Accelerated Diastolic Dysfunction in Premenopausal Women With Rheumatoid Arthritis

Gee Hee Kim; Yune-Jung Park


Arthritis Res Ther. 2021;23(247) 

In This Article

Abstract and Introduction


Background: Disturbances of diastolic function precede systolic heart failure and, although clinically silent, represent the earliest sign of cardiac involvement. Diastolic dysfunction (DD) is associated with age, gender (female), and hypertension. However, little is known about the age-specific incidence rates and risk factors for DD in patients with rheumatoid arthritis (RA).

Methods: We used standard two-dimensional/Doppler echocardiography to screen for the presence of diastolic dysfunction in 61 patients with RA and 107 healthy subjects. All participants were premenopausal women with no history of hypertension. DD includes an impaired relaxation with or without increased left ventricular (LV) filling pressures, pseudonormal filling, and restrictive filling based on parameters measured using echocardiography.

Results: The two groups were similar with respect to age (P=0.269). Patients with RA had significantly higher LV mass index, LV filling pressure, and lower E/A velocity than controls. All patients had preserved ejection fraction (EF ≥50%). DD was more common in patients with RA at 47% compared to 26% in the controls (P=0.004). Women with RA in the 30- to 49-year age range were over 3.5 times more likely to have DD than those of similar age in the control group (OR=3.54; 95% CI 1.27 to 9.85). Among patients with RA, high CRP levels were independently associated with DD even after adjustment for cardiovascular risk factors (P=0.009).

Conclusions: In premenopausal women with RA, DD is much more common and the age of onset is reduced. Early screening of myocardial function may provide an opportunity for preventing future cardiovascular disease.


As compared to the general population, patients with rheumatoid arthritis (RA) experience a higher incidence of heart failure (HF).[1] HF is a major risk factor for mortality in RA and is associated with cardiovascular deaths in patients with RA.[2] Various studies have shown that subclinical left ventricular (LV) diastolic dysfunction predicts future development of clinical HF.[3,4]

Diastolic dysfunction refers to abnormal mechanical properties of the myocardium and includes impaired LV diastolic distensibility, abnormal filling, and slow or delayed relaxation.[5] According to a recent systematic review, diastolic dysfunction affects approximately 36% of the population older than 60 years[6] and is closely associated with several cardiovascular risk factors, including hypertension, obesity, and diabetes.[7,8] In the Olmsted County Heart Function Study (a population-based cohort), 4 years of follow-up revealed that LV diastolic dysfunction is highly prevalent, tends to worsen over time, and is associated with advancing age and development of HF during 6 years of subsequent follow-up.[9]

Previous reports have demonstrated that the prevalence of diastolic dysfunction is increased in patients with RA.[10] Although inflammation such as tumor necrosis factor-alpha (TNF-α) and interleukin-6 (IL-6) levels, cardiotoxic medication, and RA disease itself have been thought to be the risk factors for the development of diastolic impairment, the precise mechanisms involved in increased cardiovascular disease (CVD) risk are various and remain elusive.[11] Moreover, few studies have been conducted specifically investigating age, which is one of the strongest risk factors. In this study, we investigate age-related prevalence and risk factors of diastolic dysfunction in RA patients.