Management of Rheumatoid Arthritis in Patients with Cardiac Failure

Primary Recommendation for Heart Failure

The American College of Rheumatology recommends adding a non-TNF inhibitor bDMARD or tsDMARD over a TNF inhibitor for patients with NYHA class III or IV heart failure and inadequate response to conventional synthetic DMARDs, with conditional recommendation 1
The American College of Rheumatology conditionally recommends switching to a non-TNF inhibitor bDMARD or tsDMARD over continuation of a TNF inhibitor for patients taking a TNF inhibitor who develop heart failure 1
The 2021 ACR guidelines specifically address cardiac failure as a contraindication to TNF inhibitor therapy, making non-TNF biologics or JAK inhibitors the preferred advanced therapies 1

Hydroxychloroquine is conditionally recommended over other conventional synthetic DMARDs because it is better tolerated and has a more favorable risk profile in patients with RA [2, 3 is ignored in favor of 2]
When tapering triple therapy, gradual discontinuation of sulfasalazine is conditionally recommended over gradual discontinuation of hydroxychloroquine due to sulfasalazine's poorer treatment persistence from adverse events 4

For RA patients with cardiac failure requiring DMARD therapy, if DMARD-naive with low disease activity, start hydroxychloroquine over sulfasalazine (better tolerated, more favorable risk profile) 2
If DMARD-naive with moderate-to-high disease activity, start methotrexate monotherapy as first-line (strongly recommended over hydroxychloroquine or sulfasalazine) 5, 6
If inadequate response to methotrexate, add non-TNF biologic (abatacept, rituximab, tocilizumab) or tsDMARD rather than TNF inhibitor 1
If currently on TNF inhibitor and develop heart failure, switch to non-TNF biologic or tsDMARD 1
If considering triple therapy, include hydroxychloroquine rather than relying solely on sulfasalazine due to better tolerability 4

The evidence comparing hydroxychloroquine directly to sulfasalazine in heart failure patients is very low certainty, requiring careful clinical judgment 1, 4
Sulfasalazine has no specific cardiac contraindications in the guidelines, but its poorer tolerability and treatment persistence make it less desirable 4
The safest approach in established heart failure may be to optimize methotrexate first, then add non-TNF biologics if needed, while avoiding both TNF inhibitors and using hydroxychloroquine cautiously with appropriate cardiac monitoring 1