Chapter 47
Cardiovascular Manifestations of Connective Tissue Disorders and the Vasculitides
1. What is the leading cause of death in rheumatoid arthritis (RA) and what are the most common cardiac manifestations of RA?
2. What are the cardiovascular manifestations of systemic lupus erythematosus (SLE)?
3. What are the cardiovascular consequences of NSAIDs with predominantly cyclooxygenase-2 (COX-2) inhibition?
4. What is the major cardiovascular concern associated with tumor necrosis factor (TNF)-α antagonists?
5. What are the clinical manifestations of antiphospholipid antibody syndrome?
Antiphospholipid antibodies (APLAs) promote intravascular clotting and can be found in primary APLA syndrome or secondary to other conditions, most commonly SLE. Clinical manifestations of APLA syndrome include spontaneous venous and arterial thromboses, strokes and neurologic syndromes, digital and extremity ischemia, livedo reticularis, thrombocytopenia, and recurrent spontaneous abortions. From a cardiac standpoint, acute coronary thromboses and diffuse small-vessel clotting resulting in global myocardial dysfunction have been described. In addition, Libman-Sacks endocarditis, defined by sterile vegetations on the mitral > aortic/tricuspid > pulmonary valves, is thought to arise from organization of thrombi and can cause valvular regurgitation or stenosis requiring surgical correction. Treatment for APLA syndrome is warfarin (goal international normalized ratio [INR] of 2.0-3.0) +/− daily low-dose aspirin, +/− hydroxychloroquine. Drugs associated with drug-induced lupus are given in Table 47-1.
TABLE. 47-1
DRUGS ASSOCIATED WITH DRUG-INDUCED LUPUS
Drugs Definitively Known to Cause Drug-Induced Lupus | Cardiovascular Medications that Probably Cause Drug-Induced Lupus |
Procainamide Hydralazine Diltiazem TNF-α antagonists Minocycline Chlorpromazine Quinidine D-Penicillamine Isoniazid Methyldopa Interferon-α | β-Blockers Captopril Hydrochlorothiazide Amiodarone |
β-Blockers, Beta-adrenergic blocking agents; TNF, tumor necrosis factor.
6. Describe the characteristic myocardial lesions of scleroderma and systemic sclerosis and their clinical manifestations.