Cardio Rheumatology Center

Podcast Transcript

Announcer:

Welcome to Cleveland Clinic Cardiac Consult, brought to you by the Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute at Cleveland Clinic.

Paul Cremer, MD:

Hi, I'm Dr. Paul Cremer. I'm a cardiovascular imager here at the Cleveland Clinic, and it's my pleasure to be here today with Dr. Heba Wassif, who will be the director, is the director, of our Center for Cardio-rheumatology and Immunology. And Heba, I really like this idea, this need that's clearly there for the patients, and specifically how it kind of relates to a couple of domains. The cardio-rheumatology patients, who have a systemic autoimmune disease that's involving the heart, or the vascular structures, and also the cardio immunology patients, who may have a primary cardiac problem, but is also related to immune dysregulation. So maybe tell me a little bit about your thoughts in terms of cardiovascular disease, complications, in patients who have an underlying systemic autoimmune disease, or rheumatologic diseases.

Heba Wassif, MD, MPH:

Thank you, Paul. Thank you very much for giving me the opportunity to talk about cardio-rheumatology, which is an evolving field. I mean, we've known about some of the aspects of cardio-rheumatology, have been known for a while, but it still remains ... there are many manifestations of rheumatologic disorder and cardiovascular disease. It ranges from coronary artery disease to valve disease, to pericardial disease, to heart failure. And what is not recognized is this increased cardiovascular risk in this population, and we're talking about them more as a unified population, but at the same time they're not a unified population. Each group of patients, whether you talk about their rheumatoid arthritis, lupus, erythematosis, ankylosing spondylitis, dermatomyositis. Each is a unique disorder, with unique treatments, which we, as a group, don't quite understand the whole ramifications and the manifestations, and their outcomes over a long period of time.

Heba Wassif, MD, MPH:

What we do know very well is that patients with connective tissue disorders or autoimmune disorders have a heightened risk for cardiovascular disease. The risk for patients with rheumatoid arthritis is, compared to the general population, is 50% more, or what you would say the older risk for lupus, it's even higher, almost threefold, some studies have said up to 19 folds. Same similar story with ankylosing spondylitis. So, what is kind of very interesting is that this information that we think is common knowledge, it's not. And neither for the patients nor for the providers. And when there was a survey that was published a few years ago, and they tried to understand do patients actually understand their risk, and 70-90% of them did not, were not aware that there was a correlation between their connective tissue disorder or rheumatologic disorder and the coronary artery disease.

Heba Wassif, MD, MPH:

And when physicians were asked, and these are general practitioners, were asked about the relation between cardiovascular disease and rheumatic disorders, less than 40% were aware of that risk, and 15% of them were able to initiate a conversation and actually refer a patient. So, there is a lot of educational gap that's out there.

Paul Cremer, MD:

And you highlighted the increased cardiovascular risk with rheumatoid arthritis being essentially double, and even higher for diseases like lupus. Is this all coronary artery disease? Or maybe touch a little bit upon other cardiovascular issues that you tend to see and think of in these patients that also may get underdiagnosed and undertreated.

Heba Wassif, MD, MPH:

Absolutely. So, it affects the valves. It affects the myocardium. It affects the pericardium. And I will have you talk a little bit about that later on. With the valve, there is some prevalence of valvular disease, particularly in the lupus patients, where they have mostly regurgitant disorders, a higher prevalence of mitral regurgitation and aortic regurgitation compared to non-lupus patients. In rheumatoid arthritis, it's not all that clear on how significant it is. It's still not very clear because most of the studies are very small. So, you will find numbers from 30% to 90%, which in my mind doesn't mean a whole lot. It just means we don't know because the numbers are very small of these cohorts.

Heba Wassif, MD, MPH:

But, it also involves ... this inflammation affects the myocardium, and patients both with rheumatoid and lupus have a higher incidence compared to the non-lupus and non-rheumatoid arthritis patients, of heart failure. And this is a correlation that is under-recognized.

Paul Cremer, MD:

Excellent. Yeah, so it's certainly the coronary atherosclerosis is there as a risk, but also, as you touched upon, the valvulitis with lupus. And I would say, as our demographics have shifted in terms of the patients we see with valvulitis, it's tending to be less rheumatic heart disease, and actually more valvulitis from lupus that we're seeing in our practices. And then you also touched upon the myopathies that we see in these patients as well.

Heba Wassif, MD, MPH:

Exactly. And then of course there's marantic endocarditis, which is very unique to lupus, which is a very difficult condition to manage, and these patients would require valve replacements and later follow-up. And again, their outcomes are still unclear due to how often do they need repeat surgery or so forth. So, there's again another education gap.

