Coronary artery disease in systemic lupus erythematosus: A review of the literature

Computed Tomography (CT) Calcium Scoring in Primary Prevention of Acute Coronary Syndrome and Future Cardiac Events in Patients With Systemic Lupus Erythematosus

Systemic lupus erythematosus (SLE) is a complex and chronic autoimmune disease that impacts multiple organ systems and presents with varying symptomatology that makes targeting treatment extremely difficult. The cardiovascular system and more specifically the coronary arteries are heavily affected by SLE causing increased atherosclerosis and subsequently increased acute coronary syndrome (ACS) and increased future cardiac events. ACS is a common occurrence in patients with SLE due to the premature development of atherosclerosis due to the dysregulation of pro-inflammatory cytokines. Calcium scoring has been effectively utilized to identify plaque burden in patients with coronary artery calcification (CAC). Calcium scoring is a score obtained from a computed tomography (CT) image using non-contrast imaging, which provides quantitative information regarding CAC and aids in assessing cardiovascular risk. A calcium score of zero Hounsfeild units can be obtained using CT calcium scoring which indicates no calcium is identified in the coronary arteries and is a strong negative risk predictor for coronary artery disease. Early screening of SLE patients with CT calcium scoring could aid in early detection and treatment subsequently leading to delay of premature coronary atherosclerosis and future cardiac events in this patient population. Multiple studies have used calcium scoring as a method to measure arterial calcification in SLE patients. The Society of Cardiovascular Imaging has now endorsed the idea of obtaining a baseline calcium artery score with a repeat progression scan in 3-5 years. Calcium scoring has also been identified as an effective initial tool for stratification and identification of possible ACS. The various advantages of early calcium scoring signify the further research needed to fully understand and implement the advantages calcium scoring has to offer patients with SLE.

Multiple coronary aneurysms and acute myocardial infarction in a female patient with rhupus: case report and literature review

Coronary artery aneurysms (CAA) are an infrequent cause of coronary artery disease in both systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA), most occurring as a result of acute coronary syndromes (ACS). Until now, no cases of CAA have been described in a patient with rhupus syndrome (RhS). Differentiating whether CAA stem from primary vasculitis, atherosclerosis, or a combination of both continues to pose a significant challenge. We present the first described clinical case of a 43-year-old patient with RhS and multiple CAA identified by the presentation of an acute myocardial infarction. The presence of multiple cardiovascular risk factors and the absence of inflammatory findings, both in PET-CT and arterial biopsy, favored an atherosclerotic versus a vasculitic etiology of the CAA. At the time of the aneurysms diagnosis, the patient showed no signs of SLE activity and only moderate RA activity, which underscores the importance of screening for silent coronary aneurysms in these patients, even in subjects exhibiting little apparent activity from their underlying disease. This case also exemplifies the severe impact of atherosclerotic burdens on such patients, demanding vigilance and aggressiveness in its prevention, early diagnosis, and treatment. We hypothesize that RhS could engender an even greater risk of presenting CAA than either SLE or RA on their own, which therefore warrants more careful follow-up in these patients.

Spontaneous coronary artery dissection in systemic lupus erythematosus: case-based review

Patients with systemic lupus erythematosus (SLE) present an increased prevalence of coronary heart disease. The majority of cases of acute coronary syndrome (ACS) in patients with SLE are due to atherosclerosis. Less common causes include thrombosis of an angiographically normal coronary artery and coronary vasculitis. Spontaneous coronary artery dissection (SCAD) is a rare cause of ACS in these patients. We report the case of a 53-year-old female diagnosed of SLE presenting with an ACS caused by SCAD. She was treated medically and her clinical course was favorable. A literature search identified seven additional cases of SCAD associated with SLE. The main clinical features found in these reports are revised. ACS caused by SCAD in SLE patients is a condition likely under-reported in literature. SCAD should be suspected in patients with SLE and ACS, especially in younger women without evident cardiovascular risk factors. An early accurate diagnosis of SCAD is key to provide specific treatment, which differs from that of usual atherosclerotic ACS.

Increased adhesion molecule levels in systemic lupus erythematosus: relationships with severity of illness, autoimmunity, metabolic syndrome and cortisol levels

Background

This study was performed to assess adhesion molecules in systemic lupus erythematosus (SLE).

