Inflammation and your heart

Inflammation that goes on for years is not confined to the joints. The immune activity that leaves joints swollen and stiff also works on the inner lining of the blood vessels, speeding up atherosclerosis: the gradual build-up of fatty plaque that narrows the arteries and can lead to heart attacks and strokes. Among the conditions affected are rheumatoid arthritis and lupus; psoriatic arthritis, axial spondyloarthritis and gout share the raised cardiovascular risk too.

How much extra risk a person carries depends on the condition, and on how well it is controlled. For rheumatoid arthritis, studies pooled together put the chance of a heart attack, a stroke or heart failure at around one and a half times that of the general population, and one study found its risk of a heart attack close to that of people with diabetes. Lupus behaves a little differently: it can hasten atherosclerosis enough for heart disease to appear unusually early, most noticeably in young people with lupus, whose risk would otherwise be small. People with gout often have high blood pressure, raised cholesterol or diabetes as well, and each brings its own risk.

Antiphospholipid syndrome raises risk by a separate route. In it the blood clots too easily, so the threat to the heart and the brain comes from clots rather than from years of plaque, and a heart attack or a stroke can follow, a stroke occasionally at a younger age than expected; preventing clots is therefore at the centre of its care, as its own guide describes.

Heart trouble is not inevitable. What the raised risk does mean is that your heart merits the attention your joints get, and that the extra risk can be checked and cut.

Here is the 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, are associated with a lower cardiovascular risk when they do their job. The JAK inhibitors are the exception here: they carry their own UK safety advice, set out below in the section on arthritis medicines and the heart.

This is the idea doctors call treating to target: the aim is remission or low disease activity, which means more than fewer symptoms. Keeping to your treatment, attending blood tests and reviews, and not leaving active disease to simmer are as good for the heart as for the joints, so part of protecting your heart is something you are already doing.

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 QRISK3, which takes rheumatoid arthritis into account as a risk factor in its own right, reflecting what the inflammation does to the arteries. Even so, NICE cautions that risk tools can underestimate the risk in autoimmune and inflammatory conditions, so a reassuring score is a conversation to have with your team rather than the last word.

The check belongs to your GP and your rheumatology team together, and a job held by two can go undone when each believes the other has done it. Ask at a review whether your heart risk has been looked at and who is following it up.

Controlling the disease matters, and the ordinary ways of protecting a heart matter for you too.

• Blood pressure. High blood pressure is found by having it measured, and when it is high, treating it lowers the risk.
• Cholesterol. Your level comes from a blood test; if your overall risk is high enough, a statin or another medicine that lowers cholesterol makes a heart attack or stroke less likely, a decision taken with your GP or specialist on your own figures.
• Smoking. It is worth being direct. Smoking raises the risk to the heart and the arteries steeply, and with inflammatory disease it also blunts the effect of treatment, leaving the disease harder to hold down and the risk raised on two fronts. For many people, stopping is the most worthwhile change they can make, and the help available for it is worth using.
• Activity. Regular activity helps the heart, and with arthritis it does the joints good rather than harm. Arthritis and exercise explains how to get going.
• Weight and diet. A healthy weight, reached and kept, eases both the heart and the joints, and a balanced diet helps them both; diet and arthritis goes into the detail.

No single step here is dramatic on its own; kept up together, year after year, they add up.

Many treatments for inflammatory arthritis do the heart good, since they damp down the inflammation that puts it at risk. A handful need thought, which calls for a specialist's eye rather than for worry.

Ibuprofen, naproxen and the other anti-inflammatory painkillers (NSAIDs) are good at relieving pain, but they can bring a small rise in the risk of a heart attack or a stroke, to differing degrees, the risk perhaps greatest with high doses taken for a long time, and they can raise blood pressure and affect the kidneys. Anyone taking them should use the lowest dose that works, for no longer than needed, and when heart risk is raised they are sometimes avoided altogether. Ask a pharmacist, your GP or your specialist what is safe in your case.

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 other risk factors for heart disease or cancer, a JAK inhibitor is used only when no suitable alternative is available; extra care is also taken where there are risk factors for blood clots. 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 are quick to settle inflammation, but a high dose, or a long course, can raise blood pressure and blood sugar, and high doses over a long period can lead to weight gain, one reason doctors keep to the smallest dose that works for the shortest sensible time. The steroids in rheumatology guide has the detail.

Most of this page is about the arteries. Less often, inflammation affects the heart directly. Effects of this kind are uncommon, and some are rare; many cause little or nothing and are found on a scan, and the serious ones are looked for when there is cause and treated together with a cardiologist, alongside treatment for the condition itself.

Pericarditis is inflammation of the pericardium, the thin sac that surrounds the heart. It can happen in lupus, in adult-onset Still's disease and in rheumatoid arthritis. The usual pain is sharp or stabbing rather than crushing, often worse with a deep breath or when lying down and better when sitting up and leaning forward, and a temperature can come with it. Stronger inflammation can leave a collection of fluid in the sac, called a pericardial effusion, and in lupus that deserves a word of reassurance: it is surprisingly common, usually causes no symptoms at all, and scans find some fluid in up to 30% of people with lupus.

