Cardio-Rheumatology Clinics Guide Care for Unique Population

Clinical cardiologist Heba Wassif, MD, MPH, knows the value of working with her fellow rheumatologists, surgeons, and other clinicians to establish a care plan for her patients with cardiac conditions and autoimmune diseases.

She is the cofounder of the Cleveland Clinic's new cardio-rheumatology program, which places an emphasis on multidisciplinary care. In her role, Dr. Wassif closely follows her patients, and if she sees any inflammation or any other condition that requires the rheumatologist, she reaches out to her colleagues to adjust medications if needed.

Collaboration with a rheumatologist was important when a patient with valvular disease was prepping for surgery. The patient was on significant immunosuppressants and the surgery had to be timed appropriately, accounting for any decreases in her immunosuppression, explained Dr. Wassif, director of inpatient clinical cardiology at Cleveland Clinic in Ohio.

Cardio-rheumatology programs are "the newest child" in a series of cardiology offshoots focusing on different populations. Cardio-oncology and cardio-obstetrics took off about 6 years ago, with cardio-rheumatology clinics and interested physicians rising in number over the last several years, Dr. Wassif noted.

The relationship between cardiovascular diseases and rheumatologic conditions is certainly recognized more often, "which means more literature is being published to discuss the link," according to Rekha Mankad, MD, a trailblazer of this model of care. She directs the Women's Heart Clinic at Mayo Clinic in Rochester, Minn., which was one of the earliest adopters of a cardio-rheumatology clinic.

Ten years ago, "nobody was talking about the link between rheumatologic conditions and cardiovascular disease," Dr. Mankad said. "I've been asked to speak on this topic, and programs have asked me to speak about establishing cardio-rheumatology practices. So, there's been an evolution as far as a recognition that these two conditions overlap."

Patients have come to her independent of internal referrals, which means they have done Google searches on cardiology and rheumatology. "I think that it has made a splash, at least in the world of cardiology," Dr. Mankad observed in an interview.

Other institutions such as NYU-Langone, Yale, Stanford, Brigham and Women's Hospital in Boston, and Women's College Hospital in Toronto have formed similar clinics whose focus is to address the specific needs of rheumatology patients with cardiac conditions through a teamwork approach.

Challenges of treating cardiac, rheumatologic conditions

The rise in clinics addresses the longstanding connection between autoimmune disorders and cardiac conditions.

Cardiologists have known that there is an element of inflammation that contributes to atherosclerosis, said Dr. Wassif, who has researched this topic extensively. A recent study she led found a strong association between rheumatic immune-mediated inflammatory diseases (IMIDs) and high risk of acute coronary syndrome in Medicare patients.

"This particular population has a very clear increased risk for cardiovascular conditions, including valve disease and heart failure," she emphasized.

Patients with rheumatoid arthritis and lupus have up to a twofold and eightfold higher risk of heart disease, respectively, noted Michael S. Garshick, MD, a cardiovascular disease specialist who directs the cardio-rheumatology program at NYU-Langone Health, in New York. Cardiologists "have really developed an understanding that the immune system can impact the heart, and that there's a need for people to understand the nuance behind how the immune system can affect them and what to do about it," Dr. Garshick said.

Caring for patients with both afflictions comes with specific challenges. Many physicians are not well trained on managing and treating patients with these dual conditions.

The "lipid paradox," in which lipids are reduced with active inflammation in some rheumatologic conditions, can make treatment more nuanced. In addition, the traditional ASCVD (atherosclerotic cardiovascular disease) score often underestimates the cardiovascular risk of these patients, noted cardiologist Margaret Furman, MD, MPH, assistant professor and codirector of Yale's Cardio-Rheumatology Program, New Haven, Conn.

Newer biologic medications used to treat rheumatologic diseases can alter a patient's lipid profile, she said in an interview.

"It can be difficult to assess each individual patient's cardiovascular risk as their disease state and treatment can vary throughout their lifetime based on their degree of inflammation. The importance of aggressive lipid management is often underestimated," Dr. Furman added.

Cardiology and rheumatology partnerships can address gaps in care of this unique group of patients, said Vaidehi R. Chowdhary, MBBS, MD, clinical chief of the Yale Section of Rheumatology, Allergy, and Immunology at Yale University.

Dr Vaidehi Chowdhary with a patient.

"The role of the rheumatologist in this dyad is to educate patients on this risk, work toward adequate control of inflammation, and minimize use of medications that contribute to increased cardiovascular risks," said Dr. Chowdhary, who cofounded Yale's cardio-rheumatology program with Dr. Furman.

Cardiologists in turn can assert their knowledge about medications and their impact on lipids and inflammation, Dr. Wassif said.

