Recognition of all diastolic HF in RA requires a complex diagnostic approach. Active rather than inactive RA places patients at a higher risk for HF, whereas influence of RA treatment on HF risk needs to be elucidated in further studies.

Background Increased prevalence of chronic heart failure is observed in patients with rheumatoid arthritis (RA) and heart failure with normal ejection fraction (HFNEF) is the predominant type. Although traditional cardiovascular risk factors are overrepresented in RA patients, they alone do not sufficiently explain higher morbidity. Chronic inflammation is a suspected contributor to myocardial dysfunction. Further data is necessary to elucidate the influence of persistent RA disease activity and RA treatment on HFNEF. Objectives To correlate clinical signs, laboratory findings and echocardiographic markers of heart failure in a well-characterized cohort of RA-patients with cardiovascular risk factors and comorbidity Methods Prospective cross-sectional study including all RA-patients consecutively treated in our community based outpatient-clinic in a 3 months period. Inclusion criteria were written consent and diagnosis of RA, fulfilling ACR/EULAR-criteria. All patients were interviewed using a standardized questionnaire. Clinical signs were evaluated based upon Framingham criteria. Laboratory tests included NT-proBNP. Echocardiography contained tissue doppler and global longitudinal strain (GLS) imaging. Results 162 patients with RA, n=110 (68%) female, mean (SD) age 61.3 (±13.1) years, mean disease duration 12.5 (±11.4) years, mean DAS28 2.8 (±1.0), mean FFbH 68 (±27)%, mean HAQ 1.3 (±0.9) were included. Rate of remission or low-disease-activity (DAS28 and lower remission rates in the biologic groups according to more severe disease state and longer disease duration. However, no significantly differences were found for HFNEF rates and cardiovascular comorbidity. Conclusions Traditional risk factors as well as RA-related factors are responsible for HFNEF in RA. RA-duration, persistent disease activity with DAS28>2.6, increased ESR as markers of chronic inflammation were shown to be significant and independent contributors. The reduced GLS in HFNEF patients supports a putative role of endomyocardial fibrosis as a link between inflammation and impaired myocardial function. Disclosure of Interest None Declared

Background Risk of heart failure (HF) is increased in patients with rheumatoid arthritis (RA) and the predominantly prevalent type is diastolic HF with normal ejection fraction (HFNEF). Traditional cardiovascular risk factors are overrepresented in RA but chronic inflammation is an independent significant contributor to myocardial dysfunction. However, there is great variance in reported prevalence of HF in RA due to differing diagnostic standards and HFNEF is apparently underestimated. Objectives To determine prevalence of heart failure in a community-based RA-cohort compared to age- and gender-matched controls using the 2008 European Society of Cardiology (ESC) diagnostic guidelines. Methods A prospective cross-sectional study including 157 consecutively recruited RA-patients from our outpatient clinic during a 3 months period. Inclusion criteria were written consent and diagnosis of RA fulfilling ACR/EULAR-criteria. Blinded to any health information an age- and gender-matched control group (n=77) was recruited from a district office and veterans of our hospital staff. Demographic and clinical data were obtained using standardized questionnaire and evaluation of Framingham criteria. Lab tests included NT-proBNP (Roche). Echocardiography of all subjects contained tissue doppler and strain imaging. Results The cohorts were comparable in gender distribution (67% vs. 69% females) and age (mean (SD) 61 years (±13) vs. 59 (±12). RA median DAS28 was 2.8 (Interquartile range (IQR) 2.0-3.4), median HAQ 1.1 (IQR 0.8-2.0) with remission (DAS28<2.6) in 45%, mild disease activity (DAS28 2.6-3.2) in 25% and higher disease activity (DAS28>3.2) in 30%. Prevalence of HF was significantly higher in RA vs. controls (38 (24%) vs. 5 (6%), p<0.001). Of all diagnosed HF, only 2 RA patients showed reduced ejection fraction. Significantly more RA patients reported on dyspnea on exertion (DOE, 66 (44%) vs. 14 (19%), p<0.001). RA patients showed significantly higher mean BMI 29 (±5) vs. 27 (±4), p<0.001 and higher prevalence of hypertension (59% vs. 40%, p=0.019). No significant differences were found for diabetes type 2 (13% vs. 8%), chronic kidney disease (GFR<60ml/min; 15% vs. 6%) and coronary artery disease (8% vs. 3%). Analyzing age decades, HF was found 10 years earlier and always more often in RA patients. Subgroup analysis revealed highest prevalence of HF in higher disease activity (37%, RR 5.7, p<0.001 compared to controls), 30% during mild disease activity (RR 4.6, p=0.0015) and 13% during remission (RR 1.95, p=0.264). In multivariate analysis adjusted for age and gender, remaining risk factors for HF in RA were DAS28≥2.6 (OR 3.4, 95%CI 1.3-9.8), RA-duration>10years (OR 2.6, 95%CI 1.2-5.8), CRP median>10mg/l (OR 4.8, 95%CI 1.1-21), and ESR>16mm/h (OR 5.4, 95%CI 2.1-16). Conclusions According to ESC guidelines, HF was found elevated 4-6fold in active RA and 2fold increased still in states of controlled disease. Heart failure with normal ejection fraction i.e. of diastolic type is found in as many as a quarter of all RA...

