Rheum for Improvement: The Emerging Field of Cardio-Rheumatology

Join our guest, Dr. Heba Wassif from The Cleveland Clinic, for a discussion about the emerging field of cardio-rheumatology.  We discuss the relationship between atherosclerosis and chronic inflammation, as well as the incidence of cardiac disease in rheumatologic patients.  We also review the role of anti-inflammatory therapy and general cardiac prevention in these patients. We finish with a discussion of the cardio-rheumatology clinic at CCF. 

For more information, see:

Embarking on a Career in Cardio-Rheumatology

Inflammatory and autoimmune mechanisms in the induction of atherosclerotic damage in systemic rheumatic diseases: two faces of the same coin.

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Transcript

Kanny 0:09

So welcome back to the Cardio Ohio podcast. This is Kenny Gral coming to you from Columbus as always. And also as always, I'd like to welcome my co-host from Cleveland, Ellen, SEIC, the current governor of the State of Ohio chapter. Alan, welcome.

Ellen 0:25

Well, welcome everyone to another episode and today we are gonna be talking about cardio rheumatology. We'll be talking to, Dr. Heba Wasif from Cleveland Clinic. so Heather, let me welcome you to our Cardio Ohio podcast and before we get started with our topic, I was hoping. Could you tell us a little bit about your professional career, your path, and how you got interested into cardio rheumatology?

Heba 0:52

Well, thank you Ellen, and thank you Kenny for inviting me. And this is a pleasure to be here on this podcast, and I am looking forward to talking with the two of you about, Cardio, rheumatology and my career path. And who can start with that? I was just saying before we started, it's somewhat of a convoluted, route, but it starts off, from the Middle East. I'm originally from Cairo, Egypt, and I actually grew up in the UE and I went back to medical school in Cairo and, transported to Minnesota for my. Residency program. and after graduation, I actually worked as an internist for a bit, before I did my Master's in public health at Hopkins. and went on to do my cardiology fellowship at Hopkins. after that, I did an interventional fellowship, at the Brigham and, and then decided, I'm then, went on to, be a general cardiologist, a non-invasive cardiologist. worked a little bit in Massachusetts, before I moved on, to, the Cleveland Clinic. and I've been here for coming up to almost eight years. There are many, been many steps along the way. But I feel that every step that I have taken, along the way, though it seems convoluted, has, helped grow and, and add qualities in, in me and in my practice that I cherish, today being a cardio rheumatologist.

Ellen 2:16

So, How did you develop your interest in cardio rheumatology?

Heba 2:22

So I think it, it was a gradual process. You, you, you start seeing patients with autoimmune disorders and you are thinking, oh, these are, this is not in my backyard. That their diseases are, their rheumatologic diseases are not related to their cardiac diseases. And then as you start reading and enhancing your knowledge, you start realizing like, there, there's. Good connection and most of the knowledge was coming from the rheumatology world where for the longest time, this very strong connection between cardiology and rheumatology has been very well established. But I personally don't recall anywhere along my training, that there was any discussion, about this very strong connection, between the two worlds. and. I started off, obviously I'm, I'm a noninvasive cardiologist. I have so many different interests. Valve disease has been one of my other major interests, which is also another thing, that I, do And, the, at the Cleveland Clinic, and I started noticing the, how the valvular disease in this particular patient population. Looks somewhat similar to patients with rheumatic disease and it's somewhat different and their trajectories are different. And that's how I started becoming more and more, interested. And then about five years ago, there was an an, an article, the, that was written by. A fellow at the time at Emory where she said, how do you establish a career in cardio rheumatology? And, it was during that time where we were considering establishing a center here, at the Cleveland clinic. and, leadership, knowing my interest felt that I would be the, the, the appropriate person, to start building that center. And, ironically when I read that article, I said to myself, well, this is quite interesting. I mean, this clearly that is not, that is very consistent that our training, does not include a lot of information about the. Systemic disorders, though it's part of Cocas, but we don't discuss it that often. We don't think about it as as often. Which brings us really to what cardio rheumatology is. It's, it's such a broad field. you can be, an noninvasive cardiologist. You can be a heart failure, specialist and have interest, in, in the field because it has a very broad spectrum. it is a systemic disorder. So that's how that came about.

