Non-ST-Segment Elevation Myocardial Infarction (NSTEMI) in a High-Risk Rheumatoid Arthritis Patient on Long-Term Baricitinib: Drug Signal or Risk Factor Convergence?
Abstract
Rheumatoid arthritis (RA) is associated with increased cardiovascular (CV) morbidity and mortality, partly related to chronic systemic inflammation and accelerated atherosclerosis. Janus kinase (JAK) inhibitors, including baricitinib, are effective targeted therapies for RA, but their use in older patients and those with baseline CV risk factors requires careful risk assessment. We report a clinically detailed case of non-ST-elevation myocardial infarction (NSTEMI) during long-term baricitinib therapy and use it to discuss real-world CV risk stratification, monitoring, and pharmacovigilance in patients with RA receiving JAK inhibitors. A 77-year-old Omani woman with seropositive erosive RA since age 69 (Month 0), poorly controlled type 2 diabetes mellitus, well-controlled hypertension, well-controlled hyperlipidemia, obesity, and family history of myocardial infarction was treated with baricitinib 4 mg daily (Month 47) after inadequate response to previous disease-modifying antirheumatic drugs. Her RA remained in sustained remission for approximately 33 months on baricitinib and methotrexate. A cardiac evaluation performed five years earlier, including echocardiography and dobutamine stress testing, had not shown evidence of inducible ischemia or structural heart disease at that time. She subsequently developed sudden chest pain during physiotherapy, was diagnosed with NSTEMI (Month 79), and underwent percutaneous coronary intervention for severe calcified coronary artery…
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