Cardiovascular manifestations of systemic lupus erythematosus

Systemic lupus erythematosus with hepatic aneurysm, Valsalva sinus aneurysm and associated polyangiitis: aneurysmal wall remodeling with dense fibrosis and calcification mediated by residual smooth muscle cells

Isolated case reports have demonstrated the combination of hepatic aneurysm and systemic lupus erythematosus (SLE). The author experienced a rare autopsy case of a 36-year old Japanese male with SLE, a hepatic aneurysm, a Valsalva sinus aneurysm and associated polyangiitis. In the histopathological and ultrastructural examinations of the postmortem organs, most of the angiitis lesions were in the scar phase associated with the histopathological features of collagenous fibrosis with the diminution of the smooth muscle cells and elastic fibre layers. Massive calcification was seen on the wall and obliterative changes in the lumen with calcified thrombi. In the dense collagenous stroma of the aneurysmal wall, residual atrophic smooth muscle cells with immunohistochemical (HHF35, alpha-smooth-muscle actin, vimentin and desmin almost-) and ultrastructural features (spindle-shapedcells with a few rER and rich intracytoplasmicfilaments with peripheraldense patches)were assumed to be involvedin the histogenesisof the aneurysmalwall. Massivecalcification and degenerationor dynamic remodelingof the extracellularmatrices in the aneurysmalwall might be mediated by the residual smooth muscle cells. It was suspected that the generalized polyangiitis as a complication of SLE might have involved the intrahepatic arteries and Valsalva sinus wall and subsequently generated the aneurysm.

Outcome of patients with systemic lupus erythematosus in intensive care unit

The objective of the study was to identify the causes, outcome and prognosis of severe illness in patients with systemic lupus erythematosus (SLE) requiring intensive care unit (ICU) care in a University Hospital over a five-year period. The design was a cohort study. Forty-eight SLE patients requiring ICU management over a five-year period (January 1997-December 2001) were studied prospectively. Of 48 patients, 14 (29.2%) died, predominantly with multiorgan dysfunction syndrome (MODS). Patients whose APACHE II score was equal to or greater than 20 had higher mortality than those with APACHE score below 20 (60 versus 7.1%; and P, 0.01). All the 18 patients whose health status rated as ‘good’ survived, while 46.7% of 30 patients whose health rated as ‘poor’ died (P, 0.01). Patients who had thrombocytopenia associated with sepsis and/or disseminated intravascular coagulopathy (DIC) had the highest mortality (75%, five-year survival). In conclusion, SLE patients admitted to the ICU had a lower mortality rate than some of the previous reports. Patients with SLE with high APACHE score, ≥20, poor health status, thrombocytopenia and multiorgan dysfunction syndrome had poor prognosis in the ICU.

Large pericardial effusions due to systemic lupus erythematosus: a report of eight cases

The aim of this study was to describe the clinical, echocardiographic and laboratory characteristics of large pericardial effusions and cardiac tamponade secondary to systemic lupus erythematosus (SLE). An ongoing prospective study was conducted at Tygerberg Academic Hospital, South Africa between 1996 and 2002. All patients older than 13 years presenting with large pericardial effusions (.10 mm) requiring pericardiocentesis were included. Eight cases (out of 258) were diagnosed with SLE. The mean (SD) age was 29.5 (10.7) years. Common clinical features were Raynaud’s phenomenon, arthralgia and lupus nephritis class III/IV. Echocardiography showed Libman-Sacks endocarditis (LSE) in all the mitral valves. Two patients developed transient left ventricular dysfunction; both these patients had pancarditis. Typical serological findings included antinuclear antibodies, anti-double stranded DNA antibodies, low complement C4 levels and low C3 levels. CRP was elevated in six cases. Treatment consisted of oral steroids and complete drainage of the pericardial effusions. No repeat pericardial effusions or constrictive pericarditis developed amongst the survivors (3.1 years follow up). This study concludes that large pericardial effusions due to SLE are rare, and associated with nephritis, LSE and myocardial dysfunction. Treatment with steroids and complete drainage is associated with a good cardiac outcome.

Cardiac tamponade due to systemic lupus erythematosus in patient with Prader-Willi syndrome after growth hormone therapy

We present a 16-year old girl with Prader-Willi syndrome who developed cardiac tamponade as an initial finding of systemic lupus erythematosus. Until one year prior to this episode, she had received growth hormone treatment for nine years. The association among Prader-Willi syndrome, growth hormone treatment and systemic lupus erythematosus is discussed. Lupus (2007) 16, 447—449.

[Off-label use of intravenous immunoglobulin therapy in the treatment of lupus myocarditis: Two case reports and literature review]

INTRODUCTION

Several case reports have reported the benefit of intravenous immunoglobulin therapy in many autoimmune diseases, including systemic lupus erythematosus.

CASE REPORTS

Here, we report on two cases of lupus myocarditis treated with high dose of intravenous immunoglobulin. The first patient was a 42-year-old woman who presented with lupus myocarditis that was resistant to corticosteroids and cyclophosphamide, and who was finally successfully treated with a single dose of 2 g/kg of intravenous immunoglobulin. The patient displayed clinical improvement a few days later. The second case - a 43-year-old woman was diagnosed with lupus myocarditis and immunosuppressive drugs were contraindicated because of the context of a recent infective endocarditis. She was treated with repeated dose of 2 g/kg of intravenous immunoglobulin. Clinical improvement was observed and the left ventricular ejection fraction increased from 20 % to 60 % within a few days. We also report 9 similar observations identified from a literature review.