Ellen 4:52

So I guess now let's, let's look directly at the relationship. So what is the connection between cardiovascular disease and rheumatology or inflammatory diseases? That sort of is what encompasses the field of cardio rheumatology. But, but what, what is that connection?

Heba 5:10

So the connection clearly is, is the underlying inflammation and many of the cytokines that are shared between the inflammatory process that leads to, for example, atherosclerosis, and I'll take atherosclerosis as an example. Ha have very, very strong similarities between that and the same cytokines that you see with, for example. rheumatoid arthritis and comparatively other, disorders as well. And when it, it comes to, you know, pericarditis obviously, for example, because it's from plaque to the pericardium, it's ever and everything in between. again, it's the inflammation though. That path of the pathophysiology of that particular pathway is not entirely clearly understood, but it, the underlying concept, it remains to be, inflammation. But what I don't want us to forget, it's not only the inflammation, many of this patient population also has a lot of cardiovascular risk factors or traditional cardiovascular risk factors. they have a very high prevalence of these risk factors. They have a very high prevalence of hypertension, hyperemia, Tobacco use. And there's actually a very strong relationship, for example, between tobacco use and rheumatoid arthritis. and to expand on that, this relationship, it's, it's bidirectional. So patients with rheumatoid arthritis who smoke, have very high disease activity and patients who smoke also have higher risk of developing rheumatoid arthritis. So it's. In two words, it's inflammation and risk factors combined.

Kanny 6:59

have a, this is Ka I wanna join Ellen in welcoming you and thank you again for participating. as you talk about the relationship between, cardiovascular disease and the rheumatologic diseases, in a general cardiology practice, obviously there's gonna be a lot of overlap. There's always gonna be some role of inflammation in many of our patients. Are, there any clinical clues you would suggest in a general cardiology practice that might indicate a patient who's like at higher risk of having, comorbidity due to rheumatologic issues or warrant a specific workup

Heba 7:31

so that is, that's a very good question because sometimes we see, we actually see the patients and we see them for coronary artery disease, but we don't. Consider or not, don't think that much about their underlying autoimmune condition. And what I think is important is to keep that in mind. If there is lupus, rheumatoid, psoriasis, enclosing spondylitis, inflammatory bowel. Don't think about them in, as, in a separate universe. They are related, to what is going on. And actually, I, again, in, in, in, in my practice, I usually ask them who the rheumatologist is and how well their disease is controlled and so forth. And I've gotten into the, the habit of even my non rheumatologic patient. I do ask them if they have autoimmune conditions. And you would be surprised that sometimes I have seen patients and they would say, oh yes, and these are my joints and they've been hurting and I have morning stiffness, and so forth. So as we are developing our, Almost history taking when we see patients, there's been a trend in the last few years that now we're asking about obstetric history. So I would say we should also be asking, about autoimmune history because it, it is an important, relation between. Autoimmunity and, cardiovascular disease.

Kanny 8:49

And what are, some of the easy questions we could ask in a general cardiology visit to kind of, clarify that relationship?

Heba 8:58

this is a challenge because like many patients and. Especially older patients, they would have like joint disorders. So I think a simple question would be, have you ever been diagnosed with any autoimmune condition? are you joint swollen? Do you have any morning stiffness? Do you have any skin rashes? And for women, of course, especially like younger women, if they have evidence of coronary artery disease, and I've had that happen, to one, a patient that I saw. and was one of the early patients that I saw in the Carter Room Clinic. this is a woman, that, had actually an event, and two years later was diagnosed with lupus. And when you dug into her history a bit further, it turns out that she was having some hair loss, and skin rash. So for younger women, it, it's important to ask questions that may be more related to lupus.

Kanny 9:47

Thanks. obviously in a, in a busy practice, I know we often have a pretty, low threshold to, use, laboratory testing and, and biomarkers to try to clarify, the issues in some of these patients. Have you found that, at least for the, non rheumatologist or non cardio rheumatologist, certain, And biomarkers are more helpful and certain ones might be, overused or, or more confusing to obtain.

