Cardiovascular implications of inflammatory bowel disease: An updated review

Table 1 Practical guide to management of cardiovascular diseases in inflammatory bowel disease

Cardiovascular disease	Risk factors	Suggested testing	Therapeutic considerations
Pericarditis and myocarditis	Disease related	Onset of symptoms within 2-4 wk of starting 5-ASA	Discontinuation of therapy
	Disease activity
	Drugs	ECG: ST-T changes	Immunesuppressives for inflammation associated myocarditis
	5-ASA
		2D Echocardiography: LV dysfunction, pericardial effusion	Pericardiocentesis or pericardial window, if cardiac tamponade
		Cardiac MRI	Control IBD disease activity
		Endo-myocardial biopsy, if cardiac MRI contraindicated or life threatening disease
		Elevated cardiac biomarkers
Venous Thromboembolism	Patient related	Screening for genetic risk factors in patients with recurrent venous thromboembolic events	Thromboprophylaxis
	Elderly age		All IBD patients during hospitalization of any cause
	Females		Ambulatory patient with active IBD and known risk factors for VTE
	Obesity		Prophylaxis should be maintained during the inpatient period
	Malnutrition
	Disease related		Treatment
	Disease activity		LMWH
	Colonic disease location		Direct oral anticoagulants
	UC > CD		Cautious use of JAK inhibitors
	Hospitalization		Aim the lowest effective dose to maintain remission
	Emergency surgery
	Longer operative time
	Open surgery
	Drugs
	JAK inhibitors
	Corticosteroids
Atherosclerotic cardiovascular disease	Patient related	Lipid profile at baseline, end of induction and every 6 mo	Treatment of ASCVD is similar to non IBD patients and should be done in close collaboration with an expert cardiologist
	Younger age
	Females
	Disease related	Test for subclinical atherosclerosis	Control IBD disease activity
	Disease activity	Carotid intima media thickness
	Colonic disease location	Pulse-wave velocity between the carotid and femoral arteries
	Increased hs CRP	Coronary artery calcium
	Increased fibrinogen
	Drugs	2D echocardiography/stress echocardiography/TMT	Cautious use of JAK inhibitors
	Corticosteroids
	JAK inhibitors
		Coronary angiography	Treat JAK inhibitor induced dyslipidemia/hyerlipidemia with statins
Heart failure	Patient related	2D Echocardiography	Avoid anti TNF in NYHA Class III or IV heart failure, especially with ejection fraction ≤ 35%
	Females	Ventricular dysfunction
	Underlying cardiac structural diseases	Structural abnormalities
	Diabetes
	Hypertensive heart disease
	Chagas disease
	Deposit diseases
	Valvular heart disease
	Disease related
	UC > CD
	Drugs
	Anti TNF agents in high dose
Arrhythmias and conduction abnormalities	Patient related	ECG	Control disease activity
	Age > 65 yr	Increased P-wave dispersion	Caution with S1P receptor modulators
	Previous arrhythmias or cardiac conduction abnormalities	Increased QTc dispersion	Caution in patients with risk factors
	Ischemic heart disease	Prolonged QTc interval
	Cardiomyopathy with septal involvement
	Drugs (e.g: beta-blockers, calciumchannel inhibitors, antiarrhythmics)
	Uncontrolled hypertension
	Previous cardiac surgery
	Surgical/percutaneous treatment of valvular disease
	Disease related
	Disease activity
	Drugs
	S1P receptor modulators

ASA: Amino salicylic acid; ECG: Electrocardiogram; LV: Left ventricular; MRI: Magnetic resonance imaging; IBD: Inflammatory bowel disease; CD: Crohn’s disease; UC: Ulcerative colitis; VTE: Venous thromboembolism; LMWH: Low-molecular-weight heparin; JAK: Janus kinase; ASCVD: Atherosclerotic cardiovascular diseases; CRP: C-reactive protein; TMT: Treadmill test; TNF: Tumor necrosis factor; NYHA: New York heart association; S1P: Sphingosine-1-phosphate.