CONCLUSION

The use of intravenous immunoglobulin in lupus myocarditis is not officially recognized but could be considered as an alternative when conventional therapies have failed or are contraindicated.

Libman-sacks endocarditis exclusively involving the tricuspid valve in a patient with systemic lupus erythematosus

Libman-Sacks endocarditis, characterized by sterile verrucous vegetations, is a rare but typical cardiac manifestation of systemic lupus erythematosus. It primarily leads to lesions of the mitral and aortic valves, but isolated tricuspid valve involvement is exceptional. We report the case of a 40-year-old woman with large tricuspid valve vegetations, thickening, and regurgitation. Clinical findings and laboratory tests confirmed the diagnosis of systemic lupus erythematosus. The patient successfully recovered following tricuspid valve replacement. Echocardiography is the definitive imaging modality for assessing cardiac valvular involvement, choosing appropriate therapy, and evaluating the prognosis of Libman-Sacks endocarditis in systemic lupus erythematosus. © 2014 Wiley Periodicals, Inc. J Clin Ultrasound 43:265-267, 2015.

Mitral valve surgery in patients with systemic lupus erythematosus

Valvular heart disease is the common cardiac manifestation of systemic lupus erythematosus (SLE) with a tendency for mitral valve regurgitation. In this study we report a case of mitral valve replacement for mitral stenosis caused by Libman-Sacks endocarditis in the setting of SLE. In addition, we provide a systematic review of the literature on mitral valve surgery in the presence of Libman-Sacks endocarditis because its challenge on surgical options continues. Surgical decision depends on structural involvement of mitral valve and presence of active lupus nephritis and antiphospholipid antibody syndrome. Review of the literature has also shown that outcome is good in most SLE patients who have undergone valvular surgery, but association of antiphospholipid antibody syndrome with SLE has negative impact on the outcome.

Subclinical deterioration of left ventricular function in patients with juvenile-onset systemic lupus erythematosus

OBJECTIVES

Patients with systemic lupus erythematosus (SLE) have a higher risk of myocardial involvement, which can result in ventricular dysfunction. Little is known about the chronic influence of SLE on heart function in children and adolescents. This is the first study to demonstrate long-term changes in left ventricular function in patients with juvenile-onset SLE.

METHODS

This was a longitudinal study of 92 patients with juvenile-onset SLE. Two-dimensional echocardiography was performed by a single pediatric cardiologist at baseline, with follow-up at six-month intervals. Clinical and laboratory parameters, disease activity, treatment, nailfold capillaroscopy, and the traditional risk factors for atherosclerosis were evaluated. The baseline comparison of ventricular function was performed against 50 age-matched controls, and the follow-up results were analyzed using generalized estimating equations.

RESULTS

The patients' mean age at baseline was 15.9 ± 4.3 years, the mean disease duration was 3.6 ± 3.2 years, and the mean follow-up duration was 4.5 ± 1.6 years. At baseline, the mean left ventricular ejection fraction (LVEF) was 74.7 ± 5.6% and the mean E/A ratio of left ventricular diastolic filling was 1.7 ± 0.3 (E: the peak velocity at rapid left ventricular filling; A: the peak velocity during left atrial contraction). The LVEF of the SLE patients was similar to the healthy controls and it did not change during the follow-up period. In contrast, the E/A ratio was lower in the SLE patients than in the healthy controls (1.7 ± 0.3 versus 1.88 ± 0.37; p = 0.002), and it decreased significantly with time (B ± SE, -0.013 ± 0.006, p = 0.023). In multiple analyses, abnormal microvasculature in nailfold capillaroscopy had a negative effect on LVEF progression (p = 0.039). Disease duration of SLE and proteinuria were risk factors associated with the descent of E/A ratio (p = 0.014 and p = 0.015, respectively).

CONCLUSION

In patients with juvenile-onset SLE who were free of cardiac symptoms, there was evidence of declining ventricular diastolic function with time. Abnormal nailfold microvasculature, proteinuria and longer disease duration were the main risk factors for worsening of ventricular function.

Chance, genetics, and the heterogeneity of disease and pathogenesis in systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is a remarkably complex and heterogeneous systemic autoimmune disease. Disease complexity within individuals and heterogeneity among individuals, even genetically identical individuals, is driven by stochastic execution of a complex inherited program. Genome-wide association studies (GWAS) have progressively improved understanding of which genes are most critical to the potential for SLE and provided illuminating insight about the immune mechanisms that are engaged in SLE. What initiates expression of the genetic program to cause SLE within an individual and how that program is initiated remains poorly understood. If we extrapolate from all of the different experimental mouse models for SLE, we can begin to appreciate why SLE is so heterogeneous and consequently why prediction of disease outcome is so difficult. In this review, we critically evaluate extrinsic versus intrinsic cellular functions in the clearance and elimination of cellular debris and how dysfunction in that system may promote autoimmunity to nuclear antigens. We also examine several mouse models genetically prone to SLE either because of natural inheritance or inheritance of induced mutations to illustrate how different immune mechanisms may initiate autoimmunity and affect disease pathogenesis. Finally, we describe the heterogeneity of disease manifestations in SLE and discuss the mechanisms of disease pathogenesis with emphasis on glomerulonephritis. Particular attention is given to discussion of how anti-DNA autoantibody initiates experimental lupus nephritis (LN) in mice.