Methods

This case-control study examined 126 SLE patients and 48 healthy individuals. Blood levels of six adhesion molecules, cortisol, nuclear autoantibody (ANA) and anti-double stranded DNA (anti-dsDNA) titers were measured, while disease activity was assessed using the SLE Disease Activity Index (SLEDAI) score.

Results

Platelet endothelial cell adhesion molecule 1 (PECAM-1), vascular cell adhesion molecule 1 (VCAM-1), E-selectin, P-selectin, and plasminogen activator inhibitor type-1 (PAI-1) were significantly higher in SLE patients than in controls. Binary logistic regression analysis showed that PECAM-1 and PAI-1 predicted SLE with a sensitivity of 86.5% and a specificity of 81.3%. ANA titers were significantly and positively associated with PECAM-1, VCAM-1, E-selectin, and PAI-1, whereas there were no associations between anti-dsDNA titers and adhesion molecules. Cortisol was negatively associated with PCAM-1 and ICAM-1. There were significant associations between metabolic syndrome (MetS) and E-selectin and PAI-1. 14.8% of the variance in the SLEDAI score was explained by the regression on PECAM-1 and MetS.

Conclusions

Our data show that adhesion molecules, especially PECAM-1, are significantly associated with SLE and disease activity, suggesting that they play a role in SLE pathophysiology. While MetS, ANA titers and cortisol levels modulate adhesion molecule levels, these associations do not explain the increased levels of adhesion molecules in SLE. Increased levels of adhesion molecules are new drug targets in SLE.

Spontaneous coronary artery dissection as the first presentation of systemic lupus erythematosus

A 33-year-old woman with no premorbidities presented to us with chest pain and worsening dyspnoea since 1 week. Systemic examination was suggestive of acute pulmonary oedema and preliminary investigations revealed evolved anterior wall myocardial infarction (MI). The patient was stabilised and taken up for angiography which revealed spontaneous coronary artery dissection (SCAD) of the left anterior descending (LAD) artery. She underwent percutaneous coronary intervention (PCI) for the same. Further investigation into the cause for the SCAD came strongly positive for systemic lupus erythematosus (SLE). She had no prior symptoms suggestive of SLE and the SCAD was its very first clinical manifestation.

The increased cardiovascular risk in patients affected by autoimmune diseases: review of the various manifestations

Cardiovascular and autoimmune diseases are among major health concerns in developed countries, and both represent a significant source of morbidity, mortality and economic costs. Despite they are thought to affect subjects at different ages, most of the deaths of patients affected by autoimmune diseases are represented by cardiovascular deaths. Several manifestations of cardiovascular diseases can be observed in patients with autoimmune diseases, such as endothelial dysfunction, accelerated atherosclerosis and an increase in the rate of acute coronary syndromes. Thus, people with autoimmune diseases have an increased cardiovascular risk and a worse outcome in the case of cardiovascular events. In this review, we will describe the correlations between the two spectra of diseases.

Coronary steal due to ruptured right coronary aneurysm causing myocardial infarction in a patient with systemic lupus erythematosus

A 34-year-old female with a history of systemic lupus erythematosus (SLE) developed an acute inferior myocardial infarction while hospitalized for methicillin-resistant Staphylococcus Aureus sepsis. An emergent coronary angiography revealed an ectatic proximal left coronary artery and a huge aneurysm (37 mm × 32 mm) in the mid-portion of the right coronary artery, which had ruptured into the right atrium. A "steal phenomenon" due to significant left to right shunt resulting from the ruptured aneurysm was the cause of the myocardial infarction. Infection of the wall of the aneurysm might have contributed to the growth and the rupture in the presence of a pre-existing coronary aneurysm.

Cardiovascular involvement in autoimmune diseases

Autoimmune diseases (AD) represent a broad spectrum of chronic conditions that may afflict specific target organs or multiple systems with a significant burden on quality of life. These conditions have common mechanisms including genetic and epigenetics factors, gender disparity, environmental triggers, pathophysiological abnormalities, and certain subphenotypes. Atherosclerosis (AT) was once considered to be a degenerative disease that was an inevitable consequence of aging. However, research in the last three decades has shown that AT is not degenerative or inevitable. It is an autoimmune-inflammatory disease associated with infectious and inflammatory factors characterized by lipoprotein metabolism alteration that leads to immune system activation with the consequent proliferation of smooth muscle cells, narrowing arteries, and atheroma formation. Both humoral and cellular immune mechanisms have been proposed to participate in the onset and progression of AT. Several risk factors, known as classic risk factors, have been described. Interestingly, the excessive cardiovascular events observed in patients with ADs are not fully explained by these factors. Several novel risk factors contribute to the development of premature vascular damage. In this review, we discuss our current understanding of how traditional and nontraditional risk factors contribute to pathogenesis of CVD in AD.

