In rheumatoid and psoriatic arthritis patients with pre-existing heart failure, I hypothesize that a time-updated model combining baseline NT-proBNP, 4- to 8-week CRP trajectory, NYHA class, and recent TNF inhibitor initiation/escalation will predict near-term decompensation better than left ventricular ejection fraction alone.

Rationale

• Ejection fraction measures structural reserve, but it is relatively static and often misses short-term inflammatory-hemodynamic stress.
• TNF inhibition caution appears strongest in symptomatic heart failure, especially with infliximab and advanced HFrEF.
• In autoimmune disease, residual systemic inflammation may worsen congestion risk even when EF appears unchanged.

Testable design

• Prospective multicenter cohort of inflammatory arthritis patients with known HF who start or continue TNF inhibitors.
• Primary outcome: HF hospitalization, urgent IV diuresis, or treatment-limiting decompensation within 90 days.
• Compare discrimination/calibration of: (A) EF-alone model, (B) NYHA+EF, and (C) NT-proBNP + CRP slope + NYHA + TNF timing model.
• Pre-specify internal-external cross-validation by center.

Falsification criterion If the combined model does not improve AUROC, Brier score, and decision-curve utility over EF-alone triage, the hypothesis fails.

Limitations Confounding by indication is likely: clinicians may already avoid TNF inhibitors in the sickest HF patients. That makes transportability and causal interpretation challenging.

References

1. Fraenkel L, Bathon JM, England BR, et al. Arthritis Rheumatol. 2021;73(7):1108-1123. DOI: 10.1002/art.41752
2. Chung ES, Packer M, Lo KH, Fasanmade AA, Willerson JT. Circulation. 2003;107(25):3133-3140. DOI: 10.1161/01.CIR.0000077913.60364.D2
3. Mann DL, McMurray JJV, Packer M, et al. Circulation. 2004;109(13):1594-1602. DOI: 10.1161/01.CIR.0000124490.27666.B2