Cardiac manifestations of systemic lupus erythematosus

The heart is one of the most frequently affected organs in SLE. Any part of the heart can be affected, including the pericardium, myocardium, coronary arteries, valves, and the conduction system. In addition to pericarditis and myocarditis, a high incidence of CAD has become increasingly recognized as a cause of mortality, especially in older adult patients and those with long-standing SLE. Many unanswered questions remain in terms of understanding the pathogenesis of cardiac manifestations of SLE. It is not currently possible to predict the patients who are at greatest risk for the various types of cardiac involvement. However, with the rapid advancement of basic science and translational research approaches, it is now becoming easier to identify specific mutations associated with SLE. A better understanding of these genetic factors may eventually allow clinicians to categorize and predict the patients who are at risk for specific cardiac manifestations of SLE.

Anti-nuclear antibodies positive serum from systemic lupus erythematosus patients promotes cardiovascular manifestations and the presence of human antibody in the brain

Background:

Systemic lupus erythematosus (SLE) is characterized by the presence of anti-nuclear antibodies (ANAs) in the serum of patients. These antibodies may cross over into the brain resulting in the development of neuropsychiatric symptoms and result in abnormal pathology in other organs such as the heart and kidneys.

Objective:

The objective of this study was to determine if SLE pathology could be detected in the hearts and brains of rats injected with positive human ANA serum.

Materials and Methods:

Lewis rats (n = 31) were selected for this study due to documented research already performed with this strain in the investigation of serum sickness, encephalitis and autoimmune related carditis. Rats were injected once a week with either ANA positive or negative control serum or saline. Hearts were examined for initial signs of heart disease including the presence of lipid deposits, vegetation, increased ventricular thickness and a change in heart weight. Brains were examined for the presence of human antibody and necrotic lesions. Animals were observed for outward signs of neuropathy as well. Blood samples were taken in order to determine final circulating concentrations of IgG and monitor histamine levels.

Results:

Animals injected with ANA were significantly higher for lipid deposits in the heart and an increased ventricular thickness was noted. One animal even displayed Libman-Sacks endocarditis. Brains were positive for the presence of human IgG and diffuse internal lesions occurred in 80% of the ANA positive serum injected animals examined. Blood histamine levels were not significantly different, but actually lower than controls by the end of the experiment.

Conclusion:

Since human antibodies were detected in the brain, further studies will have to identify which antibody cross reactions are occurring within the brain, examine cell infiltration as well as characterize the antibodies associated with more destructive consequences such as lesion formation.

Isolated tricuspid valve repair for Libman-Sacks endocarditis

Cardiac involvement is a well-known complication of systemic lupus erythematosus (SLE), which can involve most cardiac components, including pericardium, conduction system, myocardium, heart valves, and coronary arteries. Libman-Sacks (verrucous) endocarditis is the characteristic cardiac valvular manifestation. Although isolated tricuspid valve involvement is quite rare, we report a patient with SLE who had tricuspid stenosis caused by Libman-Sacks endocarditis. The patient underwent successful commisurotomy and Kay annuloplasty on the tricuspid valve under cardiopulmonary bypass.

Cardiac tamponade as an initial manifestation of systemic lupus erythematosus in a child

Cardiac involvement is a rare initial presentation of systemic lupus erythematosus. An 11-year-old girl was described to have massive haemorrhagic pericardial effusion and cardiac tamponade, which was later diagnosed as systemic lupus erythematosus. Therefore, in children presenting with cardiac tamponade, systemic lupus erythematosus should be considered as one of the differential diagnoses, as morbidity and mortality associated with cardiac tamponade can be dramatically reduced with early diagnosis and use of steroids.

Significance of chronic tachycardia in systemic lupus erythematosus

OBJECTIVE

A significant subset of systemic lupus erythematosus (SLE) patients exhibit chronic tachycardia (CT) of unknown significance. We postulated that CT is a marker of lupus activity and severity.

METHODS

A cross-sectional database at the University of Chicago recorded disease activity, damage, disease manifestations, pain, anxiety, and physical function (PF). CT was defined as a heart rate of ≥95 beats per minute in at least 3 out of 4 sequential visits. Demographic, disease-specific, and self-reported symptoms were compared between groups with and without tachycardia.

RESULTS

Of the 243 subjects analyzed, 14.8% had CT. On univariate analysis, CT was associated with younger age at the time of enrollment (P = 0.004), number of hospitalizations adjusted for years of SLE (P = 0.001), current prednisone dose (P < 0.0001), history of serositis (P = 0.03), anxiety score (P = 0.004), and poor PF (P = 0.0017). All domains of the Short Form 36 (SF-36) health survey correlated strongly with CT, but on multivariate regression this correlation appeared to be driven by poor PF. On multivariate regression, the Systemic Lupus Erythematosus Disease Activity Index score (P = 0.03), younger age (P = 0.04), and poor PF by the SF-36 domain (P = 0.006) were independently correlated with CT, and anxiety trait and hemoglobin both trended closely to significant association (P = 0.08 for both).

