Prognostic value of metabolic syndrome for the development of cardiovascular disease in a cohort of premenopausal women with systemic lupus erythematosus

Cardiovascular events and risk in patients with systemic lupus erythematosus: Systematic literature review and meta-analysis

BACKGROUND

Systemic lupus erythematosus (SLE) is an autoimmune disease that typically affects women aged 16-55 years. Cardiovascular disease (CVD) is a well-recognized complication of SLE. This systematic literature review and meta-analysis evaluated the relative risk (RR; compared with non-SLE controls), absolute risk (AR; as incidence proportion, n/N), and incidence rate (IR) of CVD events (including stroke, myocardial infarction [MI], and CVD [composite or undefined]) in adult patients with SLE. The RR of CV risk factors (including hypertension, diabetes, and metabolic syndrome [MetS]) was also examined.

METHODS

PubMed and Embase were searched on September 10, 2020. Observational studies published between January 2010 and September 2020 that reported RR, AR, and/or IR of CVD events, or RR of CV risk factors, were eligible. Pooled risk estimates were calculated using a random-effects model.

RESULTS

Forty-six studies (16 cross-sectional, 15 retrospective cohort, 14 prospective cohort, and 1 case-control) were included in meta-analyses. Most studies were considered high quality (Critical Appraisal Skills Programme checklists). Compared with adults without SLE, patients with SLE had statistically significantly higher RRs (95% CIs) of stroke (2.51 [2.03-3.10]; 12 studies), MI (2.92 [2.45-3.48]; 11 studies), CVD (2.24 [1.94-2.59]; 8 studies), and hypertension (2.70 [1.48-4.92]; 7 studies). RRs of diabetes (1.24 [0.78-1.96]; 3 studies) and MetS (1.49 [0.95-2.33]; 7 studies) were elevated but not significant. RRs of stroke and MI were generally higher in younger versus older patients with SLE. In patients with SLE, the pooled estimate of AR (95% CI) was 0.03 (0.02-0.05), 0.01 (0.00-0.02), and 0.06 (0.03-0.10) for stroke (7 studies), MI (6 studies), and CVD (8 studies), respectively. The pooled estimate of IR per 1000 person-years (95% CI) was 4.72 (3.35-6.32), 2.81 (1.61-4.32), and 11.21 (8.48-14.32) for stroke (10 studies), MI (6 studies), and CVD (8 studies), respectively. Although heterogeneity (based on I2 value) was high in most analyses, sensitivity analyses confirmed the robustness of the pooled estimates.

CONCLUSIONS

This meta-analysis found an increased risk of stroke, MI, CVD, and hypertension in patients with SLE compared with the general population, despite substantial heterogeneity across the included studies.

Systematic Literature Review and Meta-analysis of Venous Thromboembolism Events in Systemic Lupus Erythematosus

The objective of this work was to conduct a systematic literature review (SLR) and meta-analysis (MA) to evaluate the relative risk (RR) of venous thromboembolism (VTE) events, including deep vein thrombosis (DVT) and pulmonary embolism (PE), in patients with systemic lupus erythematosus (SLE) compared with patients without SLE, as well as the absolute risk (AR) (measured by incidence proportion) and incidence rate (IR) of VTE events in patients with SLE. The SLR was conducted using Embase, MEDLINE, and MEDLINE In-Process to identify observational studies evaluating the risk of VTE, DVT, and PE events in adult patients with SLE compared with the general population, published January 2000 to September 2020. Random-effects models were used as the primary approach in the MA. Heterogeneity was assessed on the basis of the I2 value. Sensitivity analyses were performed to assess the robustness of results to various conditions, and subgroup analysis was performed for the AR of VTE by antiphospholipid status (aPLs) and antiphospholipid syndrome (APS). Of the 50 publications included for data extraction, 44 contained data for consideration in the MA of any one of the measures of interest (RR, AR, or IR) for VTE, DVT, or PE. The pooled RR indicates statistically significantly higher risk of VTE (RR 4.38, 95% confidence interval 2.63-7.29) in patients with SLE compared with the general population. Considerable heterogeneity was present in nearly all MA (I2 = 75-100%). Moreover, a higher pooled AR of VTE was estimated in patients with SLE with aPLs (n/N = 0.13) and APS (n/N = 0.63) compared with patients with SLE without aPLs/APS (n/N = 0.07). Overall, there was evidence of an increased risk of VTE, DVT, and PE in patients with SLE compared with the general population.