Causes and outcome of hospitalisations in Tunisian patients with systemic lupus erythematosus

Objective

To describe the most common reasons of admission of Tunisian patients with systemic lupus erythematosus (SLE) and the outcomes of these hospitalisations.

Method

The charts of patients with SLE who were hospitalised at our Department of Internal Medicine during a 2-year period from January 2011 to December 2012 were retrospectively reviewed, and the demographic characteristics, clinical and laboratory features, as well as all comorbidities, were collected.

Results

There were 128 episodes of hospitalisation of 87 patients with SLE. 25 patients (28.7%) were admitted twice or more. The median length of stay for all admissions was 11 days (2–76). The total number of days of hospitalisation was 1896 days, which represent 10.7% of the total number of days of hospitalisation in our department. The most common overall reason for hospitalisation was active SLE (55 events, 43%). In 29 patients, SLE was newly diagnosed during hospitalisation. Other causes of hospitalisation included assessment of the disease, infections (9.4%) and associated autoimmune disease (6.25%). Adverse drug reaction (3.1%) and thromboembolic events (1.25%) were uncommon causes of hospitalisations. There was a significant difference in length of stay between patients admitted with SLE flare and those admitted for non-SLE flare reasons (p<0.01). Four hospitalisations (3%) resulted in death. The principal cause of death was active SLE.

Conclusions

Hospitalisation of patients with SLE is common in our department. Our study of this North African SLE population confirms the findings of previous studies suggesting that active SLE and infection remain the most common causes of hospitalisation of patients with SLE.

Coronary artery dilation among patients with paediatric-onset systemic lupus erythematosus

OBJECTIVES

This study aimed to evaluate increased coronary artery dimensions in patients with paediatric-onset systemic lupus erythematosus (SLE) in comparison with healthy controls, and to identify risk factors associated with increased coronary artery dimensions in the SLE patients.

METHODS

As part of a longitudinal cohort study of coronary artery disease (CAD) in paediatric-onset SLE, 83 children with SLE and 36 healthy controls were enrolled for a cross-sectional analysis. Their coronary artery diameters were measured by echocardiography while their body mass index (BMI), blood pressure, and other cardiovascular factors were recorded. The age at diagnosis, serum uric acid (UA) and creatinine levels, and other lupus-related factors were further evaluated in SLE patients. Data were analysed using linear regression.

RESULTS

Mean body surface area (BSA)-adjusted dimensions of the left coronary artery (LCA) and right coronary artery (RCA) were significantly larger in SLE patients than in controls (both p < 0.001). The age at diagnosis, BMI, and serum UA and creatinine levels were associated with LCA and RCA diameters. There were no correlations between the coronary artery diameters and blood pressure, SLE duration, SLE Disease Activity Index (SLEDAI), C-reactive protein (CRP), C3, C4, anti-double-stranded-DNA (anti-dsDNA), or lipid profile. In multivariate analysis, serum UA level, age at diagnosis, and BMI were consistently associated with coronary artery dimensions (p < 0.001, p = 0.008, and p = 0.006 for LCA; p = 0.020, 0.013, and 0.008 for RCA).

CONCLUSIONS

Increased coronary artery diameters were found in children with SLE and were associated with higher serum UA levels. The pathogenic mechanisms warrant further investigation.

Myocardial infarction due to coronary thrombosis in a patient with Henoch-Schönlein purpura

Henoch-Schönlein purpura (HSP) is characterized by vasculitic involvement of small-sized vessels and results in multisystem manifestations. Cardiac involvement is extremely rare and myocardial infarction with coronary thrombus formation in those patients has also rarely been reported. Herein, we report a 33-year-old man with acute myocardial infarction due to coronary thrombus formation and HSP.