Heba 10:11

So obviously it's a CRP that I, I'm, that, I guess that that's what you're trying to allude to is that do we get crps I mean, I tend to not, I get the CRPS in, in, in a patient that I know has established autoimmune disorder just to get a sense of, their disease activity, but not to assist with, like diagnosis or so forth. I may use it in, in some of my, patients that are not autoimmune patients where I'm trying to assess, their risk. But for my, my autoimmune patients and when I'm trying to assist their risk, I always find it extremely challenging. And it's not only me. I think in the, the whole community as a whole finds risk evaluation in this particular population is very challenging. In my mind, it's not the, the biomarkers it really will rely on in relies on imaging. I rely heavily on a coronary calcium score, for screening for cardiovascular disease. and I was very, Pleased, so to say. when I saw the, the new dyslipidemia guidelines, that, came out talking about, risk enhancers and how, coronary calcium score has been elevated, to a class, two, a indication, in patients who are borderline, but. where there's like consideration for additional, risk factors. so I, I do rely heavily, in this patient population on, on calcium score. so in other words, I'm following the algorithm that before the algorithm came out, which was CPR. which is, you calculate, you personalize and then you reassess, and treat, accordingly. And the challenge with these patients as well is that when we try to assess their risk using our traditional risk calculators. They will always underestimate, the risk. And that has been, a tremendous challenge. And when I talk about risk calculators, I'm, I am referring to the A-S-C-V-D, risk calculator. that does underestimate the risk in this particular population. For example, in one particular study that looked at different risk calculators in a lupus population, and followed them for 10 years and evaluated their events, one out of five patients ended up having an event. And when you look back and, and you calculate the risk score, the Framingham risk score in patients who had events performed extremely, poorly. Only 10% of, that population had a risk score that was elevated suggesting, disease. and when you look at the A-S-C-V-D risk score, it certainly didn't do much better. But in this particular study, the the Q risk. Had a higher sensitivity and specificity. and we don't use the Q risk, which was, validated in a UK population as often as we, as we should. So I say, when I talk to my colleagues in the uk, they do use that risk, particularly in this population more often because it does include, lupus and RA as a diagnosis in the cure risk. of course, the new guidelines now is introduced the, the prevent. risk score that has not been necessarily validated in this particular population, but it does include factors that are pertaining to, a population. for example, like lupus population where there's a GFR, and A BMI that is included in the prevent risk score.

Ellen 13:36

So I agree with you Heva, that our risk scores traditionally have really markedly underestimated the risk in this population. And so for these patients who have high inflammatory states, and we consider it at higher cardiovascular risk, do we simply really try to, well first we use all of our tools. Mm-hmm. We use the coronary calcium scoring. Very heavily here at my institution. and we've actually identified a lot of people who previously thought they had no disease at all and really had, had quite a high disease burden. But for this population at high risk, do we simply really optimize all of the risk factors, for example. Try and get to the lowest LDL target, optimize their blood pressure, optimize their behaviors, possibly start them on baby aspirin, or are there additional medications that we want to use to really knock down that inflammatory state?

Heba 14:29

So that's an excellent question, Ellen. I think that, that it, it really brings it to the core of how we manage these patients. It. It is obviously about assessing risk, but we cannot ignore the risk factors. Aggressive management of the risk factors is extremely important. And this has been also, that has also been evaluated. There was, a small cohort study, of almost, 400 patients, lupus patients as well compared to controls where. Each, each additional risk factor that was controlled, reduced the risk of progression of their carotid plaque over a 10 year period of about 30%. So with each additional risk factor control to the optimum, you are reducing the risk. So. You cannot ignore the hypertension, the hypercholesterolemia, tobacco use, all diabetes, the under control and so forth. So aggressive risk factor modification is certainly part of the management strategy to reduce for future events. The, the challenge with this patient population is what is your target? I mean, if your coronary calcium is, is, is elevated, with the new guidelines as beautifully done, we have, different levels depending on the different levels of the calcium score, which I find extremely, practical. but if you have do, if you have a patient, whose coronary calcium score is zero, what do you do? I still obviously will aggressively manage them. I would keep their, lipids under, at least under a hundred, if not, under 70, depending on how elevated I think the risk is, and reassessing, periodically, and that's very, very important to reassess it. The question in my mind is always whose responsibility is assessing the risk? You, we don't see the patients as cardiologists and as a cardiology community until they clearly have some problem, whether it's coronary artery disease or valve disease or heart failure or pericarditis or so forth. some of the. The risk evaluation needs to be done at, at a much earlier stage at the time that they're being diagnosed. And I, if you look at the, the recommendations, the ELR recommendations from the rheumatology, world, they do recommend early risk assessment. No different than the general, population.

Kanny 17:06

Heba One question that comes up, especially in the, coronary CAD population is, when is, what role is there for a medication like Colchicine? I, I know studies have shown that it reduces. Events, but we already have our patients on multiple risk reducing medications, typically if they have established CAD. So are there any clues as to what patient might benefit the most from something specific like Colchicine being added to the regimen?

Heba 17:33

I, no, I'm not aware of any work that has been done, particularly in, in patients with lupus, sorry. Or with autoimmune in general, and Colchicine. I have been using it for patients that are very high risk, that have had repeat events. I have been introducing it into my, my practice for my patients, even without autoimmune disorders. Patients who have, multiple vessels, have had multiple PCIs patients who have, refractory angina.

Ellen 18:01

so, so heba, one question I do have is we we're talking about aggressive, classic risk factor modifications. are there any studies that look at how well controlled someone's autoimmune disease is in relationship to progression of disease? Like once you've established they're at risk? Are there any, and if you're looking at a calcium score, this might be a study that can be done in the future. If you have a calcium score, now you can sort of look at level of control of the inflammatory process and see does that affect. Progression of disease as in progression of the calcium scoring or progression to disease, symptoms.

Heba 18:44

So I don't think that the, I'm aware there are no studies on those lines because that will be a very difficult study, to do because the patients along their lifespan, they have fluctuations where they go, there are times where they're in remission and where there are times they have, flares. and the other problem is when did the disease actually start? They don't usually get a diagnosis for. Lupus and I come back to, to lupus, or rheumatoid where they've had multiple years of inflammation. and I see patients repeatedly saying, yeah, I've had these joint issues for many years, but I've only been now been diagnosed with either a mixed connective tissue disorder or lupus. So it's, it's quite challenging, to, to relate that. But I think the general consensus is that the disease activity needs to be under control. And, I do recall a, a patient that I had seen in clinic, A while ago who was diagnosed with connective tissue disorder and did not want to be on medication. And a year later she ended up getting a calcium score and was found to have an exorbitantly high, calcium score. and that's when I saw her in clinic and I really emphasized that she really needs to have her disease under control. And that was one of the. Impetus for her to actually be treated, and to go back to the rheumatologist and initiate her therapy. So I think there is a consensus that, that you ha the disease needs to be under control. there've been trials looking at, is there a regimen that is better than another regiment in reducing inflammation? there's one small study that looked at vascular wall inflammation. With two different regimens. and both of them included methotrexate and TNF Alpha, but there are no large randomized trials.

Ellen 20:41

One other slight question that goes along with this is, are there any observations that if someone's having a flare, they're very high inflammatory state, does that correlate at all with plaque rupture and mis.

Heba 20:56

that's an another excellent question. I don't believe that there is anything that I am aware of, but what I can tell you though, is. That patients even like, and again, this is not related particularly to plaque rupture, but patients, after they've had their events, they remain at risk of developing future events. Even higher than controls. So, and these events would be revascularization and heart failure. So the patients are at increased risk. It's a very good question because obviously we, we think about the stab plaque and plaque stabilization, and if you have an inflammatory state, would that add to, Plaque instability. And again, very difficult because you have fluctuations, you have flares, and you have, remissions and throughout the life course of, a patient with an autoimmune disorder. it will be an, it would be an, it would make for an interesting study, if you have that information,

Kanny 22:04

I have a, I have a, a question, related to therapy as well. I, I, I actually have a very interesting patient who, had been a very challenging patient who's had recurrent pericarditis. Over the course of a year or two and was very, very symptomatic. didn't really respond to a lot of the first line kind of therapies. And then she saw a rheumatologist and was put on a anakinra, which I believe is a IL one. Used for rheumatoid arthritis as well, and she really responded well to that. So I, I was just curious, do you see patients with especially, more of a chronic. Recurrent pericarditis who might be candidates for more advanced therapy like that. And if so, would be a candidate to be referred to a cardio rheumatology clinic perhaps.

Heba 22:47

So. So, I mean, and this is the, this is not the first time I've heard this, sort of, story happen. So if, if patients have had difficult to treat pericarditis, it may be a ma one of the manifestations of an underlying autoimmune disorder, which may have not been diagnosed, or it may be the first sign of their, disorder. so was this patient diagnosed with ru with rheumatoid? She

Kanny 23:14

ultimately actually was found to, I believe, was found to have Lupus.