Metabolic syndrome and the risk of adverse cardiovascular events in patients with myocardial infarction with non-obstructive coronary arteries

BACKGROUND AND AIMS

Metabolic syndrome (MeS) is recognized as a significant predictor of poor outcomes in coronary artery disease. However, its prognostic implications in myocardial infarction with non-obstructive coronary arteries (MINOCA) have not been examined. We aimed at investigating the role of MeS on the clinical outcomes in MINOCA patients.

METHODS AND RESULTS

Patients diagnosed with MINOCA between 2015 and 2019 were included. MeS was defined according to modified NCEP-ATPIII criteria. The primary endpoint was major adverse cardiovascular events (MACE). Cox regression analysis was used to evaluate the correlation between MeS and the hazard of MACE. The integrated discrimination improvement (IDI) and net reclassification index (NRI) were performed to assess MeS incremental predictive value. Of 281 MINOCA patients, 83 (29.5%) patients satisfied the MeS criteria. During a median follow-up duration of 28 months, MINOCA patients with MeS had a notably higher rate of MACE than those without MeS (30.1% vs. 17.6%, respectively P = 0.020). Cox regression analysis revealed that MeS was associated with an increased hazard of MACE (adjusted HR 2.126; 95% CI: 1.193-3.787, P = 0.010). When each component of MeS was analyzed as a categorized variable separately, only high fasting blood glucose and BMI ≥25 kg/m² were associated with an increased hazard of MACE. Moreover, MeS had an incremental predictive ability for MACE when added to a model with clinical risk factors.

CONCLUSION

MeS is relatively common in patients with MINOCA. The presence of MeS significantly increased the hazard of MACE among the MINOCA population.

Metabolic syndrome at baseline was not predictive to new-onset cardiovascular diseases in patients with systemic lupus erythematosus: A prospective observational registry

Objective: It has been established that metabolic syndrome is prevalent in patients with systemic lupus erythematosus (SLE). The objective of this study was to investigate the effect of metabolic syndrome at baseline on new-onset cardiovascular disease (CVD) in patients with SLE. Methods: The demographic and lupus-related clinical variables of 229 patients with SLE were collected from the Korean Lupus Network (KORNET) registry. Metabolic syndrome was defined by the modified National Cholesterol Education Program’s Adult Treatment Panel III (NCEP ATP III) criteria. Binary logistic regression analysis was applied to identify clinical variables including metabolic syndrome related to pre-existing CVD at the time of enrollment or new-onset CVD during 3 years of follow-up.

Results: Patients with pre-existing CVD at baseline had higher rates of metabolic syndrome than those without CVD in SLE ( p = .022), whereas there was no difference in the frequency of metabolic syndrome between patients with and without new-onset CVD. Logistic regression analysis revealed that metabolic syndrome and the number of its components were associated with pre-existing CVD, together with body mass index and hypertriglyceridemia. Metabolic syndrome at baseline and its components were not related with increased risk of new-onset CVD. On the contrary, anti-dsDNA antibody titer, anti-ds DNA positivity, and lower diastolic blood pressure increased the risk of new-onset CVD. Conclusion: This study demonstrated that metabolic syndrome at baseline was not predictive to new-onset CVD at 3 years of follow-up, although it was associated with pre-existing CVD in SLE.

