Inflammation and your heart

Long-term inflammation does not stay in the joints. The same process that swells and stiffens joints also acts on the walls of the blood vessels, where over years it speeds up the furring and narrowing of the arteries, known as atherosclerosis, that underlies heart attacks and strokes. This is why several inflammatory conditions carry a higher cardiovascular risk than the general population, including rheumatoid arthritis, lupus, psoriatic arthritis, axial spondyloarthritis and gout.

The size of that added risk varies with the condition and, importantly, with how well it is controlled. In rheumatoid arthritis the risk of heart disease is roughly 50% higher than in someone of the same age without it, an increase broadly comparable to that carried by diabetes. In lupus the pattern is a little different: the disease can accelerate atherosclerosis, so heart problems can appear earlier than expected, particularly in younger women who would otherwise be at low risk. Gout tends to arrive alongside high blood pressure, raised cholesterol and diabetes, and each of those adds risk of its own.

A different mechanism operates in antiphospholipid syndrome, where the added risk to the heart and brain comes from a tendency to form clots rather than from inflammation furring the arteries over years. Because of that, a heart attack or stroke can occasionally come at a younger age than expected, which is why that condition is managed with particular attention to clotting, as its own guide explains.

None of this means heart trouble is inevitable. It means the heart deserves the same attention as the joints, and that much of the added risk can be both measured and reduced.

Here is the reassuring core of this guide: controlling the inflammation is itself one of the best things you can do for your heart. Because the raised risk is driven in large part by inflammation, quietening that inflammation lowers it. People whose disease is well controlled have fewer heart problems than those whose disease stays active, and the disease-modifying treatments used to reach that control, such as methotrexate and the biologics and JAK inhibitors, are associated with a lower cardiovascular risk when they do their job.

This is what "treating to target" means in practice: aiming for low disease activity or remission, not merely for fewer symptoms. Sticking with your treatment, keeping up your blood tests and reviews, and not letting active disease simmer on are heart protection as much as joint protection. The single most powerful lever, in other words, is often the treatment you are already on.

Because the risk is higher, it is worth having it looked at properly rather than assumed. A cardiovascular risk check is straightforward: your blood pressure, a cholesterol blood test, a few questions about smoking, family history and lifestyle, and a calculation of your overall risk over the years ahead. In the UK this is usually done with a tool called QRISK, which now takes rheumatoid arthritis into account as a risk factor in its own right, reflecting what the inflammation does to the arteries.

The practical question is whose job it is. Cardiovascular risk assessment is shared between your GP and your rheumatology team, and it can fall between the two if each assumes the other has it covered. So it is well worth raising at a review: has my heart risk been assessed, and who is keeping track of it? Asking is often what makes sure it happens.

Alongside good disease control, the ordinary heart-health measures matter just as much for people with an inflammatory rheumatic condition, and arguably a little more.

• Blood pressure. High blood pressure usually has no symptoms, so it needs checking rather than feeling for. If it is raised it can be treated, and bringing it down lowers your risk.
• Cholesterol. A simple blood test shows your cholesterol, and where your overall risk warrants it, a cholesterol-lowering medicine such as a statin reduces the chance of a heart attack or stroke. Whether one is right for you is a decision made with your GP or specialist, weighing up your own risk.
• Stopping smoking. This guide is the place to be blunt about smoking. It raises cardiovascular risk sharply, and in inflammatory disease it does something extra: it blunts how well your treatment works, so the disease is harder to control and the heart risk stays higher on both counts. Stopping is the single most valuable change many people can make, and the support available to help is well worth taking up.
• Staying active. Regular movement lowers blood pressure, improves cholesterol and helps the heart directly, and it is safe and beneficial in arthritis rather than harmful to the joints. Our guide to arthritis and exercise explains how to start.
• Weight and diet. Reaching and keeping a healthy weight eases the joints and the heart alike, and a balanced diet supports both; diet and arthritis covers the practical side.

