What is Cardio-Rheumatology?

Podcast Transcript

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Paul Cremer, MD:

I'm Paul Cremer. I'm a cardiovascular imager here at the Cleveland Clinic. Today, it's my pleasure to be speaking with Dr. Heba Wassif, who's the head of our Cardio-Rheumatology and Immunology Center.

Paul Cremer, MD:

So, Heba, I think this is a great center in part because it encompasses so many different types of patients, and the underlying commonality is the role of inflammation in their disease. It may be a patient who has a systemic autoimmune disease with cardiac involvement or it may be a patient who has an abnormal immune system with primary involvement of the cardiac or vascular system. But maybe speak a little bit to the types of patients who can be seen at the Center for Cardio-Rheumatology and Immunology.

Heba Wassif, MD, MPH:

Well, thank you, Paul, for the introduction. A lot of patients ... I mean it's a broad spectrum of patients that can be seen in the center, patients with any underlying rheumatologic disorder. Again, the wording is variable, whether you use the word connective tissue disorder, autoimmune connective tissue disorder or rheumatologic disorder. But it's primarily patients who have underlying autoimmune disease and rheumatoid arthritis, lupus erythematosus, dermatomyositis, ankylosing spondylitis, and psoriatic arthritis. Of course from the immunologic side, we're talking about the patients with sarcoidosis.

Heba Wassif, MD, MPH:

So that is just a sample of patients that can be seen in the Cardio-Rheumatology Center. Whether they're seen for prevention, that they're trying to assess their risk for cardiovascular disease, because we know patients have heightened risk for cardiovascular events with any of these disorders, or they're under treatment for another condition, whether it's a valve disorder or if it's myocardial disorder, if it's a pericardial disorder. So it's a variety of conditions for this specific population of patients.

Paul Cremer, MD:

That's great. And so, yeah, it really covers a lot of patients who have inflammation, systemically or primarily involving the heart. But just to hone in on a couple of examples, I guess, just say if you're seeing a patient with lupus, what kind of things come to mind in terms of cardiac involvement and what kind of testing may that patient need if they come to see you in the Clinic?

Heba Wassif, MD, MPH:

So lupus patients are obviously ... They're at a very high risk for coronary artery disease. Their risk is, in some studies, up to 19 folds. I'm not trying to scare patients, but it's somewhere between a two to 19-fold increase in cardiovascular risk compared to other populations that don't have lupus.

Heba Wassif, MD, MPH:

So I probably would screen them for atherosclerosis, maybe by a coronary calcium score or stress test, depending on if they're having symptoms or if they're not having symptoms. But certainly, maybe a coronary calcium score trying to assess their risk.

Heba Wassif, MD, MPH:

I'll probably get an echo looking at their valves, particularly that these patients also have a higher prevalence of valvular disorder. It also depends on what symptoms they're having, but those would be my two basic tests to do for our lupus patients as I'm seeing them in Clinic for the first time.

Paul Cremer, MD:

Okay. So they're at increased risk for atherosclerosis, for cholesterol buildup in the coronary arteries, and also at increased risk of valve problems. What kind of valve problems do you see in these types of patients?

Heba Wassif, MD, MPH:

So the leaky valves. They're more likely to develop leaky valves than to develop tight valves. They're also more likely to develop what we call marantic endocarditis, which is a form of a vegetation or a thickening of their valves, which is related to inflammation.

Paul Cremer, MD:

Okay. Then, of course, if the patient is having symptoms, there'll be more directed testing-

Heba Wassif, MD, MPH:

Absolutely.

Paul Cremer, MD:

... based upon that, be it a stress test. But that would, of course, warrant further evaluation. How often do these patients need to be seen? You talked about the risk. Maybe speak to the ... Is there a longitudinal follow-up that's really necessary here for optimal care of the patient?

Heba Wassif, MD, MPH:

It depends on which kind of problem we're dealing with the patient. So if it's just for screening and cardiovascular risk, they probably will need to be seen on annual basis. It depends if they have a valvular condition, depending on the extent of the valve disease, whether it's seen on an annual basis or spaced out further, depending on the severity of the valvular disease. If they're being managed for heart failure, they may be seen more frequently than that.

Heba Wassif, MD, MPH:

So the frequency depends on what they're being seen for. But I do think that there has to be some longitudinal care with a cardiologist for patients with rheumatologic disorders.

Paul Cremer, MD:

Right. I think an important part of having expertise here related to the longitudinal care is really the collaboration across subspecialties. We have used cardio-oncology as our model where we have specialists who really understand the therapeutics and their complications. And so, maybe speak a little bit to ... in cardio-rheumatology, understanding how the drugs work, the benefits, the side effects and, yeah, really collaborating with the patients' rheumatologists, be it here or locally, and their local physicians to provide optimal care in these complex patients.

Heba Wassif, MD, MPH:

As you know, I mean the drugs are changing at a very rapid speed. There are more drugs that are coming on the market for the treatment of inflammation than we can even keep track of. Most of the drug management is with the rheumatologist that's caring for the patient, but there are some cardiovascular side effects for some of the drugs where that's where we play an important role in trying to manage some of these side effects.

Heba Wassif, MD, MPH:

But also, interestingly, some of the drugs also have some beneficial effects for reducing cardiovascular risk. We may have talked before about methotrexate, which is a drug that is a very old drug, not even a newer drug, that has been used in patients to decrease inflammation and has shown effective in many studies that it does reduce the risk of cardiovascular events. Whether that should be prescribed by a cardiologist or not, I don't think that's what we're talking about here.

