Patients with autoimmune diseases have an increased risk for cardiovascular disease and microvascular dysfunction. The Yale School of Medicine Section of Cardiovascular Medicine and the Section of Rheumatology, Allergy, and Immunology offer a Cardio-Rheumatology Program to provide personalized cardiovascular risk assessment and treatment for patients with autoimmune diseases, including rheumatoid arthritis, systemic lupus, scleroderma, psoriatic arthritis, and vasculitis.
Co-directed by Margaret L. Furman, MD, MPH, assistant professor at the Yale School of Medicine, the program specializes in risk and medication management. Dr. Furman was drawn to these patients early in her career where she specialized in preventive cardiology and lipidology.
“My interest has focused on preventive cardiology and lipidology, however my involvement in rheumatology developed after receiving referrals for patient’s intolerant of statins. The referrals began to go both ways after referrals from internists and other physicians for statin intolerance would reveal an autoimmune disease.”
Patients with autoimmune diseases are complex, Dr. Furman explains. “Studies have shown that people with rheumatoid arthritis have a higher prevalence elevated lipoprotein (a), and this increases your risk for heart disease. Within this patient population — what I call the big four — rheumatoid arthritis, systemic lupus, scleroderma, and psoriatic arthritis, the cardiovascular disease risk is often underestimated, especially in the lupus patients, as they tend to be a younger patient population at time of diagnosis.”
“Several of the autoimmune diseases have plenty of cardiac problems associated with them. Patients with systemic lupus have a greater risk for myocarditis and pericarditis. Often the medications used to treat their autoimmune diseases can cause cardiac conditions or increase their lipids. In the case of arrhythmias, we may not be able to use our traditional treatment medication beta blockers because they can worsen Raynaud’s,” Dr. Furman said.
Traditional risk stratification scores often underestimate these patient’s cardiovascular risk. Patients with an autoimmune disease often need additional risk stratification testing to better assess and risk stratify. Traditional risk scores do not include chronic inflammation, which contributes to the development of atherosclerosis. Additionally, active inflammation can suppress a lipid panel, leading physicians to misinterpret cholesterol levels in the test results.
Furthermore, the medications physicians prescribe to treat various autoimmune diseases can increase lipid levels. The Cardio-Rheumatology Program uses advanced lipid testing in many patients to help determine the best course of treatment. “Patients with autoimmune diseases may not tolerate certain widely prescribed first line medications. Statin use requires monitoring liver function to prevent drug-induced liver injury, one of the potential side effects of statins in rare cases. These patients are often on other medications that also increase the risk of liver injury. A lot of these diseases each have a cardiac complication that could be unique.”
After ten years at Mount Sinai Beth Israel in New York City, Dr. Furman joined the Yale Section of Cardiovascular Medicine and the Heart and Vascular Center where she developed a Cardio-Rheumatology Program with Vaidehi Chowdhary, MBBS, MD, DM, clinical chief of rheumatology.
“Dr. Monique Hinchcliff and I collaborated on a patient, and it was a natural progression from there. It has been an amazing collaboration with rheumatology. In general, patients with ongoing inflammation are going to be at higher risk for cardiovascular disease beyond the disease itself. However, we do not have a factor to multiply that risk by or enter it in into an equation. Researchers have tried to develop various risk scores, but nothing has proven to have great sensitivity or specificity together. In my notes, I try to discuss the traditional risk factors (hypertension, smoking, hypercholesterolemia, and family history), noting their increased risk associated with non-traditional or emerging risk factors such as autoimmune diseases or lipoprotein (a).”
Dr. Furman works in an interdisciplinary team environment to provide comprehensive care. Attila Feher, MD, PhD, an assistant professor, has joined the multidisciplinary team, which includes specialists in cardiology, gastroenterology, pulmonology including the interstitial lung disease and pulmonary hypertension teams, and diagnostic radiologists. Dr. Feher researches the interaction between autoimmunity and the microcirculation by using molecular imaging and multimodality imaging techniques. Dr. Feher’s productive research in this field has been recognized by the Hal O’Brien Rising Star Award and the American Society of Nuclear Cardiology Young Investigator Award.
The collaboration between the various specialist teams makes the work extremely enjoyable and rewarding. “Every patient is a little different,” said Dr. Furman. “As a physician, we need to think about the patient’s disease and the potential risks and benefits of treatment. It's not straightforward. Our job is not only to just treat the disease, but to help our patients understand the medical information and weed through it. Knowledge is power!”