CONCLUSION

CT is prevalent in SLE and is a clinically relevant physical finding. It implies greater lupus activity and physical frailty. Univariate association with serositis raises the possibility of subclinical serositis or pancarditis. Further study to elucidate the cardiopulmonary status of SLE patients with unexplained CT is planned.

Long-term cardiac changes in patients with systemic lupus erythematosus

Background

The aim of this study was evaluate the late-onset repercussions of heart alterations of patients with systemic lupus erythematosus (SLE) after a 13-year follow up.

Methods

A historical prospective study was carried out involving the analysis of data from the charts of patients with a confirmed diagnosis of lupus in follow up since 1998. The 13-year evolution was systematically reviewed and tabulated to facilitate the interpretation of the data.

Results

Forty-eight patient charts were analyzed. Mean patient age was 34.5 ± 10.8 years at the time of diagnosis and 41.0 ± 10.3 years at the time of the study (45 women and 3 men). Eight deaths occurred in the follow-up period (two due to heart problems). Among the alterations found on the complementary exams, 46.2% of cases demonstrated worsening at reevaluation and four patients required a heart catheterization. In these cases, coronary angioplasty was performed due to the severity of the obstructions and one case required a further catheterization, culminating in the need for surgical myocardial revascularization.

Conclusion

The analysis demonstrated progressive heart impairment, with high rates of alterations on conventional complementary exams, including the need for angioplasty or revascularization surgery in four patients. These findings indicate the need for rigorous cardiac follow up in patients with systemic lupus erythematosus.

Libman-Sacks endocarditis as the first manifestation of systemic lupus erythematosus in an adolescent, with a review of the literature

Libman-Sacks endocarditis is rare in children and adolescents, more so as a first manifestation of systemic lupus erythematosus. Currently, sterile verrucous lesions of Libman-Sacks endocarditis are recognised as a cardiac manifestation of both systemic lupus erythematosus and antiphospholipid syndrome. They are clinically silent in a majority of the cases. The presence of antiphospholipid antibodies in systemic lupus erythematosus is associated with three times higher prevalence of mitral valve nodules and significant mitral regurgitation. We present the case of isolated mitral regurgitation with abnormal looking mitral valve, detected in early childhood, which deteriorated to a severe degree in the next decade and was diagnosed as Libman-Sacks endocarditis after surgical repair from histopathology. The full-blown clinical spectrum of systemic lupus erythematosus with antiphospholipid antibodies was observed several weeks after cardiac surgery. We discuss the atypical course of Libman-Sacks endocarditis with follow-up for 10 years, along with a review of the literature.

Normal response of cardiac flow and function to adenosine stress as assessed by cardiac MR

AIMS

To establish the response of cardiac flow and function to adenosine stress using phase-contrast magnetic resonance (pcMR) and cine steady-state free precession (SSFP) cardiac magnetic resonance (CMR).

METHODS

Healthy volunteers (n = 10) were scanned on 1.5T at rest and under adenosine stress utilizing short-axis SSFP sequences and pcMR of the aorta and pulmonary trunk.

RESULTS

Adenosine-induced increase in heart rate was 62.7% (P < 0.001). Left and right-ventricular stroke volumes (SVs) increased by 12.2% (P = 0.048) and 11.9% (P = 0.044), left-ventricular ejection fraction by 11.8% (P = 0.002), and left-ventricular and right-ventricular cardiac output (CO) by 81.0% (P < 0.001) and 81.8% (P = 0.005). Average flow velocities in the ascending aorta and pulmonary trunk increased by 77.3% (P < 0.001) and 73.6% (P < 0.001), and peak flow velocities in the ascending aorta and pulmonary trunk by 27.2% (P < 0.001) and 22.4% (P = 0.003). End-systolic volumes in the left ventricle (LV) and right ventricle (RV) decreased by 16.4% (P = 0.020) and 19.2% (P = 0.028). Planimetric cine SSFP and pcMR-derived SV showed an excellent correlation.

CONCLUSION

In healthy volunteers, response to adenosine stress is characterized by an increase in heart rate, CO and SV of both ventricles. Excellent correlation is demonstrated between these increases and the increased blood flow velocities in the aorta and the pulmonary trunk. Thus, results support the use of flow measurements as an internal control of planimetric measurements of ventricular SV and CO.

Pathophysiology of Q waves in II, III, avF in systemic lupus erythematosus. Evaluation using cardiovascular magnetic resonance imaging

Objectives: To investigate the pathophysiology of Q waves in II, III, avF in systemic lupus erythematosus (SLE) by cardiovascular magnetic resonance (CMR). Methods: Inflammation evaluation by CMR using T2, early (EGE) and late gadolinium enhanced images (LGE) was performed in 20 SLE patients with mild cardiac symptoms and Q in leads II, III, avF of ECG. Their results were compared with 20 SLE patients with the same symptoms and normal ECG. Results: In both groups, T2, EGE and left ventricular ejection fraction were normal. However, in 3/20 with Q in II, III, avF, CMR revealed lesions indicative of acute myocarditis. In the rest of them, CMR documented transmural LGE, due to past inferior myocardial infarction in 4/20 and epicardial LGE due to past myocarditis in 8/20 (4/8 in the inferior and 4/8 in the lateral wall of left ventricle). No LGE was found in 5/20 and the Q was attributed to the position of the heart. In 3/20 with normal ECG, CMR detected past myocarditis in 2/3 and myocardial infarction in 1/3. Coronary angiography assessed coronary artery disease in all SLE with evidence of myocardial infarction and normal coronaries in 9/10 patients with past myocarditis. Conclusion: Q in II, III, avF in SLE may indicate myocardial infarction, acute or past inflammation or be a positional finding. The lack of Q does not exclude the possibility of infarction or inflammation. CMR is the best tool to reveal the pathophysiology of Q waves in SLE and guide treatment of heart involvement in these patients.

