‘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.
Harold Shapiro
Dr. Margaret Furman listens to the carotid arteries of a patient in Yale School of Medicine's Cardio-Rheumatology Clinic.
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.”