Many anti-inflammatory therapies are now within the cardiologist's purview, Dr. Garshick noted. "For example, specifically with pericarditis, there's [Food and Drug Administration]–approved anti-inflammatories or biologics. We're the ones who feel the most comfortable giving them right now." Cardiologists quite often are consulted about medications that are efficacious in rheumatologic conditions but could negatively impact the cardiovascular system, such as Janus kinase inhibitors, he added.

'Reading the tea leaves'

Each program has its own unique story. For the Cleveland Clinic, the concept of a cardio-rheumatology program began during the COVID-19 pandemic in 2020. Developing such a concept and gaining institutional acceptance is always a work in process, Dr. Wassif said. "It's not that you decide one day that you're going to build a center, and that center is going to come into fruition overnight. You first gauge interest within your division. Who are the individuals that are interested in this area?"

Cleveland Clinic's center is seeking to build relations between medical disciplines while spotlighting the concept of cardio-rheumatology, said Dr. Wassif, who has been providing education within the clinic and at other health institutions to ensure that patients receive appropriate attention early.

NYU-Langone launched its program amid this heightened awareness that the immune system could affect atherosclerosis, "kind of reading of the tea leaves, so to speak," Dr. Garshick said.

Several clinical trials served as a catalyst for this movement. "A lot of clinical cardiologists were never 100% convinced that targeting the immune system reduced cardiovascular disease," he said. Then the CANTOS clinical trial came along and showed for the first time that a therapeutic monoclonal antibody targeting interleukin-1beta, a cytokine central to inflammatory response, could in fact reduce cardiovascular disease.

Trials like this, along with epidemiologic literature connecting the rheumatologic and the autoimmune conditions with cardiovascular disease, pushed this concept to the forefront, Dr. Garshick said.

The notion that a clinic could successfully address cardiac problems in patients with rheumatic diseases yielded promising returns at Women's College Hospital in Toronto, according to a report presented at the 2018 American College of Rheumatology annual meeting. Researchers reported that patients with rheumatologic conditions who attended a cardio-rheumatology clinic at this center saw improvements in care. The clinic identified increased cardiovascular risk and early atherosclerosis, and 53.8% of patients altered their medications after being seen in the clinic.

A total of 39.7% and 32.1% received lipid lowering and antiplatelet therapies, respectively, and 14% received antihypertensive therapy. A small percentage were treated for heart failure or placed on lifelong anticoagulation therapy for atrial fibrillation, and one patient received a percutaneous coronary stent.

Ins and outs of the referral process

Initially designed for preventive cardiac risk assessment, Yale's program evolved into a multidisciplinary, patient-centered approach for the management of complex cardiovascular conditions in patients with autoimmune rheumatologic diseases.

The program is open to anyone who carries a diagnosis of rheumatologic disease or has elevated inflammatory markers. "Every patient, regardless of the reason for the referral, receives a cardiovascular risk assessment," Dr. Furman said.

Most referrals come from rheumatologists, although cardiology colleagues and pulmonologists have also sent referrals. A pulmonologist, for example, may want to rule out a cardiac cause to shortness of breath. The patient's workup, care, and follow-up are based on the reason for referral.

"We are currently referring patients with established cardiac disease, traditional risk factors, or for better risk assessment for primary prevention of coronary artery disease," Dr. Chowdhary said. "We communicate very frequently about medication changes, and patients are aware of goals of care from both sides."

Dr. Furman works closely with several of the rheumatology specialists taking care of patients with rheumatoid arthritis, systemic lupus erythematosus, and scleroderma.

Rheumatology follows patients every 3-6 months or more frequently based on their disease activity.

Dr. Mankad uses her sleuthing skills at Mayo Clinic to determine what the patients need. If they come in for a preventive assessment, she looks more closely at their cardiovascular risks and may order additional imaging to look for subclinical atherosclerosis. "We're more aggressive with statin therapy in this population because of that," she said.

If it's valve disease, she pays extra attention to the patients' valves in the echocardiograms and follows them a bit more regularly than someone without a rheumatologic condition and valve disease.

For patients with heart failure signs or symptoms, "it depends on how symptomatic they are," Dr. Mankad said. In some instances, she may look for evidence of heart failure with preserved ejection fraction in patients who have rheumatoid arthritis who happen to be short of breath. "There's so many different manifestations that patients with rheumatologic conditions can have as far as what could be affected in the heart," she noted.

Quite frequently, Dr. Mankad identifies subclinical disease in her patients with rheumatoid arthritis. "I've seen many patients whose risk scores would not dictate statin therapy. But I went looking for subclinical disease by either doing coronary assessment or carotid assessment and have found atherosclerosis that would be enough to warrant statin therapy."

A personalized assessment to reduce cardiac risk

NYU-Langone's program offers opportunities to educate patients about the link between cardiac and rheumatologic disease.

"Their rheumatologist or their dermatologist will say, 'Hey, have you heard about the connection between psoriasis, psoriatic or rheumatoid arthritis, and heart disease and the risk of heart attack or stroke?' " Dr. Garshick said.