Cardio-renal syndrome type 5: epidemiology, pathophysiology, and treatment

The cardio-renal syndromes (CRS) recently were defined systematically as disorders of the heart or kidney whereby dysfunction of one organ leads to dysfunction of another. Five types of CRS are defined. The first four types describe acute or chronic cardio-renal or renocardiac syndromes. Type 5 CRS refers to secondary cardio-renal syndrome or cardio-renal involvement in systemic conditions. It is a clinical and pathophysiological entity to describe the concomitant presence of renal and cardiovascular dysfunction. Type 5 CRS can be acute or chronic and it does not strictly satisfy the definition of CRS. However, it encompasses many conditions in which combined heart and kidney dysfunction is observed. Because this entity has been described only recently there is limited information about the epidemiology, clinical course, and treatment of this condition.

Acute lupus myocarditis: Clinical features and outcome

Background: Cardiomyopathy in systemic lupus erythematosus (SLE) may be secondary to myocardial inflammation (i.e. myocarditis) or to systemic complications such as hypertension. Symptomatic left ventricular dysfunction is the most common clinical presentation of cardiomyopathy and is potentially life threatening. Identifying the cause is critical as it dictates therapy.

Methods: We present three cases of left ventricular failure suggestive of myocarditis in SLE patients followed in the Lupus Clinic of the Montreal General Hospital over a 5-year period.

Results: The most frequent presentation is acute onset of a marked reduction of the left ventricular ejection fraction (LVEF). All patients were treated with cardiac support, prednisone, and additional immunosuppressive medications. Improvement of symptoms and LVEF was observed in two of three patients.

Conclusion: Myocarditis is a rare, but life-threatening, manifestation of SLE. With immunosuppressive medications and cardiovascular support, the long-term outcome is usually favorable.

Systemic lupus erythematosus complicated with acute myocardial infarction and ischemic colitis

Acute myocardial infarction (AMI) is one of the most severe manifestations in patients with systemic lupus erythematosus (SLE). Ischemic colitis, mainly caused by intestinal vasculitis, is also one of the most serious, but uncommon, complications in SLE patients. "SLE vasculitis" simultaneously involving cardiac and gastrointestinal vessels has yet to be reported. This is the first report of SLE accompanying AMI, ischemic colitis and perforation of the digestive tract possibly due to SLE vasculitis, which was dramatically improved by treatment with high-dose glucocorticoid.

[A wolf in sheep's clothing: atypical systemic lupus erythematosus (SLE) presenting as cardiovascular disease]

CASE REPORT

A 51-year-old woman diagnosed as having valvular cardiomyopathy since age 34 was admitted for an evaluation for a heart transplant because of progressive congestive heart failure. When antiphospholipid antibodies were detected, the diagnosis of a thus far undetected systemic lupus erythematosus (SLE) was confirmed, manifesting primarily by cardiac involvement and an antiphospholipid antibody syndrome. Despite an advanced stage of heart failure, the patient responded well to azathioprine. Nevertheless, the potential necessity of a heart transplant remained. Its atypical presentation impeded a timely diagnosis of SLE significantly, however, in retrospect the correct diagnosis would have been possible at an earlier time point.

CONCLUSION

Though rare, SLE represents an important differential diagnosis in cases of severe valvular disease and cardiomyopathy, particularly in young women.

Deterioration of heart rate recovery index in patients with systemic lupus erythematosus

OBJECTIVE

Systemic lupus erythematosus (SLE) is an autoimmune disorder resulting in multisystemic inflammatory damage. It is reported that cardiovascular diseases (CVD) are responsible for 20%-30% of deaths in patients with SLE. Heart rate recovery after exercise is a function of vagal reactivation, and its impairment is an independent prognostic indicator for cardiovascular and all-cause mortality. The aim of our study was to evaluate the heart rate recovery index in patients with SLE.

METHODS

The study population included 48 patients with SLE (35 women, mean age 46.3 ± 12.8 yrs, mean disease duration 6.0 ± 2.3 yrs) and 44 healthy controls (30 women, mean age 45.7 ± 12.9 yrs). Basal electrocardiography, echocardiography, and treadmill exercise testing were performed on all patients and controls. The heart rate recovery index was defined as the reduction in the heart rate from the rate at peak exercise to the rate at the first minute (HRR(1)), second minute (HRR(2)), third minute (HRR(3)), and fifth minute (HRR(5)) after stopping exercise stress testing.

