A 52-year-old woman has long-standing rheumatoid ahritis (RA) and is being treated with coicosteroids and nonsteroidal anti-inflammatory drugs (NSAIDs). Which of the following cardiac complications may arise in this clinical setting?
Long-standing inflammatory conditions such as RA are associated with deposition of a form of amyloid known as AA (amyloid-associated protein), which may involve kidneys, hea, liver, skeletal muscle, and skin, for example. Amyloid deposition in the myocardium results in decreased compliance and impaired diastolic filling, i.e., restrictive cardiomyopathy. The myocardium has a rigid and waxy texture. This form of amyloid, as well as any other biochemical form, can be visualized on tissue section by staining with Congo red, which acquires a characteristic apple-green birefringence under polarized light. Note:Constrictive pericarditis is due to any pathologic process that results in fibrous thickening of the pericardium, with resultant impaired compliance. Clinically, therefore, this condition manifests with a picture similar to restrictive cardiomyopathy because of impaired diastolic filling. Constrictive pericarditis is usually caused by previous episodes of acute pericarditis, especially hemorrhagic, suppurative, and caseous pericarditis.Dilated cardiomyopathy is characterized by massive ventricular dilatation and may be caused by genetic alterations, myocarditis, toxic insults (alcohol), metabolic disorders (hemochromatosis), etc. Most cases are idiopathic. The main pathophysiologic alteration is impaired contractility. Most cases of hyperophic cardiomyopathy are familial and due to mutations in one of the genes encoding proteins of the sarcomeres, most frequently b-myosin heavy chain. This form of cardiomyopathy leads to asymmetric hyperophy of the left ventricle, with prominent thickening of the interventricular septum. In this case, too, impairment of ventricular compliance is the basic mechanism leading to reduced diastolic filling and hea failure. Ref: Stevenson L.W., Loscalzo J. (2012). Chapter 238. Cardiomyopathy and Myocarditis. In D.L. Longo, A.S. Fauci, D.L. Kasper, S.L. Hauser, J.L. Jameson, J. Loscalzo (Eds), Harrison's Principles of Internal Medicine, 18e.
Constrictive pericarditis
Restrictive cardiomyopathy
Dilated cardiomyopathy
Hyperophic cardiomyopathy