The key word is "usual", not "certain". Never decide for yourself that a chest pain is pericarditis, because its features overlap with much more dangerous causes. Chest pain with any of the signs in the first list under When to seek help is a 999 or A&E emergency, and with lupus or antiphospholipid syndrome that includes chest pain that catches as you breathe in, which can mean a clot on the lung; short of those, a new sharp chest pain that is worse on a deep breath, on swallowing, coughing or lying down is for your GP, your rheumatology team or NHS 111 the same day. When pericarditis has been properly diagnosed, it usually clears well as the inflammation is treated, and most people feel better within a few weeks.

Other parts of the heart are involved less often. Myocarditis, inflammation of the heart muscle, is uncommon; it can happen in lupus and in the inflammatory myopathies. Palpitations happening now that do not stop, or that come with chest pain, breathlessness, feeling faint or fainting, are a 999 or A&E emergency; short of that, new breathlessness or palpitations, especially with tiredness far beyond the usual, are for the same day, as the list below says, rather than something to blame on a flare. Antiphospholipid syndrome and lupus can affect the heart's valves, as, occasionally, can relapsing polychondritis; this often causes no symptoms, is found on a heart scan, and is managed with a cardiologist.

Inflammation can reach the aorta too, the large artery leading out of the heart, and the electrical system that keeps the heartbeat steady. In axial spondyloarthritis this is uncommon and generally comes only after many years, involving the root of the aorta, the aortic valve or the heart's rhythm; most people never develop it, there is no routine UK screening, and it is investigated when symptoms or an examination give cause. The aorta can be inflamed in large-vessel vasculitis, whose two forms are giant cell arteritis and Takayasu arteritis; sudden severe pain in the abdomen or back is a 999 or A&E emergency, as the first list says. Systemic sclerosis can affect both the heart and the circulation through the lungs, so its guide describes regular checks of the two. Occasionally the heart is involved in sarcoidosis, an inflammatory illness of several organs; it is uncommon and often silent, and that guide explains how it is looked for and managed.

Heart risk is mostly a matter for planned checks, but a few symptoms cannot wait, and the lists below say where to go for each, starting with the most urgent; the paragraph after them covers what belongs at a routine appointment.

Treat any of these as a 999 or A&E emergency: call 999 and do not drive yourself to A&E.

• Severe illness with suspected sepsis: a high fever with shaking, confusion, rapid breathing, or feeling dramatically worse over hours
• With a fever or feeling unwell, a rash that does not fade when you press it, a stiff neck with eyes that cannot bear bright light, or skin, lips or tongue turning blue, grey, pale or blotchy, since these can be signs of meningitis or sepsis; on black or brown skin the rash and the change of colour may be easier to see on the palms of the hands or the soles of the feet
• Chest pain that is crushing, tight or like a pressure, that spreads to an arm, the jaw, the neck, the stomach or the back, that comes with breathlessness, sweating, feeling sick or feeling light-headed, or that came on suddenly and does not go away
• Sudden severe pain in the abdomen or back, since in large-vessel vasculitis an inflamed aorta can tear or burst
• Breathlessness that is severe, with gasping, choking or no breath to get words out; coughing up blood; or, with lupus or antiphospholipid syndrome, chest pain that catches as you breathe in, or, with antiphospholipid syndrome, chest or upper back pain that comes on suddenly, since these can mean a clot on the lung
• Palpitations happening now that do not stop, or that come with chest pain, breathlessness, feeling faint or fainting, since a heart whose muscle or rhythm is affected has to be checked at once
• A blackout, since inflammation can, uncommonly, reach the heart's muscle or disturb its rhythm
• Sudden weakness or numbness on one side, a drooping face or difficulty speaking, a sudden severe headache, sudden confusion or a seizure, or sudden loss of vision, any of which can be a stroke, even if it stops after a short time
• An eye that suddenly and completely loses its sight
• Lips, mouth, throat or tongue that suddenly swell, a throat that feels tight, very fast breathing or a struggle to breathe or to swallow, skin, tongue or lips turning blue, grey or pale (on black or brown skin this may be easier to see on the palms of the hands or the soles of the feet), becoming suddenly very confused, drowsy or dizzy, or fainting and not being able to be woken, since this can be a severe allergic reaction, anaphylaxis, which can follow a dose of any medicine

Any of these needs an assessment that is urgent, on the same day, from your GP, your rheumatology team or NHS 111:

