A study of autonomic nervous system dysfunction in subjects with chronic rheumatoid arthritis with relation to their age and duration of the disease

Abstract

Neurological manifestations are seen relatively frequently in patients with rheumatoid arthritis. The occurrence of a peripheral neuropathy is well recognised. Since the 1960s there has been a growing interest in the role of the autonomic nervous system in rheumatoid arthritis. There is conflicting evidence to support this view. The aim of this study was to investigate whether autonomic impairment occurs in rheumatoid arthritis, and if so, whether this is related to age, disease duration or rheumatoid factor status. The influence of disease activity was also investigated. Clinical assessment of autonomic function was carried out using the battery of cardiovascular reflex tests as described by Ewing and Clarke, 1982. The use of these tests is established in clinical practice. Cardiovascular reflexes were measured in 62 rheumatoid arthritis outpatients aged between 38-84 years old (mean age 63.2yrs) and 41 healthy controls aged between 22-82 years old (mean age 48.0yrs) of either sex. None of these subjects had overt cardiovascular disease, other co-pathology known to interfere with autonomic function (such as diabetes), or were taking medication known to interfere with heart rate or blood pressure. The results demonstrated significant differences between the rheumatoid and control group in heart rate responses to the Valsalva manoeuvre (p=0.03), to deep breathing (p=0.01), to standing (p=0.001) and in the rise in the diastolic pressure in response to sustained handgrip (p<0.001). These differences indicate autonomic impairment in the rheumatoid patients, which was not clinically apparent with a fall in systolic blood pressure. Significant differences were also demonstrated in the heart rate responses to the Valsalva manoeuvre between the control group and the rheumatoid factor positive patients (p=0.02), those who had had the disease for longer than 10 years (p=0.01) and in the older subjects (p=0.02). In general this trend is observed when each of the subgroups was compared against controls for the other cardiovascular autonomic reflexes. The exception being age group where no consistent pattern emerged. There was no difference observed in the cardiovascular reflexes when patients with or without peripheral neuropathy were compared with the controls. Furthermore there was no correlation with disease activity. In conclusion, the results indicate that there is a tendency to impaired autonomic function as assessed by the cardiovascular reflexes. This exists on a subclinical level.

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