Heart Failure in Patients with Inflammatory Arthritis: An Underrecognized Cardiovascular Burden

Heart failure (HF) is an underrecognized complication of inflammatory arthritis that is incompletely addressed by atherosclerosis-centered prevention. This critical narrative review examines epidemiological, mechanistic, diagnostic, and treatment evidence in rheumatoid arthritis (RA), psoriatic arthritis (PsA), and axial spondyloarthritis. RA cohorts support excess HF risk, with a stronger preserved ejection fraction signal; evidence in PsA and axial spondyloarthritis is less extensive and should not be inferred from RA or psoriasis-only populations. Inflammatory activity and traditional cardiovascular factors interact, and their causal contributions cannot be reliably partitioned. Diagnosis should integrate symptoms, natriuretic peptides, comprehensive echocardiography, and selective advanced testing. Reduced global longitudinal strain (GLS) can reveal subclinical systolic dysfunction despite preserved ejection fraction but does not, in isolation, establish HF. RA serostatus, interstitial lung disease, thromboembolism, and renal impairment require explicit characterization. Management should coordinate HF care with disease-specific selection of disease-modifying antirheumatic drugs (DMARDs), renal and fluid surveillance, and review of glucocorticoids and nonsteroidal anti-inflammatory drugs (NSAIDs). Lower composite cardiovascular event rates during antirheumatic therapy do not establish prevention or reversal of HF. Prospective disease-specific phenotyping and adjudicated HF outcomes are needed.