RESULTS

There were significant differences in HRR(1) and HRR(2) indices between patients with SLE and the control group (24.1 ± 6.5 vs 33.3 ± 9.3; p < 0.001, and 44.6 ± 13.3 vs 53.7 ± 9.9; p < 0.001, respectively). Similarly, HRR(3) and HRR(5) indices of the recovery period were lower in patients with SLE, compared with indices in the control group (57.6 ± 13.0 vs 64.9 ± 11.7; p = 0.006, and 67.2 ± 12.3 vs 75.0 ± 15.4; p = 0.009, respectively). Effort capacity was markedly lower (9.0 ± 1.9 vs 11.1 ± 2.3 metabolic equivalents; p = 0.001, respectively) among the patients with SLE.

CONCLUSION

The heart rate recovery index is deteriorated in patients with SLE. When the prognostic significance of the heart rate recovery index is considered, these results may contribute to explain the increased occurrence of cardiac death. It points to the importance of the heart rate recovery index in the identification of high-risk patients.

Pediatric lupus--are there differences in presentation, genetics, response to therapy, and damage accrual compared with adult lupus?

Some complement deficiencies predispose to systemic lupus erythematosus (SLE) early in life. Currently, there are no known unique physiologic or genetic pathways that can explain the variability in disease phenotypes. Children present with more acute illness and have more frequent renal, hematologic, and central nervous system involvement compared to adults with SLE. Almost all children require corticosteroids during the course of their disease; many are treated with immunosuppressive drugs. Mortality rates remain higher with pediatric SLE. Children and adolescents accrue more damage, especially in the renal, ocular and musculoskeletal organ systems. Conversely, cardiovascular mortality is more prevalent in adults with SLE.

Endothelial function and its implications for cardiovascular and renal disease in systemic lupus erythematosus

Vascular manifestations associated with systemic lupus erythematosus (SLE) span a broad range, including vasculopathy. An understudied pathway of this morbidity is a repair component. Recent studies have elevated the anti-injury biomarkers, adiponectin and membrane endothelial protein C receptor (EPCR), for consideration with roles to antagonize premature atherosclerosis and SLE nephritis, respectively. For example, adiponectin was found to serve as an independent predictor of carotid plaque, and its elevations were persistent over more than one visit. Unexpectedly, this biomarker was present despite clinical quiescence. In vasculopathy as a comorbidity to SLE nephritis, the persistent expression of membrane EPCR at peritubular capillaries may represent a response to the local cues of a deficit of active protein C. Under conditions of unresolved morbidity, higher levels of adiponectin and membrane EPCR may represent a physiologic attempt to limit further endothelial damage, and the observed increase in plaque and progression of SLE nephritis represent an overwhelming of this reparative process by disease-provoking stimuli.

Mitral valve surgery for mitral regurgitation caused by Libman-Sacks endocarditis: a report of four cases and a systematic review of the literature

Libman-Sacks endocarditis of the mitral valve was first described by Libman and Sacks in 1924. Currently, the sterile verrucous vegetative lesions seen in Libman-Sacks endocarditis are regarded as a cardiac manifestation of both systemic lupus erythematosus (SLE) and the antiphospholipid syndrome (APS). Although typically mild and asymptomatic, complications of Libman-Sacks endocarditis may include superimposed bacterial endocarditis, thromboembolic events, and severe valvular regurgitation and/or stenosis requiring surgery. In this study we report two cases of mitral valve repair and two cases of mitral valve replacement for mitral regurgitation (MR) caused by Libman-Sacks endocarditis. In addition, we provide a systematic review of the English literature on mitral valve surgery for MR caused by Libman-Sacks endocarditis. This report shows that mitral valve repair is feasible and effective in young patients with relatively stable SLE and/or APS and only localized mitral valve abnormalities caused by Libman-Sacks endocarditis. Both clinical and echocardiographic follow-up after repair show excellent mid- and long-term results.

Cardiac Tamponade in a Patient With Dengue Fever and Lupus Nephritis: A Case Report

Cases of small pericardial effusion have been reported in association with dengue fever (DF), largely with dengue hemorrhagic fever during epidemic outbreaks. However, cardiac tamponade developed by a patient with DF has not yet been reported in the English literature. We report a case of cardiac tamponade in a patient with DF and lupus nephritis. We describe the characteristic features to differentiate pericardial effusion of lupus origin from that of viral etiology. A 59-year-old Hispanic woman presented to the emergency department with complaints of 5 to 6 days of fever, myalgia, headache, and retro-orbital pain. Her symptoms started 3 days after returning from the Dominican Republic, where a dengue outbreak was reported. Her past medical history was significant for hypertension and lupus nephritis diagnosed 3 months earlier. On day 2, patient developed a large pericardial effusion that progressed to tamponade over the next 2 days, requiring surgical drainage. Subsequently, the patient improved; however, serological analysis did not suggest any lupus flare-up. Pericardial fluid analysis showed hypocellularity without lupus erythematosus cell and biopsy revealed only reactive mesothelial cells suggestive of viral etiology. Dengue serology was reported as markedly elevated, supporting a diagnosis of classic DF (both immunoglobulin M [IgM] titer 2.93 and IgG titer 12.13 by enzyme-linked immunosorbent assay [ELISA]; reference range: <0.90 for both). Absence of rise in serum antinuclear antibody (ANA) titer correlated with lack of inflammatory changes on the pericardium favored viral etiology over lupus origin. This differentiation is pertinent from a management perspective.