• New chest pain, new palpitations, or breathlessness that is new or getting worse, since pericarditis or myocarditis can start this way: a sharp chest pain that is worse on a deep breath, on swallowing, coughing or lying down, or breathlessness or palpitations with tiredness out of all proportion; palpitations happening now that do not stop, or that come with chest pain, breathlessness, feeling faint or fainting, belong to the first list, and so, with lupus or antiphospholipid syndrome, does chest pain that catches as you breathe in, and, with antiphospholipid syndrome, chest or upper back pain that comes on suddenly; in pregnancy, breathlessness that comes on suddenly, or when you lie down, or with dizziness, is for your midwife or maternity unit straight away
• Chest pain that comes on when you walk, climb stairs, are upset or are out in the cold, and fades within a few minutes of rest, or angina you already have that is getting worse, coming more often, lasting longer or coming on at rest, since this can mean the heart's own arteries are narrowing; NHS 111 will tell you where to be seen; chest pain that does not ease after a few minutes of rest, or after your angina medicine, belongs to the first list

If you have never had a heart-risk check, or had one years ago, ask for it at your next GP or rheumatology review; blood pressure, cholesterol and whether you need a statin are for a routine GP appointment. If you take a JAK inhibitor or steroids and want to know what they mean for your heart, raise it at your next review rather than stopping the medicine; for an anti-inflammatory painkiller, ask a pharmacist, your GP or your specialist. No referral is needed to be seen here; next-working-day appointments can almost always be arranged, and same-day appointments are sometimes possible. If you take methotrexate, another DMARD, a steroid, a biologic or a JAK inhibitor, the warning signs that belong to each are set out in our guides to methotrexate, DMARDs, steroids and biologics and JAK inhibitors. If you cannot tell how urgent something is, asking is never a mistake.

When it is your joints that hurt, the heart slips easily out of mind, yet for someone with an inflammatory rheumatic condition it repays care. The added risk is real, and it can be measured and brought down. Controlling the inflammation, checking blood pressure and cholesterol, not smoking, keeping active and staying a healthy weight belong to your arthritis care rather than standing apart from it, and each works best with the others. If you are not sure whether your heart risk has been checked, or who is keeping an eye on it, a specialist review is a sensible place to find out.

Why do inflammatory conditions raise the risk to the heart?

Inflammation that affects your joints acts on your artery walls as well, hastening the build-up of fatty plaque that causes heart attacks and strokes. The inflammatory conditions this page covers, from rheumatoid arthritis and lupus to gout, therefore carry a somewhat higher cardiovascular risk. With rheumatoid arthritis, the combined chance of heart attack, stroke and heart failure runs at around one and a half times that of the general population; with lupus, heart disease tends to appear younger than usual. The encouraging part is that the extra risk can be checked and reduced.

Does getting my arthritis under control help my heart?

It does, and that is the best news on this page. Part of the added risk comes from the inflammation itself, so calming the inflammation is likely to lessen it. Heart risk has been linked with how active the disease is, and in rheumatoid arthritis, disease-modifying treatment that works has been tied to lower cardiovascular risk. Staying on your treatment and going to your reviews looks after your heart as well as your joints.

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 QRISK3, which counts rheumatoid arthritis as a risk factor, though NICE notes that even then such tools can underestimate the risk in inflammatory conditions. 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?

Could any of my arthritis medicines affect my heart?

Many protect it, because quietening inflammation is good for the heart, but a few call for care. Anti-inflammatory painkillers (NSAIDs) can bring a small rise in the risk of a heart attack or a stroke, perhaps greatest with high doses taken for a long time, and can raise blood pressure, so the lowest dose is used for the shortest time, and they are sometimes avoided when heart risk is raised. JAK inhibitors come with UK safety advice for people aged 65 or over, current or past long-term smokers and those with risk factors for heart disease or cancer. A high dose of steroids, or a long course, can raise blood sugar and blood pressure, and high doses over a long period can lead to weight gain. None of these is a reason to stop a medicine yourself; each is a reason to make the choice, and to keep reviewing it, with your specialist.

Is the heart itself ever inflamed by these conditions?

It can happen, though it is uncommon, and when it does it is often mild or found only on a scan. It can affect the pericardium, the sac around the heart (pericarditis), in lupus, adult-onset Still's disease and rheumatoid arthritis; and, more rarely, the heart muscle (myocarditis), the valves and, in axial spondyloarthritis, the start of the aorta. Doctors look for these when there is cause and treat them with cardiologists, alongside treatment for the condition itself.

How can I tell whether chest pain is pericarditis or something serious?

You cannot work that out safely on your own, so do not try. Chest pain that is crushing, tight or like a pressure, that spreads to an arm, the jaw, the neck, the stomach or the back, that comes with breathlessness, sweating, feeling sick or feeling light-headed, or that came on suddenly and does not go away, is a 999 or A&E emergency. Call 999 and do not drive yourself to A&E. Without those signs, any chest pain that is new to you is for your GP, your rheumatology team or NHS 111 the same day, even a sharp pain that eases when you lean forward and sounds like pericarditis, since pericarditis shares features with more dangerous causes; with lupus or antiphospholipid syndrome, though, chest pain that catches as you breathe in, and, with antiphospholipid syndrome, chest or upper back pain that comes on suddenly, belong to the first list under When to seek help, since they can mean a clot on the lung. Pain from the chest wall itself is covered in our costochondritis guide.