Reversing myocardial microvascular disease in a patient with rheumatoid arthritis.

Rheumatoid arthritis (RA) is associated with increased cardiovascular mortality. This is regarded as being due to accelerated coronary atherosclerosis. We describe a 62-year-old man with seropositive erosive RA and extraarticular manifestations but no history of cardiovascular disease. Noninvasive assessment of myocardial blood flow by adenosine stressed thallium scanning showed reversible ischemia and diffusely poor myocardial perfusion. Repeat assessment after intensive immunosuppression for rheumatoid vasculitis revealed resolution of the ischemic changes and generally increased myocardial perfusion. Coronary angiography revealed no significant atheroma, suggesting that myocardial microvascular disease was responsible for the ischemia. This may be an important determinant of cardiovascular outcome in RA, and this case indicated that it can be reversed with immunosuppression.