Feature

Teamwork guides cardio-rheumatology clinics that care for unique patient population


 

Clinical cardiologist Heba Wassif, MD, MPH, knows the value of working with her fellow rheumatologists, surgeons, and other clinicians to establish a care plan for her patients with cardiac conditions and autoimmune diseases.

She is the cofounder of the Cleveland Clinic’s new cardio-rheumatology program, which places an emphasis on multidisciplinary care. In her role, Dr. Wassif closely follows her patients, and if she sees any inflammation or any other condition that requires the rheumatologist, she reaches out to her colleagues to adjust medications if needed.

Dr. Heba Wassif, director of inpatient clinical cardiology and cofounder of the cardio-rheumatology program at Cleveland Clinic in Ohio

Dr. Heba Wassif

Collaboration with a rheumatologist was important when a patient with valvular disease was prepping for surgery. The patient was on significant immunosuppressants and the surgery had to be timed appropriately, accounting for any decreases in her immunosuppression, explained Dr. Wassif, director of inpatient clinical cardiology at Cleveland Clinic in Ohio.

Cardio-rheumatology programs are “the newest child” in a series of cardiology offshoots focusing on different populations. Cardio-oncology and cardio-obstetrics took off about 6 years ago, with cardio-rheumatology clinics and interested physicians rising in number over the last several years, Dr. Wassif noted.

The relationship between cardiovascular diseases and rheumatologic conditions is certainly recognized more often, “which means more literature is being published to discuss the link,” according to Rekha Mankad, MD, a trailblazer of this model of care. She directs the Women’s Heart Clinic at Mayo Clinic in Rochester, Minn., which was one of the earliest adopters of a cardio-rheumatology clinic.

Dr. Rekha Mankad, director of the Women's Heart Clinic at Mayo Clinic in Rochester, Minn.

Dr. Rekha Mankad

Ten years ago, “nobody was talking about the link between rheumatologic conditions and cardiovascular disease,” Dr. Mankad said. “I’ve been asked to speak on this topic, and programs have asked me to speak about establishing cardio-rheumatology practices. So, there’s been an evolution as far as a recognition that these two conditions overlap.”

Patients have come to her independent of internal referrals, which means they have done Google searches on cardiology and rheumatology. “I think that it has made a splash, at least in the world of cardiology,” Dr. Mankad observed in an interview.

Other institutions such as NYU-Langone, Yale, Stanford, Brigham and Women’s Hospital in Boston, and Women’s College Hospital in Toronto have formed similar clinics whose focus is to address the specific needs of rheumatology patients with cardiac conditions through a teamwork approach.

Challenges of treating cardiac, rheumatologic conditions

The rise in clinics addresses the longstanding connection between autoimmune disorders and cardiac conditions.

Cardiologists have known that there is an element of inflammation that contributes to atherosclerosis, said Dr. Wassif, who has researched this topic extensively. A recent study she led found a strong association between rheumatic immune-mediated inflammatory diseases (IMIDs) and high risk of acute coronary syndrome in Medicare patients.

“This particular population has a very clear increased risk for cardiovascular conditions, including valve disease and heart failure,” she emphasized.

Patients with rheumatoid arthritis and lupus have up to a twofold and eightfold higher risk of heart disease, respectively, noted Michael S. Garshick, MD, a cardiovascular disease specialist who directs the cardio-rheumatology program at NYU-Langone Health, in New York. Cardiologists “have really developed an understanding that the immune system can impact the heart, and that there’s a need for people to understand the nuance behind how the immune system can affect them and what to do about it,” Dr. Garshick said.

Michael S. Garshick, caridiologist, New York University, NYU Langone

Dr. Michael S. Garshick

Caring for patients with both afflictions comes with specific challenges. Many physicians are not well trained on managing and treating patients with these dual conditions.

The “lipid paradox,” in which lipids are reduced with active inflammation in some rheumatologic conditions, can make treatment more nuanced. In addition, the traditional ASCVD (atherosclerotic cardiovascular disease) score often underestimates the cardiovascular risk of these patients, noted cardiologist Margaret Furman, MD, MPH, assistant professor and codirector of Yale’s Cardio-Rheumatology Program, New Haven, Conn.

Newer biologic medications used to treat rheumatologic diseases can alter a patient’s lipid profile, she said in an interview.

“It can be difficult to assess each individual patient’s cardiovascular risk as their disease state and treatment can vary throughout their lifetime based on their degree of inflammation. The importance of aggressive lipid management is often underestimated,” Dr. Furman added.

Cardiology and rheumatology partnerships can address gaps in care of this unique group of patients, said Vaidehi R. Chowdhary, MBBS, MD, clinical chief of the Yale Section of Rheumatology, Allergy, and Immunology at Yale University.

Dr. Vaidehi R. Chowdhary, cofounder of the cardio-rheumatology program at Yale University, listens to a patient's heart. Courtesy Rob Lisak

Dr. Vaidehi R. Chowdhary, cofounder of the cardio-rheumatology program at Yale University, listens to a patient's heart.

“The role of the rheumatologist in this dyad is to educate patients on this risk, work toward adequate control of inflammation, and minimize use of medications that contribute to increased cardiovascular risks,” said Dr. Chowdhary, who cofounded Yale’s cardio-rheumatology program with Dr. Furman.

Cardiologists in turn can assert their knowledge about medications and their impact on lipids and inflammation, Dr. Wassif said.

Many anti-inflammatory therapies are now within the cardiologist’s purview, Dr. Garshick noted. “For example, specifically with pericarditis, there’s [Food and Drug Administration]–approved anti-inflammatories or biologics. We’re the ones who feel the most comfortable giving them right now.” Cardiologists quite often are consulted about medications that are efficacious in rheumatologic conditions but could negatively impact the cardiovascular system, such as Janus kinase inhibitors, he added.

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