The patients will often say they know nothing about these connections and want to learn more about how to treat it.

"We'll say, 'we have someone here that can help you.' They'll send them to myself or other colleagues like me across the country. We'll assess blood pressure, weight, lipids, hemoglobin A1c, and other serologic and oftentimes imaging biomarkers of cardiovascular risk." The patients will receive a personalized assessment, listing things they can do to lower their risk, whether it's diet, exercise, or lifestyle. "Many times it can involve medications to reduce heart disease risk," said Dr. Garshick.

In some instances, a rheumatologist or dermatologist may be concerned about starting a patient on a specific medication for the disease such as a JAK inhibitor. "We'll help assess their risk because there's been a lot of literature out in the rheumatology world about the risk of JAK inhibitors and heart disease and blood clots," said Dr. Garshick.

Dr. Garshick also sees patients with rheumatologic conditions who have a specific cardiovascular concern or complaint such as shortness of breath or chest pain. "We'll work that up with a specific knowledge of the underlying immune condition and how that may impact their heart," he said.

Advances in research

As they continue to see patients and devise specific care plans, developers of cardio-rheumatology programs have been supplementing their work with ongoing research.

Yale's clinic is expanding this year to include a new attending physician, Attila Feher, MD, PhD, who has conducted research in autoimmunity and microcirculation using molecular imaging and multimodality imaging techniques. Prevalence of coronary microvascular dysfunction appears to be increased in this patient population, Dr. Furman said.

Dr. Wassif recently coauthored a paper that examined patients with underlying rheumatologic conditions who undergo valvular and aortic valve replacement. "To our surprise, there was really no difference between patients with autoimmune conditions and others with nonautoimmune conditions," she said, adding that the study had its limitations.

Other work includes data on Medicare patients with ST- and non-ST-elevation myocardial infarctions who have an underlying autoimmune disorder. Dr. Wassif and her colleagues found that their long-term outcomes are worse than those of patients without these conditions. "It's unclear if worse outcomes are related to complications of autoimmunity versus the extent of their underlying disease. This is a work in progress and certainly an area that is ripe for research."

Dr. Garshick and other collaborators at NYU have been focusing on the endothelium, specifically platelet biology in patients with psoriasis, psoriatic arthritis, and lupus. "We're about to start the same research with gout as well," he said.

"The process we're most interested in is understanding how these diseases impact the early stages of cholesterol. And the way we're doing that is evaluating the vasculature, specifically the endothelium," he said.

He has finished two clinical trials that evaluate how standard heart disease medications such as aspirin and statins impact or can potentially benefit patients with psoriasis and/or psoriatic arthritis. "We have a whole list of other trials in the pipeline with other institutions across the country."

Through a grant, Dr. Mankad is assessing whether a PET scan could detect inflammation in the hearts of rheumatoid arthritis patients. "We're looking to see if the reason these patients have heart failure later in life is because their heart muscle actually shows evidence of inflammation, even when they have no symptoms," she explained.

Other tests such as echocardiogram and CT scans will be used to evaluate coronary disease in about 40-50 patients. The goal of using these multiple imaging tools is to find markers indicating that the heart is affected by rheumatoid arthritis, which may indicate a higher likelihood of developing heart failure, she said.

Clinics are popping up

Through these new clinics, some collaborations have emerged. Dr. Garshick works closely with Brigham and Women's Hospital, which has a similar cardio-rheumatology program, run by Brittany Weber, MD, to exchange ideas, discuss challenging cases, and collaborate.

"There are a lot of clinics like us popping up across the country," he observed. Every so often, he hears from other institutions that are interested in starting their own cardio-rheumatology programs. "They ask us: How do you start, what should we look for?"

It's an education process for both patients and providers, Dr. Garshick emphasized. "I also think it's a bandwidth issue. Many of our rheumatology and dermatology colleagues are acutely aware of the connection, but there may not be enough time at a clinic visit to really go in depth" with these dual conditions, he said.

NYU-Langone Health for the past several years has been holding a symposium to educate people on the cardio-rheumatology connection and treating inflammation in cardiovascular disease. This year's symposium, held in conjunction with Brigham and Women's Hospital, is scheduled for April 28. For more information, visit the course website: nyulmc.org/cvinflammationcme.

"What we're trying to do is help [other institutions] get that bandwidth" to adequately help and serve these patients, he said.

Dr. Garshick has received consultant fees from Abbvie and Horizon therapeutics and an unrestricted research grant from Pfizer. No other sources had relevant financial disclosures.

This article originally appeared on MDedge.com, part of the Medscape Professional Network.

Credits:

Lead image: Rob Lisak

Image 1: Cleveland Clinic

Image 2: Mayo Clinic

Image 3: Harold Shapiro

Image 4: Rob Lisak

Image 5: NYU-Langone Health

Cite this: Cardio-Rheumatology Clinics Guide Care for Unique Population - Medscape - Jan 23, 2023.