None of these is dramatic on its own. Kept up over years, and working together, they add up to a real reduction in risk.

Most arthritis treatments are good for the heart precisely because they control the inflammation that threatens it. A few carry considerations worth knowing about, which is a reason for specialist oversight rather than for alarm.

Anti-inflammatory painkillers (NSAIDs) such as ibuprofen and naproxen are useful for pain, but taken regularly they can raise blood pressure and place extra load on the heart and kidneys. In people with cardiovascular risk they are therefore used at the lowest helpful dose for the shortest time, and sometimes avoided altogether. A pharmacist, your GP or your specialist can advise on what is sensible for you.

JAK inhibitors, one of the newer targeted treatments, come with specific safety advice about the heart. Following a large safety study, the UK medicines regulator advises that in people aged 65 or over, current or past long-term smokers, and those with risk factors for heart disease or blood clots, a JAK inhibitor is used only when no suitable alternative is available. That is not a ban, and for many people they remain a good option; it means the choice is made individually, with your own heart risk weighed openly. Our guide to biologics, biosimilars and JAK inhibitors explains this in full.

Steroids deserve a mention too. They are helpful for settling inflammation quickly, but at higher doses over longer periods they can nudge up blood pressure, blood sugar, cholesterol and weight, which is part of why they are kept to the lowest effective dose for the shortest sensible time. Our guide to steroids in rheumatology covers this in more detail.

Most of this guide is about the heart's arteries, because that is where the largest and most measurable risk lies. Less often, inflammation can affect the heart itself. These direct effects are uncommon, some of them rare; most are mild or found only on a scan, and the more serious forms are looked for when there is a reason to and managed together with cardiology. Here too, good control of the underlying condition is what prevents most of them.

The most familiar example is pericarditis, inflammation of the thin lining around the heart, called the pericardium. It is a recognised feature of some inflammatory conditions, notably lupus and, less often, rheumatoid arthritis and adult-onset Still's disease. Its typical symptom is chest pain that is sharp rather than crushing, often worse when lying down or breathing in and eased by sitting up and leaning forward. Sometimes fluid gathers around the heart, a pericardial effusion, and in lupus this is common enough to deserve a reassuring word. Scans pick up a little fluid around the heart in somewhere between a fifth and a half of people with lupus, most of whom have no symptoms from it at all. It is usually small and needs no treatment of its own, and the serious form, where enough fluid builds up to press on the heart (called cardiac tamponade), is uncommon.

The important word there is "typical", not "diagnostic". Chest pain must never be self-diagnosed as pericarditis, because its features overlap with far more urgent causes, and the same person can have both at once. Any new chest pain needs proper assessment first: our guide to costochondritis sets out the chest-pain warning signs in full, and the banner at the top of this page tells you when to call 999. Pericarditis, once it has been properly diagnosed, usually settles well as the inflammation is treated.

The heart's other structures are involved less often. Inflammation of the heart muscle, myocarditis, is uncommon; it can occur in lupus and in the inflammatory myopathies, and new breathlessness, palpitations or unusual tiredness are worth prompt review rather than being put down to a flare. The heart valves can be affected in antiphospholipid syndrome and lupus, and occasionally in relapsing polychondritis, though this is usually silent and found on a scan rather than felt.

Inflammation can also reach the aorta, the large vessel leaving the heart, and the electrical wiring that keeps the heart in rhythm. In axial spondyloarthritis this happens uncommonly, and usually only after many years, affecting the aortic root, the aortic valve or the rhythm; most people are never affected, there is no routine screening for it in the UK, and it is looked into when symptoms or an examination give a reason. The aorta can also be involved in large-vessel vasculitis such as giant cell arteritis and Takayasu arteritis. And in systemic sclerosis the heart muscle and the lung circulation can be affected, which is why that guide describes the regular heart and lung checks arranged for it. Sarcoidosis, an inflammatory condition that can affect several organs, can occasionally involve the heart too; this is uncommon, often silent and found only on a scan, looked for when there is a reason and managed together with cardiology, and our sarcoidosis guide explains it.