Association of plasma soluble E-selectin and adiponectin with carotid plaque in patients with systemic lupus erythematosus

BACKGROUND

Systemic lupus erythematosus (SLE) is associated with premature atherosclerosis but the mechanisms underlying this association are not understood. The role of endothelial dysfunction is hypothesized.

METHODS

In predominantly non-Caucasian patients with SLE (N=119) and controls (N=71), carotid ultrasonography was performed and circulating endothelial cells (CECs), soluble endothelial protein C receptor and gene polymorphism at A6936G, soluble E-selectin (sE-selectin), and adiponectin were assessed.

RESULTS

Carotid plaque was more prevalent among patients than controls (43% vs 17%, p=0.0002). Mean CCA IMT was greater in patients compared to controls (0.59+/-0.19 mm vs 0.54+/-0.11 mm, p=0.03). Among SLE patients, plaque was not associated with smoking, body-mass index, LDL, triglycerides, homocysteine, C-reactive protein, anti-ds DNA antibody, C3, C4, SLE activity, or medications. Age and levels of soluble E-selectin and adiponectin were significantly higher in the SLE patients with plaque compared to those without plaque in univariate and multivariate analyses. sE-selectin and adiponectin were found to serve as independent predictors of carotid plaque and that elevations were persistent over more than one visit. Unexpectedly, these biomarkers were present despite clinical quiescence.

CONCLUSION

Premature atherosclerosis is a consistent feature of SLE and extends across ethnicities. Higher levels of adiponectin may represent a physiological attempt to limit further endothelial damage already reflected by the elevation in sE-selectin and the observed increase in plaque represents overwhelming of this reparative process by atherogenic stimuli.

Coronary vasculitis with acute myocardial infarction in a young woman with systemic lupus erythematosus

Myocardial infarction in patients with systemic lupus erythematosus (SLE) is most commonly a consequence of atherosclerosis. Coronary vasculitis with aneurysms is a rare cause of myocardial ischemia in SLE. We present a case of a 22-year-old woman with a 4-year history of SLE who was admitted with acute onset of chest pain. Although initially treated for lupus pericarditis, she was subsequently found to have an acute myocardial infarction. Cardiac catheterization revealed multiple areas of aneurysmal coronary dilatation and only moderate stenoses of the secondary branches.In view of the angiographic findings, coronary revascularization was not indicated. Anticoagulant therapy was initiated as a result of the presence of large aneurysmal coronary dilatations, which are predisposed to in situ thrombosis and distal embolization. The coronary vasculitis was treated with immunosuppressive therapy. Measures aimed at secondary prevention of coronary artery disease, including optimization of lipid profile, blood pressure control, and prevention of left ventricular postinfarct remodeling, were initiated and continued indefinitely.

Myocardial Left Ventricular Dysfunction in Patients with Systemic Lupus Erythematosus: New Insights from Tissue Doppler and Strain Imaging

Objective.

Systemic lupus erythematosus (SLE) is associated with high cardiovascular morbidity and mortality. Cardiovascular involvement is frequently underestimated by routine imaging techniques. Our aim was to determine if new echocardiographic imaging modalities like tissue Doppler (TDI), strain rate (SRR), and strain (SRI) imaging detect abnormalities in left ventricular (LV) function in asymptomatic patients with SLE.

Methods.

Sixty-seven young patients with SLE (mean age 42 ± 10 yrs) without typical symptoms or signs of heart failure or angina, and a matched healthy control group (n = 40), underwent standard transthoracic echocardiography, TDI, SRR, and SRI imaging of the LV as well as assessment of disease characteristics.

Results.

Despite findings within the normal range on routine standard 2-dimensional echocardiography, SLE was associated with significantly impaired systolic and diastolic myocardial velocities of the LV measured by TDI [mean global TDI: systolic (s): 2.9 ± 0.9 vs 3.9 ± 0.7 cm/s, p < 0.05; early (e): 4.3 ± 1.5 vs 6.3 ± 1.3 cm/s, p < 0.05; late (a): 2.9 ± 0.8 vs 3.4 ± 0.8 cm/s, p < 0.05; values ± SD); SRR (s: −0.8 ± 0.1 vs −1.1 ± 0.1 s−1; e: 1.1 ± 0.2 vs 1.6 ± 0.3 s−1; a: 0.7 ± 0.1 vs 1.0 ± 0.2 s−1; all p < 0.05); and SR (−15.11 ± 2.2% vs −19.7 ± 1.9%; p < 0.05) compared to the control group. Further, elevated disease activity, measured with the ECLAM and the SLEDAI score, resulted in significantly lower values for LV longitudinal function measured by SRR and SR, but not by TDI.

Conclusion.

SLE is associated with a significant impairment of systolic and diastolic LV longitudinal function in patients without cardiac symptoms. New imaging modalities provide earlier insight into cardiovascular involvement in SLE and seem to be superior to standard echocardiography to detect subclinical myocardial disease.