Spontaneous coronary artery dissection in the context of positive anticardiolipin antibodies and clinically undiagnosed systemic lupus erythematosus

Spontaneous coronary artery dissection (SCAD) is an extremely uncommon condition that can lead to fatal acute myocardial infarction. There have been very few case reports of SCAD in patients with systemic lupus erythematosus (SLE) and even fewer in association with antiphospholipid antibodies - mainly postpartum. This is the first reported case of SCAD in a patient who was confirmed to have SLE and tested positive for anticardiolipin antibody and lupus anticoagulant. This case demonstrates the importance of carefully considering the differential diagnoses of SCAD at presentation. It also highlights the need for further research to explore the link between SLE, antiphospholipid antibodies and SCAD.

Lethal manifestations of systemic lupus erythematosus in a forensic context

Systemic lupus erythematosus is an autoimmune connective tissue disorder that affects multiple organs. While the clinical manifestations may vary in intensity over time and be associated with chronic disease, occasional cases occur where sudden and unexpected death has occurred. Cardiovascular disease is common, with accelerated atherosclerosis, intravascular thrombosis associated with antiphospholipid syndrome, and hypertensive cardiomegaly. Vasculitis with superimposed thrombosis may result in critical reduction in blood to vital organs, such as the heart and brain with infarction. Mesenteric ischemia may be caused by vasculitis, thrombosis, and accelerated atherosclerosis and may result in lethal intestinal infarction. Other diverse causes of sudden death include myocarditis, epilepsy, pulmonary hypertension, pulmonary thromboembolism, and sepsis. The autopsy evaluation of such cases requires careful examination of all organs with extensive histological sampling to include blood vessels, and microbiological sampling for bacteria, viruses, and fungi.

Acute myocardial infarction as the first presentation of thyrotoxicosis in a 31-year old woman - case report

A 31-year old woman, previously fit & well was admitted with pressing retrosternal chest pain and palpitations of sudden onset. Her body weight was normal (BMI 20.5 kg/m²) and there was no significant family history of cardiac disease. She smoked, however, about 15 cigarettes a day and she had been taking combined oral contraceptive pill (Cilest^®) for about three years. On admission she appeared sweaty and in pain, blood pressure 130/70 mmHg, heart rate about 110/min, mild lid-lag sign. Heart sounds were normal and chest was clear. ECG revealed 2-3 mm ST segment elevations in II, III, aVF as well as V2 to V5. Troponin I was raised and she was qualified to an emergency coronary angiography. This revealed a massive spasm of left anterior descending (LAD) coronary artery that responded to intracoronary glyceryl trinitrite administration, however, with the presence of critical narrowing of the LAD apical segment with possible superimposed thrombus. Cardiac ultrasound revealed akinesis of 1/2 of apical area consistent with myocardial infarction

Treatment and progress

She was started on Aspirin, Simvastatin, and Diltiazem, but continued to have persistent tachycardia and tremor. Thyroid function tests were ordered and showed thyrotoxicosis [free T4-46.9 pmol/l (ref. range 9-25), free T3-11.9 pmol/l (2-5), TSH - 0.02 mIU/l (0.27-4.2)]. She was referred for an endocrine opinion and started on Thiamazole. Other investigations revealed elevated anti-TPO and anti-TSH receptor antibodies consistent with Graves' disease. Thrombophilia screen was negative. She had remained euthyroid on a "block & replace" regimen (Thiamazole plus L-Thyroxine) that was discontinued after 18 months. She denies any anginal symptoms, but continues to smoke against medical advice.

Conclusions

Our case highlights the possibility of development of an acute myocardial infarction in a young subject with thyrotoxicosis. We speculate that patient's smoking habit combined with subtle thyrotoxicosis-induced prothrombotic state and/or coronary-artery spasm had lead to the above-mentioned acute coronary event.

Renal manifestations of systemic illness in children

Kidney disease may be associated with a systemic disorder or found in isolation. With advances in the understanding of the pathophysiology of glomerular disorders, the distinction between primary and secondary glomerular disease is no longer valid. A wide spectrum of glomerular, vascular, and tubulointerstitial diseases may accompany autoimmune disorders, nephritogenic pharmaceuticals, infections, or complement dysregulation. This article focuses on renal manifestations of systemic diseases such as vasculitis, drug- and infection-related tubulointerstitial injury, and thrombotic disorders.

Iron behaving badly: inappropriate iron chelation as a major contributor to the aetiology of vascular and other progressive inflammatory and degenerative diseases

BACKGROUND

The production of peroxide and superoxide is an inevitable consequence of aerobic metabolism, and while these particular 'reactive oxygen species' (ROSs) can exhibit a number of biological effects, they are not of themselves excessively reactive and thus they are not especially damaging at physiological concentrations. However, their reactions with poorly liganded iron species can lead to the catalytic production of the very reactive and dangerous hydroxyl radical, which is exceptionally damaging, and a major cause of chronic inflammation.