The heart is easy to overlook when the joints are what hurt, yet for people with an inflammatory rheumatic condition it is one of the most rewarding things to look after. The risk is real but far from fixed: most of it can be measured, and most of it can be lowered. Controlling the inflammation, having your blood pressure and cholesterol checked, not smoking, staying active and keeping a healthy weight are not separate from your arthritis care, they are part of it, and each works better alongside the others. Bringing the same steady attention to the heart that goes into the joints is one of the best long-term investments you can make. If you are unsure whether your heart risk has been assessed, or who is keeping track of it, that is exactly the kind of question a specialist review can help you answer.

Why does inflammation raise the risk to my heart?

The inflammation that affects your joints also acts on the walls of your arteries, gradually speeding up the furring and narrowing that leads to heart attacks and strokes. This is why conditions such as rheumatoid arthritis, lupus, psoriatic arthritis, axial spondyloarthritis and gout carry a somewhat higher cardiovascular risk than average. In rheumatoid arthritis the risk is roughly 50% higher; in lupus, heart problems can appear at a younger age than expected. The reassuring part is that much of this added risk can be measured and lowered.

Does treating my arthritis well protect my heart?

Yes, and this is the most encouraging message here. Because the extra risk is driven largely by inflammation, keeping the inflammation under control lowers it. People whose disease is well controlled have fewer heart problems than those whose disease stays active, and the disease-modifying treatments that achieve that control are linked with lower cardiovascular risk when they are doing their job. Sticking with your treatment and keeping up your reviews is heart protection as much as joint protection.

Whose job is it to check my heart risk, my GP or my rheumatology team?

Both share it, which is exactly why it can occasionally be missed if each assumes the other has it in hand. A heart-risk check is simple: your blood pressure, a cholesterol test and a calculation of your overall risk, done in the UK with a tool called QRISK that now takes rheumatoid arthritis into account. It is a fair and useful thing to ask at a review: has my heart risk been assessed, and who is keeping an eye on it?

Are any arthritis medicines bad for the heart?

Most are good for the heart, because controlling inflammation protects it. A few need care. Anti-inflammatory painkillers (NSAIDs) can raise blood pressure and load the heart and kidneys with regular use, so they are used sparingly in people at cardiovascular risk. JAK inhibitors carry specific UK safety advice in people aged 65 or over, smokers and those with heart-disease risk factors, and steroids at higher doses over time can nudge up blood pressure, blood sugar and weight. None of this is a reason to stop a medicine on your own; it is a reason for the choices to be made and reviewed with your specialist.

Can these conditions inflame the heart itself, not just the arteries?

Occasionally, yes, though direct inflammation of the heart is much rarer than the slow artery changes that drive the extra heart-attack and stroke risk, and most cases are mild or picked up only on a scan. The usual site is the thin lining around the heart (pericarditis), seen most often in lupus and, less often, rheumatoid arthritis and adult-onset Still's disease. Less commonly still, inflammation can affect the heart muscle (myocarditis), the valves, or, in axial spondyloarthritis, the root of the aorta. All of these are looked for when there is a reason to and managed together with cardiology, and good control of the underlying condition is what prevents most of them.

How do I know if chest pain is pericarditis and not something serious?

You cannot safely settle that yourself, and you should not try. Pericarditis typically causes sharp chest pain that eases when you sit up and lean forward, but its features overlap with far more urgent causes, and the same person can have both. Call 999 if chest pain is crushing, tight or pressure-like, spreads to an arm, the jaw, the neck or the back, or comes with breathlessness, sweating or feeling sick. Any new chest pain needs assessment first; our costochondritis guide sets out the chest-pain warning signs in full.