[Postpartum pericardic tamponade revealing systemic lupus erythematosus]

Pericarditis is the most common manifestation of systemic lupus erythematosus and is clinically found in 62% of the autopsies. Cardiac tamponade is a deadly but rare complication found in less than 1% of all lupus cases. It is highly revealing. The authors report the case of a 29-year old woman presenting postpartum cardiac tamponade. The diagnosis of systemic lupus erythematosus was based on the association of haematological disorders (anaemia and leukopenia), pericarditis, pleurisy and positive anti-nuclear and anti-native DNA antibodies. The patient was treated with pericardiac drainage and cortisone therapy. The evolution was favourable after 22 months. Using this case study, the authors note the rarity of cardiac tamponade as a manifestation inaugurating lupus and discuss the relationship between pregnancy and lupus disease.

Aortic valve replacement for Libman-Sacks endocarditis

Cardiac involvement is a recognized complication of systemic lupus erythematosus (SLE), which can involve most cardiac components, including pericardium, conduction system, myocardium, heart valves, and coronaries. Libman-Sacks (verrucous) endocarditis is the characteristic cardiac valvular manifestation. We report a patient with SLE who had severe aortic regurgitation caused by Libman-Sacks endocarditis. The patient underwent successful mechanical aortic valve replacement.

Therapeutic Apheresis of Immune Diseases in Nephrology Department

OBJECTIVE

The clinical efficacy of therapeutic apheresis is still controversial. We undertook a retrospective review of apheresis treatment to ascertain its safety and efficacy.

METHODS

We reviewed 31 patients (13 male, 18 female). Plasmapheresis was performed on 7 patients with hematologic disorders, 5 patients with neurologic disorders, 6 patients with systemic diseases, and 3 patients with Lyell syndrome. Immunoadsorption onto protein A sepharose was evaluated as rescue therapy in 7 patients. Low-density lipoprotein (LDL) apheresis was performed on 3 patients.

RESULTS

There were five mortalities due to serious complications of their primary disease. Most complications were mild such as hypotension and hypocalcemia. Two patients who received LDL apheresis had severe anaphylactic reactions. Apheresis was effective in the remaining 24 patients.

CONCLUSIONS

The therapeutic apheresis consists of a continuously improving therapeutic method for diseases with high mortality and morbidity, especially in cases with poor outcome by using current medications.

The spectrum of clinical manifestations, outcome and treatment of pericardial tamponade in patients with systemic lupus erythematosus: a retrospective study and literature review

Pericardial effusions causing pericardial tamponade are rare in patients with systemic lupus erythematosus (SLE). The goal of this study is to describe in detail the clinical and laboratory characteristics of a group of patients with pericardial effusions and pericardial tamponade secondary to SLE. We retrospectively reviewed the records of 71 patients with SLE, admitted to our Hospital between 1985 and 2006 with a diagnosis of pericarditis, pericardial effusion and tamponade. Clinical features in the patients with tamponade were compared with those with pericardial effusions without tamponade. Pericardial effusion and SLE was confirmed in 41 patients. Pericardial tamponade occurred in nine of these patients (21.9%) at the time of presentation. All tamponade patients were women. Patients with pericardial effusions who developed tamponade had a statistically significant ( P = 0.05) lower C4 level as compared with patients who did not develop tamponade. A pericardial window was required in five patients even though the patients were receiving high-dose corticosteroids. In the present series, all patients with tamponade were treated with high-dose corticosteroids though five of nine patients required a pericardial window in contrast to previous studies. A low C4 level at presentation was predictive of the development of tamponade physiology.

The role of B lymphocyte stimulator (BLyS) in systemic lupus erythematosus

SLE, a chronic, multisystem autoimmune disorder with a broad range of symptoms, involves defective B cell selection and elimination of self-reactive B cells. B lymphocyte stimulator (BLyS), a soluble ligand of the TNF cytokine family, is a prominent factor in B cell differentiation, homeostasis, and selection. BLyS levels affect survival signals and selective apoptosis of autoantibody-producing B cells. High levels of BLyS may relax B cell selection and contribute to autoantibody production, exacerbating the SLE disease state. This review discusses the mechanism of BLyS action on B cells, its role in SLE, and specific targeting of BLyS in the treatment of SLE.

Asymptomatic pericardial effusion in patients with systemic lupus erythematosus

To determine the frequency and clinical correlates of asymptomatic pericardial effusion (PE) in patients with systemic lupus erythematosus (SLE), echocardiography and electrocardiography were performed in 50 consecutive patients with SLE. Among 50 patients with SLE, 12 patients (24%) had PE and 17 patients (34%) had hypoalbuminaemia. Patients with PE had a significantly lower serum albumin (P < 0.001), higher incidence of proteinuria (P = 0.003), higher C-reactive protein (P = 0.036) and pulmonary artery systolic pressure (P = 0.011) and tended to have a higher incidence of PR-segment depression (P = 0.082) compared with those without PE. When four variables (PR-segment depression, C-reactive protein, serum albumin and pulmonary artery systolic pressure) were used in the multivariate analysis, serum albumin (P = 0.005, odds ratio = 0.016) and pulmonary artery systolic pressure (P = 0.010, odds ratio = 1.106) emerged as significant variables related to the occurrence of asymptomatic PE. Thus, an increase in hydrostatic pressure of the right heart cavities and a decrease in colloid osmotic pressure were important factors associated with the presence of asymptomatic PE in patients with SLE.