Celiac disease and the heart.

Celiac disease (CD), an immune disorder primarily affecting the gut, occurs in nearly 1% of the general US population. Extraintestinal manifestations of CD include dermatitis herpetiformis, osteoporosis, hyposplenism and a susceptibility to streptococcal sepsis, thyroid disorders and connective tissue disorders. Iodha et al report a case of dilated cardiomyopathy which was found to have symptomatic CD. The first suggestions of a link between CD and idiopathic dilated cardiomyopathy (IDCM) were made a decade ago, when Curione et al found a prevalence of 5.8% for CD in a cohort of Italian IDCM patients. The study had no control group however, and a comparison to the prevalence of CD in the general population revealed a significant increased risk for IDCM patients. Prati et al similarly found a raised incidence of CD in a cohort of Italian end-stage heart failure patients compared to controls. An association of CD with autoimmune myocarditis was detected by Frustaci et al in an Italian cohort of patients, while De Bem et al found raised antiendomysial antibodies in 2.63% of Brazilian precardiac transplant patients suffering from IDCM. The highest quality study so far by Elfström et al used the Swedish National Inpatient Register to conduct a case control study of CD patients. The authors concluded that there was no association between CD, myocarditis, cardiomyopathy and pericarditis. They did, however, find some statistically significant associations. An association was found between CD and any cardiomyopathy prior to 1987; however, diagnostic documentation became more precise after 1987, at which point no association between CD and IDCM was found. Interestingly, a prior diagnosis of cardiomyopathy was associated with a later diagnosis of CD. The currently available data is conflicting. The quality of studies is variable as most of them do not have control groups. Up-to-date evidence does not, therefore, allow a firm conclusion that CD and IDCM, or indeed any heart diseases, are statistically associated. The issue could be attacked from two angles and there are two unanswered questions in principle: