Download Sudden flare of rheumatoid arthritis associated

Sudden flare of rheumatoid arthritis associated with newly
diagnosed atrial flutter
Muthiah Vaduganathan, MD, MPH, and Joel N. Auslander, MD
We present an 89-year-old woman with newly diagnosed atrial flutter
associated with a flare of her rheumatoid arthritis (RA). She had a history of diet-controlled type 2 diabetes mellitus, hypertension, and RA
and presented with lightheadedness and worsening hand pain. She was
found to be in new atrial flutter with rapid ventricular response and to
have an active RA flare. In addition to adequate atrial flutter rate control,
her RA flare was managed by adding hydroxychloroquine and doubling
her existing methotrexate dose.
A
trial flutter is a common arrhythmia that carries a high
burden of morbidity in the elderly population (1).
Cardiac-specific mechanisms often are implicated in
contributing to disease onset, but systemic factors may
play an important role in triggering or initiating newly identified cases of atrial flutter.
CASE DESCRIPTION
An 89-year-old woman with diet-controlled type 2 diabetes mellitus, hypertension, and rheumatoid arthritis (RA)
presented with lightheadedness and worsening hand pain. Her
initial electrocardiogram revealed atrial flutter with variable
block and a rapid ventricular response (Figure 1). Her body
mass index was 31.2 kg/m2, and her proximal interphalangeal
joints were mildly warm and tender bilaterally (Figure 2). Her
leukocyte count ranged from 10.4 to 14.6 × 103 /µL, and her
erythrocyte sedimentation rate was 119 mm/h. Chest radiography and urine and blood cultures revealed no source of
active infection, and she remained afebrile during the course
of the admission. Her echocardiogram showed moderate left
atrial dilation, mild right atrial dilation, thickened ventricular
walls without wall motion abnormalities, and an ejection fraction of 65%. Her thyroid function testing was within normal
limits. She had been admitted with acute kidney injury and
mild altered mental status 2 weeks prior to the present admission. Due to concerns for potential medication-related
side effects, her RA regimen was changed. Specifically, her
hydroxychloroquine was discontinued and her methotrexate dose was decreased by half (from 20 to 10 mg/m2 once
weekly). No other medication changes to her home regimen
preceded this admission.
Proc (Bayl Univ Med Cent) 2014;27(3):233–234
During the current admission, her rapid ventricular response
required high-dose multiagent nodal blockade to achieve
adequate control. After several days of dose titration, her heart
rate normalized with metoprolol succinate 150 mg twice daily,
diltiazem sustained-release 180 mg twice daily, and digoxin
0.125 mg daily. She remained in atrial flutter throughout
hospitalization, and her symptoms quickly resolved with heart
rate control. Her RA flare was managed by reinstating the
hydroxychloroquine and doubling the methotrexate dose to
20 mg weekly (her original dose).
DISCUSSION
Approximately 200,000 patients are newly diagnosed with
atrial flutter annually in the United States (1). These estimates
are likely higher in elderly patients with comorbid cardiopulmonary disease. In population-based studies, atrial flutter represents
a predictor of late mortality independent of other traditional
cardiovascular risk factors (2).
There is increasing recognition of the systemic inflammatory profile of RA and its potent effects on cardiac function.
Mechanistically, RA may contribute to conduction disturbances (3) and progressive diastolic dysfunction (4). To the
best of our knowledge, no data are available evaluating the
association between RA and atrial flutter, and particularly
RA flares and atrial flutter. Although often approached and
managed similarly, atrial flutter and atrial fibrillation have distinct epidemiological and clinical risk factors (5). A Danish
national cohort study of over 4 million patients in inpatient
and outpatient care centers showed that patients with RA were
at increased risk for atrial fibrillation and stroke, regardless of
age and sex, over a mean follow-up of 4.8 years (6). A more
recent investigation showed an increased rate of hospitalization
for atrial fibrillation in RA patients compared with matched
controls (7). However, after accounting for relevant baseline
covariates, no increased risk of atrial fibrillation was observed
From the Department of Medicine, Massachusetts General Hospital, Harvard
Medical School, Boston, Massachusetts (Vaduganathan); and Hospitalist Services,
Newton Wellesley Hospital, Newton, Massachusetts (Auslander).
Corresponding author: Muthiah Vaduganathan, MD, MPH, Department of
Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit
Street, GRB 740, Boston, MA 02114 (e-mail: [email protected]).
233
Figure 1. Presenting electrocardiogram that revealed new atrial flutter with variable block and rapid ventricular response.
in RA patients (7). Our patient had evidence of a concurrent
active RA flare given her exacerbated pain symptoms and elevated inflammatory markers. She developed atrial flutter after
her RA medications were both discontinued and decreased,
likely leading to an RA flare. Active disease and augmentation
of circulating inflammatory markers may have contributed to
her new-onset atrial flutter (8).
The implications of a potential relation between RA and
atrial flutter are presently unclear. Routine screening of patients
with systemic inflammatory disorders with electrocardiograms
is controversial (9). Our initial experience raises the question of
whether the relation between these clinical entities is coinciden-
tal, correlated, or causal. Our patient’s medical comorbidities
and enlarged biatrial sizes likely increased her baseline risk of
experiencing atrial flutter.
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Figure 2. Active inflammation of metacarpal and proximal interphalangeal joints
in rheumatoid arthritis.
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Baylor University Medical Center Proceedings
Volume 27, Number 3