First time myocardial infarction in a rheumatic patient after elective arthroplasty

The management of perioperative cardiovascular risk in patients with rheumatoid arthritis (RA) is challenging due to the independent contribution to risk by high grade inflammatory mechanisms and the underestimation of risk by traditional cardiac risk factors alone. RA is associated with accelerated rates of subclinical atherosclerosis and markedly higher rates of both myocardial infarction and sudden cardiac death over non-RA controls. There is an absence of prospectively validated perioperative coronary heart disease (CHD) risk assessment tools for this unique patient population and available guidelines may fail to identify those patients most at risk. We examine a singular case of first time myocardial infarction after uncomplicated elective surgery in an adult RA patient with an unrevealing preoperative cardiac assessment. We also review the current literature for shared pathogenic mechanisms between systemic inflammation and atherosclerosis, discuss clinical and biologic markers such as C-reactive protein (CRP) in RA patients associated with heightened cardiac risk and discuss recommendations based on available evidence for cardiovascular risk management in this at risk cohort.