REVIEW

We review the considerable and wide-ranging evidence for the involvement of this combination of (su)peroxide and poorly liganded iron in a large number of physiological and indeed pathological processes and inflammatory disorders, especially those involving the progressive degradation of cellular and organismal performance. These diseases share a great many similarities and thus might be considered to have a common cause (i.e. iron-catalysed free radical and especially hydroxyl radical generation).The studies reviewed include those focused on a series of cardiovascular, metabolic and neurological diseases, where iron can be found at the sites of plaques and lesions, as well as studies showing the significance of iron to aging and longevity. The effective chelation of iron by natural or synthetic ligands is thus of major physiological (and potentially therapeutic) importance. As systems properties, we need to recognise that physiological observables have multiple molecular causes, and studying them in isolation leads to inconsistent patterns of apparent causality when it is the simultaneous combination of multiple factors that is responsible.This explains, for instance, the decidedly mixed effects of antioxidants that have been observed, since in some circumstances (especially the presence of poorly liganded iron) molecules that are nominally antioxidants can actually act as pro-oxidants. The reduction of redox stress thus requires suitable levels of both antioxidants and effective iron chelators. Some polyphenolic antioxidants may serve both roles.Understanding the exact speciation and liganding of iron in all its states is thus crucial to separating its various pro- and anti-inflammatory activities. Redox stress, innate immunity and pro- (and some anti-)inflammatory cytokines are linked in particular via signalling pathways involving NF-kappaB and p38, with the oxidative roles of iron here seemingly involved upstream of the IkappaB kinase (IKK) reaction. In a number of cases it is possible to identify mechanisms by which ROSs and poorly liganded iron act synergistically and autocatalytically, leading to 'runaway' reactions that are hard to control unless one tackles multiple sites of action simultaneously. Some molecules such as statins and erythropoietin, not traditionally associated with anti-inflammatory activity, do indeed have 'pleiotropic' anti-inflammatory effects that may be of benefit here.

CONCLUSION

Overall we argue, by synthesising a widely dispersed literature, that the role of poorly liganded iron has been rather underappreciated in the past, and that in combination with peroxide and superoxide its activity underpins the behaviour of a great many physiological processes that degrade over time. Understanding these requires an integrative, systems-level approach that may lead to novel therapeutic targets.

Von Willebrand factor, red cell fragmentation, and disease activity in systemic lupus erythematosus

This study sought to determine whether the plasma levels of Von Willebrand factor (vWf) and the degree of red blood cell (RBC) fragmentation on peripheral smear correlate with disease activity in systemic lupus erythematosus (SLE). Forty consecutive patients who fulfilled the criteria for SLE were studied prospectively for 1 year. Patients were categorized according to the SLE Disease Activity Index (SLEDAI) as either active (>2) or inactive disease and followed up monthly (active) or quarterly (inactive). At each visit, patients were examined fully and had complete blood count, tests on antibodies to double-stranded DNA, C3, and C4 levels, and urinalysis. Citrated plasma was analyzed for vWf antigen by standard enzyme-linked immunosorbent assay. A Wright's stained blood smear was obtained and schistocytes were quantitated on blood smear. The number of schistocytes per 500 RBCs was determined and a schistocyte index (SI) was calculated. At baseline, vWf correlated with SLEDAI (r = 0.64, p < 0.01), SI correlated with SLEDAI (r = 0.62, p < 0.01), and vWf and SI correlated with each other (r = 0.41, p = 0.01). There was an inverse correlation between baseline C3 levels and vWf (r = 0.49, p = 0.0013) and C3 levels and SI (r = 0.40, p = 0.01). Over time, there was also a correlation of SLEDAI with vWf (r = 0.53, p = 0.002) and SI (r = 0.57;p = 0.002). The relation of vWf with SI approached but did not reach statistical significance (r = 0.37, p = 0.06). We found that the plasma levels of vWf and the degree of RBC fragmentation correlate with lupus disease activity over time. Therefore, inflammation in SLE may be associated with endothelial injury.

