The Relationship Between Rheumatoid Arthritis and Heart Failure

RHEUMATOID ARTHRITIS IS AN AUTOIMMUNE disease that affects 1.3 million adults in the United States.1 Of these, about 75 percent are women. Disease onset generally occurs between 30 and 50 years of age. Disease hallmarks are synovial infl ammation, progressive bone erosion, joint mal-alignment and destruction, and subsequent weakness of surrounding tissues and muscles. Systemic manifestations also occur. Presentations range from mild to severe, although the typical patient has a progressive course leading to functional limitations. Therapies commonly used include anti-infl ammatory agents [corticosteroids and nonsteroidal antiinfl ammatory agents (NSAIDs)], nonbiologic disease-modifying antirheumatic drugs (DMARDs) [hydroxychloroquine, lefl unomide, methotrexate, and sulfasalazine], and biologic DMARDs [abatacept, adalimumab, anakinra, etanercept, infl iximab, and rituximab] (Exhibit 1). The biologic DMARDS are also known as biologic response modifi ers. The DMARDs are used to inhibit or halt the underlying immune process and prevent long-term damage. The era of biologic response modifi ers revolutionized treatment of RA by directly targeting specifi c underlying immune system abnormalities. Tumor necrosis factor alpha (TNF-alpha) is one of the most important cytokines involved in the cascade of infl ammatory reactions in RA. TNF-alpha inhibitors (TNFIs) bind to TNF-alpha, rendering it inactive, and interfering with infl ammatory activity, ultimately decreasing joint damage. Etanercept (Enbrel), the fi rst TNFI, was FDA-approved in late 1998. Infl iximab (Remicade) followed in 1999 and Adalimumab (Humira) in 2002. Anakinra (Kineret) is a selective blocker of interleukin one (IL-1), an infl ammatory protein found in excess in rheumatoid arthritis patients. By blocking IL-1, anakinra inhibits infl ammation and pain associated with rheumatoid arthritis. It appears to be less effective compared with the TNFIs and is used in less than fi ve percent of patients. Abatacept (Orencia®) is the fi rst T-cell co-stimulation modulator approved for The Relationship Between Rheumatoid Arthritis and Heart Failure