Metabolic syndrome and systemic lupus erythematosus: the connection

Introduction: The metabolic syndrome (MetS) is now recognized as a chronic proinflammatory and prothrombotic state that aggravates insulin resistance, oxidative injury, and cardiovascular risk. MetS is more prevalent in patients with systemic lupus erythematosus (SLE), a prototype of systemic autoimmune disease associated with premature atherosclerosis that cannot be accounted by traditional vascular risk factors alone. Dysregulation of the cytokines and adipokines is a common feature in both SLE and MetS, suggesting a complex relationship among autoimmunity, obesity, inflammation, and atherosclerosis. Areas covered: This review summarizes the prevalence of MetS and its effect on cardiovascular outcome and organ damage in patients with SLE. The pathophysiology of MetS and its relevance to SLE is also briefly discussed. Expert opinion: Imbalance of adipokine production in MetS contributes to inflammation and atherosclerosis. MetS predisposes SLE patients to new cardiovascular events and vascular mortality, as well as the development of chronic kidney disease and diabetes mellitus. However, conflicting results have been reported in the literature regarding the levels of the proinflammatory leptin and anti-inflammatory adiponectin, and their relationship with disease activity in SLE patients. While lifestyle modifications and targeting dyslipidemia, hypertension and diabetes mellitus is essential, there is little information on the efficacy and safety of metformin and hydroxychloroquine in alleviating insulin resistance in SLE or MetS. Further research on adipokines in SLE and the role of anti-obesity medications and probiotics in MetS is necessary.

Cardiovascular Disease Prevention Counseling Program for Systemic Lupus Erythematosus Patients

OBJECTIVE

To determine if a cardiovascular disease (CVD) prevention counseling program for lupus patients decreases the prevalence of CVD risk factors.

METHODS

The assessment phase of a 3-year CVD prevention counseling program included the evaluation of CVD risk factors, diet, exercise habits, and medications. The education phase included discussion of the above risk factors, as well as CVD and thrombosis prevention strategies. Patients were prospectively followed every 3-6 months for risk assessment and continued education by a nurse practitioner and a medical doctor.

RESULTS

Between March 2009 and December 2014, 121 patients were included. At baseline, abnormal blood pressure, blood glucose, cholesterol profile, and body mass index were found in 50 (41%), 7 (6%), 82 (68%), and 77 (64%) patients, respectively. During the 3-year followup, among those with abnormal baseline values, prevalence of abnormal blood pressure significantly decreased (odds ratio [OR] 0.94, 95% confidence interval [95% CI] 0.92-0.96, P < 0.0001) with significant mean ± SD systolic blood pressure improvement (-6.12 ± 2.16 mm Hg; P < 0.05). The prevalence of abnormal cholesterol profile significantly decreased (OR 0.90, 95% CI 0.92-0.96) with significant improvements in mean ± SD high-density lipoprotein (+5.4 ± 0.36 mg/dl; P < 0.0001) and triglyceride levels (-12.6 ± 5.40 mg/dl; P < 0.05), and no significant change in blood glucose and body mass index was observed. At baseline, 100 (83%) and 95 (79%) patients had poor diet and physical activity, respectively; during the followup, both significantly improved in the entire population.

CONCLUSION

Our data suggest that a CVD prevention counseling program decreases the prevalence of some CVD risk factors in lupus patients.

25-hydroxyvitamin D is associated with metabolic syndrome among premenopausal women with systemic lupus erythematosus in China

Objectives

This study aimed to investigate the status of 25-hydroxyvitamin D (25(OH)D) and its association with metabolic syndrome (MS) and different MS components among premenopausal women with systemic lupus erythematosus (SLE) in China.

Patients and methods

Altogether 113 premenopausal women with SLE and the age-matched healthy cohorts were recruited in this cross-sectional study. Clinical manifestations and laboratory data including serum 25(OH)D concentration were collected. A multivariable analysis was performed to analyze the association of 25(OH)D with MS and its components.

Results

The prevalence of 25(OH)D deficiency (25(OH)D < 20 ng/ml) and MS were common (24.8% and 30.1%, respectively) in premenopausal patients with SLE in China. Analysis of the association between 25(OH)D, MS and its components demonstrated that the lower level of 25(OH)D was associated with increased MS prevalence (OR = 0.920, p = 0.012), a decreased level of high-density lipoprotein (OR = 1.059, p = 0.033) and a higher level of fasting glucose (OR = 0.810, p = 0.004). These associations were still detectible after adjustment for age, body mass index and SLE-related variables.

Conclusion

The level of 25(OH)D is associated with MS and its components in premenopausal women with SLE.