Paul Cremer, MD:

Right. But I guess one thing that does come to mind in terms of cardiovascular medications is really understanding ... In some of these patients who are prone to getting blood clots, knowing what kind of blood thinners they should be on and at what levels. We certainly have seen that overlooked or perhaps the wrong medication prescribed for some of these patients, not understanding really how some of these patients can clot so much and really have difficulties with them.

Heba Wassif, MD, MPH:

You're referring, obviously, to patients with lupus anticoagulant. These are patients that have a higher risk of clotting and management. We certainly would be more than available to understand how to handle their anticoagulation.

Paul Cremer, MD:

I think that is also a very important point and ties into when these patients get valve disease. As you said, I think the follow-up there really depends on, one, how bad is the valve and, two, how bad are the symptoms. When it does come time to needing valvular intervention-

Heba Wassif, MD, MPH:

What do you do?

Paul Cremer, MD:

... what do you do? You really need that expertise and, again, the team-based approach with a surgical team to make sure you're having the best outcome for the patient.

Heba Wassif, MD, MPH:

Then the follow-up after they've had their valves, and we were talking about how closely do they need follow-up, where it depends also if you're starting to see that the valve is not looking as good as you think, then you would need closer follow up. So it won't be once a year. It may be even every six months depending on what the situation is. So the choice of the valve, and then the follow up after the valve replacement.

Paul Cremer, MD:

Absolutely. As you talked about at the beginning, the underlying diagnoses for these patients are so broad. So I was just thinking of the patients who present for surgical valve disease. There are also the patients who have an aortitis or a vasculitis, which is, again, being primarily the immunosuppressive therapy being managed by the rheumatologist, but often need experts-

Heba Wassif, MD, MPH:

To inform.

Paul Cremer, MD:

... to inform the appropriate timing of intervention for aortic surgery as well.

Heba Wassif, MD, MPH:

Then understanding the outcomes after their surgery and how the impact of these therapies are on the outcomes of the surgery later on. That's an area that's not all fully understood. I mean there are very few studies that have looked at outcomes of patients, but there are more and more coming out.

Heba Wassif, MD, MPH:

We actually have looked at ... Not on aortitis, but just valve replacement in patients with connective tissue disorders. In our study, at least, which was looking at the national dataset, there was no difference in outcomes, which was a bit of a surprise knowing that these patients are immune-suppressed. But that's where knowledge is power, and we need to understand more what's happening with these patients and what their outcomes are.

Paul Cremer, MD:

Yeah, certainly more research is needed. But it also just speaks to the lifelong care for these patients, that it really shouldn't be, oh, you've had your intervention. Now you can just be followed like any other patient. You really need to specifically understand-

Heba Wassif, MD, MPH:

Absolutely.

Paul Cremer, MD:

... their underlying conditions and the specific risk they may have.

Heba Wassif, MD, MPH:

It's a lifelong risk as long as they continue to have active inflammation.

Paul Cremer, MD:

Absolutely. So I think I'll switch gears a little bit. We've been focusing on the patients with systemic autoimmune disease or systemic autoinflammatory disease involving the heart to patients where the heart or the vascular system may be the primary problem. Obviously, there's a lot of overlap here. I mean we've been talking about, in terms of the valvular disease, the lupus patients, and certainly some of our worst patients with pericarditis. So that is, who get inflammation of the lining around the heart, our patients who have lupus.

Paul Cremer, MD:

But most of the patients with pericarditis don't have an underlying systemic autoimmune disease. However, we're beginning to think more and more that they do have an autoinflammatory disease. Some of the drugs that had been used decades ago for rheumatoid arthritis have proved to be game-changers for us for pericarditis.

Heba Wassif, MD, MPH:

Which is a game-changer, because we used to say that most of these are viral, or related to viral, pericarditis. That's a very change of paradigm for how we think about patients.

Paul Cremer, MD:

Right. Then I think that there may have been an initial viral insult, but in terms of the recurrence of the attacks, it's clearly driven by an abnormal autoinflammatory response. So the body's innate immune system attacks itself.

Paul Cremer, MD:

Similar to what's been done in rheumatology for a long time, is really looking for steroid-sparing therapies. So I think in pericarditis, we now have that with the interleukin-1 antagonist. So for patients who have recurrences of inflammation of the lining around the heart, we now have therapies that are highly effective.

Paul Cremer, MD:

There's also certain patients who have inflammation of the heart muscle. So some of those will have an underlying autoimmune disease, some of them won't, and we're still learning a lot about the best treatment and follow-up for those patients as well.

Heba Wassif, MD, MPH:

It certainly is an evolving field.

Paul Cremer, MD:

Evolving field and really relates to all aspects of cardiovascular medicine, even bread and butter coronary atherosclerosis, which we thought we've understood very well. There's clearly patients who have inappropriate innate immune responses with coronary artery disease as well. In the future, we may have treatments that specifically target the immune system for those patients also.

Heba Wassif, MD, MPH:

Absolutely. It's been tried previously in coronary artery disease, and there was an impact. But it's always about the risk of infection as well with these medications.

Paul Cremer, MD:

Right. Right. I think with some of the newer therapies, we're figuring that out. But the risk of infection seems to be quite low. Just to conclude, I think that this is really a new frontier for us as cardiologists. Frankly, I think we've been behind some other subspecialties in medicine in terms of just appreciating the role of the immune system in cardiovascular disease.

Heba Wassif, MD, MPH:

I 100% agree with you. This is an evolving field and we are learning a lot.

Paul Cremer, MD:

Excellent. So certainly more to come. Thanks for taking the time to speak with us today.

Heba Wassif, MD, MPH:

Thank you so much.

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