Acute coronary syndrome as a first presentation of systemic lupus erythematosus in a teenager: revascularization by hybrid coronary artery bypass graft surgery and percutaneous coronary intervention: case report

Patients with systemic lupus erythematosus (SLE) may present with acute coronary syndrome (ACS) due to coronary vasculitis or premature atherosclerosis. There is a paucity of data on invasive management strategies for young adults who present with an ACS secondary to active vasculitis. This article describes the case of a teenager who presented with an ACS secondary to lupus vasculitis as his first presentation of active SLE. Coronary angiography showed a left main equivalent lesion involving a proximal very large left anterior descending artery (LAD) and diagonal stenosis (with a diminutive left circumflex artery). The boy underwent a successful endoscopic coronary bypass surgery to his LAD followed by percutaneous coronary intervention to his diagonal artery. This case demonstrates the feasibility and safety of a hybrid coronary revascularization in a teenager with acute coronary syndrome due to coronary vasculitis.

Serum protein oxidation and apolipoprotein CIII levels in people with systemic lupus erythematosus with and without nephritis

Increased oxidative stress is a hallmark of the autoimmune disease systemic lupus erythematosus (SLE). This study compares serum protein oxidation levels in SLE patients without and with renal involvement (lupus nephritis); the latter have a significantly poorer prognosis. Similar increases in protein carbonyls and decreases in protein thiols were observed in both SLE groups compared to controls. Protein carbonyl distribution, determined by Western blotting of 2D gels, was similar in both SLE groups, suggesting factors other than oxidation also play a role in SLE complications. 2D electrophoresis examined the serum proteome further. Six proteins were significantly decreases in non-renal SLE patients compared to controls; five were identified by mass spectrometry, including one isoform of pro-atherogenic apoCIII. Total apoCIII levels (assessed by ELISA) in lupus nephritis patients were significantly elevated compared to controls or non-renal SLE patients. Thus, levels of oxidized proteins and apoCIII may be useful biomarkers in SLE studies.

Treatment with an apolipoprotein A-1 mimetic peptide in combination with pravastatin inhibits collagen-induced arthritis

To evaluate the therapeutic potential of an apolipoprotein A-1 (apoA-1) mimetic peptide, D-4F, in combination with pravastatin in collagen-induced arthritis (CIA), syngeneic Louvain rats were immunized with type II collagen and randomized to vehicle control, D-4F monotherapy, pravastatin monotherapy, or D-4F + pravastatin combination therapy. Clinical arthritis activity was evaluated and radiographs, type II collagen antibody titers, cytokine/chemokine levels, and HDL function analysis were obtained. There was significant reduction in clinical severity scores in the high and medium dose D-4F + pravastatin groups compared to controls (p< or =0.0001). Reduction in erosive disease occurred in the medium/high dose combination groups compared to non-combination groups (p< or =0.01). Favorable changes in cytokines/chemokines were noted with treatment, and response to combination D-4F/pravastatin therapy was associated with improvement in HDL's anti-inflammatory properties. Combination D-4F/pravastatin significantly reduced clinical disease activity in CIA, and may have dual therapeutic potential in other autoimmune diseases with increased cardiovascular morbidity and mortality.

Coronary electron beam computed tomography in 13 patients with systemic lupus erythematosus and two or more cardiovascular risk factors

Cardiovascular and cerebrovascular events, the third leading cause of death in patients with systemic lupus erythematosus (SLE), are disproportionately common by age and gender. Risk factors for atherosclerotic cardiovascular disease (ASCVD) cannot reliably predict subsets of patients at risk for events. Coronary electron beam computed tomography (EBCT), a noninvasive imaging technique that quantifies ASCVD by measuring calcium deposition in the walls of coronary arteries, has been demonstrated to be a marker of ASCVD in traditional populations. A pilot group of 13 SLE patients (ages, 33-48 years) with two or more traditional risk factors for cardiovascular disease were studied by EBCT. Five of these SLE patients had calcification scores in the 70th percentile or higher, as compared with age-matched women without known coronary artery disease, and three had scores in the 90th percentile. Four of these five patients had antiphospholipid antibodies currently or in the past. These data suggest that EBCT may be able to detect premature ASCVD in SLE patients and may be a useful noninvasive tool as more attention is directed to ASCVD as a major complication of SLE.

Vascular bed-specific thrombosis

Hemostasis represents a finely tuned balance between procoagulant and anticoagulant forces. An imbalance of these forces may lead to clinically significant disease, including arterial, venous and/or microvascular thrombosis. The vast majority of hypercoagulable states are associated with local thrombus formation. The goal of this review is to discuss the mechanisms underlying site-specific thrombosis.

