Table 1.
Practical guide to management of cardiovascular diseases in inflammatory bowel disease
|
Cardiovascular disease
|
Risk factors
|
Suggested testing
|
Therapeutic considerations
|
| Pericarditis and myocarditis | Disease related | Onset of symptoms within 2-4 wk of starting 5-ASA | Discontinuation of therapy |
| Disease activity | |||
| Drugs | ECG: ST-T changes | Immunesuppressives for inflammation associated myocarditis | |
| 5-ASA | |||
| 2D Echocardiography: LV dysfunction, pericardial effusion | Pericardiocentesis or pericardial window, if cardiac tamponade | ||
| Cardiac MRI | Control IBD disease activity | ||
| Endo-myocardial biopsy, if cardiac MRI contraindicated or life threatening disease | |||
| Elevated cardiac biomarkers | |||
| Venous Thromboembolism | Patient related | Screening for genetic risk factors in patients with recurrent venous thromboembolic events | Thromboprophylaxis |
| Elderly age | All IBD patients during hospitalization of any cause | ||
| Females | Ambulatory patient with active IBD and known risk factors for VTE | ||
| Obesity | Prophylaxis should be maintained during the inpatient period | ||
| Malnutrition | |||
| Disease related | Treatment | ||
| Disease activity | LMWH | ||
| Colonic disease location | Direct oral anticoagulants | ||
| UC > CD | Cautious use of JAK inhibitors | ||
| Hospitalization | Aim the lowest effective dose to maintain remission | ||
| Emergency surgery | |||
| Longer operative time | |||
| Open surgery | |||
| Drugs | |||
| JAK inhibitors | |||
| Corticosteroids | |||
| Atherosclerotic cardiovascular disease | Patient related | Lipid profile at baseline, end of induction and every 6 mo | Treatment of ASCVD is similar to non IBD patients and should be done in close collaboration with an expert cardiologist |
| Younger age | |||
| Females | |||
| Disease related | Test for subclinical atherosclerosis | Control IBD disease activity | |
| Disease activity | Carotid intima media thickness | ||
| Colonic disease location | Pulse-wave velocity between the carotid and femoral arteries | ||
| Increased hs CRP | Coronary artery calcium | ||
| Increased fibrinogen | |||
| Drugs | 2D echocardiography/stress echocardiography/TMT | Cautious use of JAK inhibitors | |
| Corticosteroids | |||
| JAK inhibitors | |||
| Coronary angiography | Treat JAK inhibitor induced dyslipidemia/hyerlipidemia with statins | ||
| Heart failure | Patient related | 2D Echocardiography | Avoid anti TNF in NYHA Class III or IV heart failure, especially with ejection fraction ≤ 35% |
| Females | Ventricular dysfunction | ||
| Underlying cardiac structural diseases | Structural abnormalities | ||
| Diabetes | |||
| Hypertensive heart disease | |||
| Chagas disease | |||
| Deposit diseases | |||
| Valvular heart disease | |||
| Disease related | |||
| UC > CD | |||
| Drugs | |||
| Anti TNF agents in high dose | |||
| Arrhythmias and conduction abnormalities | Patient related | ECG | Control disease activity |
| Age > 65 yr | Increased P-wave dispersion | Caution with S1P receptor modulators | |
| Previous arrhythmias or cardiac conduction abnormalities | Increased QTc dispersion | Caution in patients with risk factors | |
| Ischemic heart disease | Prolonged QTc interval | ||
| Cardiomyopathy with septal involvement | |||
| Drugs (e.g: beta-blockers, calciumchannel inhibitors, antiarrhythmics) | |||
| Uncontrolled hypertension | |||
| Previous cardiac surgery | |||
| Surgical/percutaneous treatment of valvular disease | |||
| Disease related | |||
| Disease activity | |||
| Drugs | |||
| S1P receptor modulators |
ASA: Amino salicylic acid; ECG: Electrocardiogram; LV: Left ventricular; MRI: Magnetic resonance imaging; IBD: Inflammatory bowel disease; CD: Crohn’s disease; UC: Ulcerative colitis; VTE: Venous thromboembolism; LMWH: Low-molecular-weight heparin; JAK: Janus kinase; ASCVD: Atherosclerotic cardiovascular diseases; CRP: C-reactive protein; TMT: Treadmill test; TNF: Tumor necrosis factor; NYHA: New York heart association; S1P: Sphingosine-1-phosphate.