Heart Failure Revealing Occult Rheumatoid Aortitis Presenting as a Giant Ascending Aortic Aneurysm With Functional...

Rheumatoid arthritis (RA) is a systemic inflammatory disease that can rarely involve the aorta and remain clinically silent until severe complications occur. We report the case of an 80-year-old woman with no cardiovascular risk factors who presented with acute left-sided heart failure that led to the diagnosis of previously unrecognized rheumatoid arthritis. Transthoracic echocardiography demonstrated global left ventricular hypokinesia with a left ventricular ejection fraction of 34%, a structurally preserved tricuspid aortic valve, and moderate-to-severe functional aortic regurgitation related to ascending aortic dilation. The ascending aorta was markedly dilated, predominantly at the sinotubular junction and tubular segment. Computed tomography confirmed a giant ascending aortic aneurysm measuring 6.2 cm and revealed additional dilation of the right subclavian artery, suggesting multifocal large-vessel involvement. Laboratory investigations showed elevated inflammatory markers, and immunological testing supported the diagnosis of rheumatoid arthritis. These findings were highly suggestive of an underlying inflammatory aortopathy, although a definitive causal relationship could not be established. This case highlights that heart failure may be the presenting event revealing occult inflammatory aortopathy and underscores the importance of considering systemic inflammatory diseases in patients with unexplained aortic pathology, even in the absence of traditional cardiovascular risk factors.