The heart in rheumatoid arthritis
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# Overview
The cardiac complications in rheumatoid arthritis are usually due to involvement by rheumatoid nodule, inflammatory mediators and antirheumatic drugs.  There is increased risk of coronary atherosclerosis and thereby increasing the risk of heart failure and atrial fibrillation.  Other possible complications include pericarditis, myocarditis and conduction defects. Cardiac disease with rheumatoid arthritis can be related to granulomatous proliferation, inflammatory mediators, and antirheumatic drugs . Echocardiography is helpful in diagnosing pericarditis, ejection fraction and endocardial inflammation. Other useful tests are ECG, CBC, ESR, CRP, and troponins. Treatment of underlying cause is important. Treatment of pericarditis include NSAIDs and glucocorticoids. Treatment of myocarditis is methylprednisolone pulse therapy. Pacemakers are used for conduction defects.

# Cardiac complications of rheumatoid arthritis
The cardiac complications in rheumatoid arthritis are usually due to involvement by rheumatoid nodule, inflammatory mediators and antirheumatic drugs.  There is increased risk of coronary atherosclerosis and thereby increasing the risk of heart failure and atrial fibrillation. Various cardiac complications include:
Coronary artery disease
There is increased risk of coronary artery disease in rheumatoid arthritis. It could be due to chronic inflammation caused by cytokines, lymphocytes, macrophages, and dendritic cells. Other factors responsible are coagulation abnormalities, immune complexes, and oxidative stress.
Heart failure
The risk of heart failure is relatively more common in patient with coronary artery disease in rheumatoid arthritis. This is caused by left ventricular dysfunction, inflammatory mediators, and antirheumatic drugs.
Atrial fibrillation
The risk of atrial fibrillation is common in patients with heart failure and coronary artery disease in rheumatoid arthritis.
Aortic insufficiency
RA rarely causes symptomatic AR, but can as a result of granulomatous nodules that may form on the aortic leaflets.
Pericarditis
Pericarditis is common in active rheumatoid arthritis. Symptomatic patients have RA factor positive.
Myocarditis
Myocarditis can take the form of either a granulomatous disease or interstitial myocarditis.
Nodules
Rheumatoid nodules are formed in the different parts of the heart such pericardium, myocardium, and valvular structures. Nodules can lead to different kind of symptoms depending upon the location of nodules such as syncope and conduction defects.

# Diagnosis of cardiac disease in rheumatoid arthritis
Various abnormal laboratory tests are discussed below:
- CBC
Low hemoglobin
Low hematocrit
- Low hemoglobin
- Low hematocrit
- Troponins-I or Troponins-T are usually raised in the patient with MI
- ESR and CRP are raised
- RA factor is positive
ECG
ECG  changes in MI are ST segment changes. In pericarditis, there is diffuse ST-segment elevation and PR segment depression. In the conductions defects such complete heart block, it shows AV dissociation.
Echocardiography
Echocardiography is useful in measuring in ejection fraction in heart failure and to diagnose pericarditis and myocarditis.

# Management of various cardiac disease in rheumatic arthritis
Treatment of pericarditis:
- NSAIDs are best initial therapy.
- Glucocorticoids are added if NSAIDs are not effective.
- Preferred regimen: Prednisone 1 mg/kg PO 24qh.
Treatment of myocarditis:
- Preferred regimen: Methylprednisolone pulse therapy 500 to 1000 mg PO 24qh for 3 days.
Treatment of conductions defects:
- The pacemaker is preferred the choice of treatment.