Heba 23:18

Lupus. Very interesting.

Kanny 23:19

Yeah. She's a 50 ish African American woman and did not have any manifestations when she had pericarditis, but then ultimately, I believe, had the diagnosis of lupus made.

Heba 23:29

So lupus was one of the primary, manifestations of her underlying disorder. Yeah. So usually if patients have had recurrent events or difficult to treat events, pericarditis, it's very important to look into their autoimmune history. It's highly recommended. I think it's also, if I believe, it's also recommended in the new, both the European and the consensus, pericarditis that just, came out last year.

Ellen 23:57

So Heba, I have a question for you is sort of summing up some of the lessons we're learning from today is as a general cardiologist, I think for one, as part of my risk factor assessment for people, I do need to make sure I'm asking, about. Do they have any rheumatologic history or do they have any joint issues and all that? So sort of add that as yet another risk factor for assessment and for anybody who has that history. If I am their cardiologist looking either to be their preventive cardiologist or general cardiologist I do in those patients really need to optimize all of the risk factors. But are there any particular patients with rheumatologic disease that really should go s. Straight to a cardio rheumatologist as opposed to my first doing the basics. Are there certain red flags or people that we should send directly to a cardio rheumatologist?

Heba 24:57

So the field is evolving. I mean the, the field has been in existence. As it as it's shaping up. In the last five years, but the field is evolving and trying to. Determine what would be the appropriate candidates for referral to a cardio rheumatologist. I mean, prevention still remains part, of that though I believe that prevention should not be the only part of cardio rheumatology. partly because prevention is everybody's job. Any cardiologist, any primary care, it should be all our job to prevent. Atherosclerosis. It is preventable. but I do think complex patient beyond patients with, coronary artery disease, but complex valve patient, complex pericarditis patients, complex. Patients with myocardial disease and, and, and myocarditis. For example, I've had a patient, with lo loefflers, disease secondary to EGPA, patients with vasculitis. So those are the patients that really need to exist in, in the, in a cardio room. practice

Kanny 26:05

I think that's a great point to have. Thank you for emphasizing that to all of us. we're just on to our last few minutes here. so I just, before we wrap up, I wanted to just ask, since you brought up your cardio rheumatology, clinic, how do you actually staff that clinic and what are the components of, providers you have there? Since obviously most institutions may not necessarily have a cardio room program.

Heba 26:26

So the cardio room program, it, it's evolving so. There. we've created, in part of my practice, in my men in my regular clinic, we try to have slots that are allocated to cardio room patients. So if a patient calls and they want to be seen in the clinic, they will be seen, in those slots. We're obviously expanding these slots as are referral is increasing. we're also identifying, Pathways to improve referral internally, as well as externally. and it's hugely staffed by me and, one of the nurse practitioners, that I work with who has special interest in, in the area. So between the two of us, I also have colleagues in other departments that have interest in the area that I collaborate with. For example, colleagues in, advanced heart failure. that are interested in, in the area that take care of patients when they reach, a state in their disease that requires advanced heart failure, management. So it's, it's really evolving to be on, on a multidisciplinary, level. not, one person, but it, it's increasing, as the years are going on.

Kanny 27:34

Well, thank you so much, Heba. That was really a great discussion. I think we covered, a lot of material in the time we had. we really look forward, to hearing more about this, area in cardio rheumatology since it's such a new, topic. we, we look forward to hearing how your clinic evolves and also how you, your practice evolves. And, and I also wanna thank you for your service to the, state chapter, which reminds me that. As we were talking about pericarditis, I do want all our listeners to remember that, our spring summit is actually coming up on Saturday, April 18th, and one of the topics we're highlighting is pericarditis. And I believe, he, your, your colleague Dr. Klein, is gonna be talking about pericarditis. And, so, hopefully, we'll learn a little bit more of that and we hope the audience can join us at the Spring Summit.

Heba 28:21

Well, thank you, Kenny. This was a wonderful, Podcast, I'm, thank you for the invitation.

28:25

Thank you for joining today's podcast. For more information about the speakers or the topics, please go to Ohio acc.org,