Paul Cremer, MD:

Yeah, and I agree, and it's a good point you brought up about the patients with marantic endocarditis. They're often very difficult to manage, and difficult decision-making that really needs to be in a team-based approach because they are at such often such thrombotic risk.

Heba Wassif, MD, MPH:

Absolutely.

Paul Cremer, MD:

These are patients who've had thrombotic complications before and are at risk for having them in the future. So, you have to be very careful in terms of choice of valve selection, how you manage their anticoagulation, and how you think of them really in the decades to come.

Heba Wassif, MD, MPH:

Exactly, and these are usually a lot younger patients, and it's very difficult in terms of valve choice, as you said. What do you do with these patients?

Paul Cremer, MD:

Excellent. And maybe touch a little bit upon ... now, there are so many new drugs in rheumatology, and it's hard for us, as cardiologists, to kind of keep track of it all. And it's similar to cardio-oncology, where you really need experts who understand the therapies and understand the side effects of the therapies, and potentially any cardiovascular complications. Any thoughts on that?

Heba Wassif, MD, MPH:

I think that that's one of the main reasons why developing these very specialized domains within cardiology is important. You touched upon the cardio-oncology and how developing expertise in that had improved patient care, and I also think that developing specialized care in cardio-rheumatology will also improve care because of the evolving field from the rheumatologic standpoint. But surprisingly, an older drug, like methotrexate, that drug that has been around for decades, has been the drug that has been associated with reducing cardiovascular risk in many of these patients, whereas it had no impact in patients who have cardiovascular disease but don't have rheumatologic disorders.

Paul Cremer, MD:

Right.

Heba Wassif, MD, MPH:

So, I find this dichotomy very fascinating, so to say. But again, what these drugs do to inflammation is suppressing inflammation, is probably what improves their cardiovascular outcome. Because, as we all know, how the impact of inflammation is on cardiovascular disease, and with these drugs, how effective they are in suppressing the inflammation, they will alter cardiovascular outcomes.

Paul Cremer, MD:

Excellent. And I think you touched upon an important point, which we also mentioned earlier, is just the importance of team based care for these patients. Co-management with the rheumatologist, understanding the therapies, understanding their efficacy and their side effects as well, and the necessary long-term and lifetime management of often people who have very debilitating disease.

Heba Wassif, MD, MPH:

Absolutely. So now I throw it back to you. Tell us a little bit more about what you do with the pericardial patients.

Paul Cremer, MD:

Yeah, so I mean I think when we think about the immune system in cardiovascular disease, we have what we were just talking about, which is people who have a systemic autoimmune disease and get cardiovascular involvement. The lupus patients, which you mentioned, I have to say some of our most challenging lupus patients are the lupus pericarditis patients. And that is where you have to work really closely with a rheumatologist and follow these patients really vigilantly to try and control their pericarditis symptoms, which are often debilitating.

Paul Cremer, MD:

But then there's often patients who have immune dysregulation, but it's primarily involving the heart, so that can be patients with what we've called idiopathic pericarditis, which we now think of as auto-inflammatory pericarditis, and we have a lot of new therapies for these patients. The interleukin-1 antagonist in particular have been a game-changer, and have really allowed us to get patients off of chronic steroids. And this is similar to what the rheumatologists have done for decades now, is really look for steroid-sparing therapies. So, recurrent or chronic pericarditis, where patients are steroid-dependent, now we really have good therapies to get patients off of the steroids and the long-term adverse events associated with that.

Paul Cremer, MD:

But beyond the pericardium, you talked about myopathies as well. There's inflammatory cardiomyopathies. I mean, there's a lot that we're still learning about the management of sarcoid patients. Again, early steroid-sparing therapies, and how to manage those patients based on serial imaging evaluations. But, there's also patients, and this is maybe getting more into the cardio-rheumatology space, who have aortitis. So, who have giant cell arteritis, who are on chronic therapy. And then finally, there's some patients with coronary atherosclerosis, who don't have an autoimmune disease, but clearly the inflammation is contributing to that, and we're involved in studies looking at targeting the innate immune system to improve outcomes in patients with coronary disease and acute coronary syndromes.

Paul Cremer, MD:

So yeah, I think that cardio-rheumatology and immunology really affects all aspects of the cardiovascular system, and I think this is really unmet and underdeveloped need for our patients.

Heba Wassif, MD, MPH:

I 100% agree with you, and I think developing a specialized group of cardiologists that are involved in care of these patients will also lead to improvement in their care and understanding their outcomes.

Paul Cremer, MD:

Absolutely. Well again, thanks so much for taking the time, and letting us know a little bit more about this center, and really the range of diagnoses and patients that can be seen here.

Heba Wassif, MD, MPH:

Thank you.

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