascular risk 3
- The development of a proatherogenic dyslipidemic state, characterized by dysfunctional HDLs and increased oxidation of LDLs, which is a common feature observed in many autoimmune inflammatory diseases 4
Increased Risk of Cardiovascular Disease
The increased risk of cardiovascular disease in patients with autoimmune inflammatory disorders is supported by various studies, including:
- A systematic review and meta-analysis, which found that the prevalence of hypertension and cardiovascular complications is higher among patients with inflammatory and autoimmune diseases than controls 5
- A study, which found that 19 autoimmune diseases are associated with a composite of cardiovascular disease, and that inflammation promotes atherosclerotic CVD 6
- Evidence, which suggests that patients with autoimmune inflammatory diseases, such as systemic lupus erythematosus, rheumatoid arthritis, and psoriasis, are at increased risk for cardiovascular disease 4
Management and Screening
Management and screening of cardiovascular risk factors, such as hypertension, are crucial in patients with autoimmune inflammatory disorders. This includes:
- Screening for hypertension and cardiovascular complications, which is of paramount importance in these patients 5
- Management of hypertension, which appears to be critical in reducing the risk of cardiovascular disease in patients with autoimmune inflammatory disorders 5
- Consideration of the complex and variable effects of disease-modifying antirheumatic drugs on lipids, which is critical when evaluating lipid-related risk in individuals with immune-mediated inflammatory conditions 4