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Background Patients with rheumatoid arthritis (RA) share an increased risk of diastolic heart failure with normal ejection fraction (HFNEF), which is often underrecognized. Age, female gender and history of hypertension are important risk factors. Also, persistant disease activity and disease duration have been shown to be significant contributors. Therefore, effective screening for heart failure should be part of follow-up evaluation in RA-patients. However, not all patients with HFNEF are symptomatic. In contrast, RA-related fatigue and functional impairment may influence symptoms of heart failure and interfere with exercise testing. Objectives To determine diagnostic value of symptoms, laboratory results, and technical findings for classification of HFNEF in RA-patients. Methods We analyzed data of our prospective heart failure study of consecutively recruited RA-patients showing up in our community based outpatient-clinic. All patients were interviewed using a standardized questionnaire. Clinical signs were evaluated based upon Framingham criteria. Laboratory tests included NT-proBNP. Echocardiography contained tissue doppler and global longitudinal strain (GLS) imaging. Results 162 pat., n=110 (68%) female, mean (SD) age 61.3 (±13.1) years, mean disease duration 12.5 (±11.4) years, mean DAS28 2.8 (±1.0) were enrolled. Appropriate echocardiographic data was available in 155 pat. LVEF<50% was found in 6 pat. (3.7%), 3 (2%) pat. had additional symptoms of NYHA class>1 and were classified having systolic heart failure. Of the remaining 149 pat. with normal EF, 62 (41,6%) had symptoms of NYHA-class>1, and HFNEF according to ESC criteria was finally classified in 31 (21%) pat. In the group with normal EF, hypertension was found in 83 (56%), diabetes in 21 (14%), GFR<60 ml/min in 22 (15%), PAOD in 14 (9%), CAD in 25 (17%), prior MI in 8 (5%), stroke/TIA in 3 (2%) pat. Table 1. Diagnostic value of symptoms and clinical findings for classification of HFNEF SensitivitySpecificityLR+95% CILR–95% CI Edema0,680,672,051.44–2.920,480.28–0.82 Dyspnea NYHA-class >10,940,723,342.47–4.530,090.02–0.34 Dyspnea NYHA-class >20,650,864,762.81–8.040,410.25–0.66 Dyspnea NYHA-class >30,061,000,940.84–1.02 Orthopnea0,320,956,342.50–160,710.56–0.91 Nocturia >10,610,792,891.85–4.520,490.31–0.77 Nocturia >20,350,924,652.12–100,700.54–0.91 Abnormal Auscultation0,160,911,730.64–4.610,920.78–1.09 S3 Gallop0,060,951,300.27–5.981,000.89–1.09 NT-proBNP >222 pg/ml1,000,867,384.53–110,000.00–0.28 Abnormal ECG0,610,692,011.36–2.970,560.35–0.88 Abnormal Chest X-Ray0,550,812,821.72–4.610,560.38–0.84 Cardio Thoracic Ratio>.550,520,812,781.66–4.650,590.41–0.86 Concentric Hypertrophy0,450,792,201.30–3.730,690.49–0.96 Reduced GLS >–180,540,812,881.72–4.840,570.38–0.86 Diastolic Dysfunction 1°0,290,791,370.71–2.630,900.71–1.15 Diastolic Dysfunction 2°0,480,691,540.89–2.420,750.52–1.08 Diastolic Dysfunction 3°0,130,987,611.46–400,890.77–1.02 Conclusions When screening RA-patients, peripheral edema, dyspnea on exertion, nocturia, increased NTproBNP, ...