Pathogen-sensing plasmacytoid dendritic cells stimulate cytotoxic T-cell function in the atherosclerotic plaque through interferon-alpha

BACKGROUND

Unstable atherosclerotic plaque is characterized by an infiltrate of inflammatory cells. Both macrophages and T cells have been implicated in mediating the tissue injury leading to plaque rupture; however, signals regulating their activation remain unidentified. Infectious episodes have been suspected to render plaques vulnerable to rupture. We therefore explored whether plasmacytoid dendritic cells (pDCs) that specialize in sensing bacterial and viral products can regulate effector functions of plaque-residing T cells and thus connect host infection and plaque instability.

METHODS AND RESULTS

pDCs were identified in 53% of carotid atheromas (n=30) in which they localized to the shoulder region and produced the potent immunoregulatory cytokine interferon (INF)-alpha. IFN-alpha transcript concentrations in atheroma tissues correlated strongly with plaque instability (P<0.0001). Plaque-residing pDCs responded to pathogen-derived motifs, CpG-containing oligodeoxynucleotides binding to toll-like receptor 9, with enhanced IFN-alpha transcription (P=0.03) and secretion (P=0.007). IFN-alpha emerged as a potent regulator of T-cell function, even in the absence of antigen recognition. Specifically, IFN-alpha induced a 10-fold increase of tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) on the surface of CD4 T cells (P<0.0001) and enabled them to effectively kill vascular smooth muscle cells (P=0.0003).

CONCLUSIONS

pDCs in atherosclerotic plaque sense microbial motifs and amplify cytolytic T-cell functions, thus providing a link between host-infectious episodes and acute immune-mediated complications of atherosclerosis.

Identifying Chest Pain Emergencies in the Primary Care Setting

The majority of patients presenting to a primary care physician with acute chest pain will have non-life-threatening etiologies. Nevertheless, catastrophic cause of chest pain such as ACS, AD, PE, esophageal perforation, and pericarditis must be considered in the differential diagnosis. Often, these deadly conditions have atypical clinical presentations that must be recognized. Furthermore, the physical examination can be deceptively benign in patients harboring a catastrophic etiology of chest pain. By identifying these atypical presentations, recognizing the utility of the physical examination, and understanding of the limitations of traditional diagnostic imaging, primary care physicians can effectively diagnose patients who have life-threatening cause of acute chest pain.

Vasculitis in systemic lupus erythematosus: prevalence and clinical characteristics in 670 patients

We conducted the current study to determine the prevalence and clinical characteristics of vasculitis in a large series of patients with systemic lupus erythematosus (SLE), focusing on the classification and clinical significance of the different types of vasculitis. We studied 670 consecutive patients who fulfilled 4 or more of the 1997 revised criteria for SLE. Definite vasculitis was diagnosed histologically and/or by arteriography, and probable vasculitis was diagnosed clinically when there were characteristic cutaneous lesions. Vasculitides were categorized according to the definitions adopted by the Chapel Hill Consensus Conference. Seventy-six (11%) patients with SLE had vasculitis (68 female patients and 8 male; mean age, 37.8 yr); only 32 (42%) fulfilled the Chapel Hill definitions. Cutaneous lesions were the main clinical presentation of vasculitis, present in 68 (89%) patients, while the remaining 8 (11%) had isolated visceral vasculitis. Compared with SLE patients without vasculitis, patients with vasculitis had a higher prevalence of livedo reticularis (22% vs. 3%; p = 0.028); a higher mean European Consensus Lupus Activity Measurement (ECLAM) score (5.86 vs. 3.87; p < 0.001); and a higher frequency of anemia (62% vs. 17%; p < 0.001), erythrocyte sedimentation rate (ESR) >50 mm/h (60% vs. 15%; p < 0.001), and anti-La/SS-B antibodies (19% vs. 5%; p = 0.014) in the multivariate analysis. With respect to the size of the vessels involved, 65 (86%) patients had small vessel vasculitis (SVV) and 11 (14%) had medium-sized vessel vasculitis (MVV). SLE patients with MVV had a higher prevalence of mononeuritis multiplex (54% vs. 2%; p < 0.001), visceral vasculitis (100% vs. 5%; p < 0.001), and ulcerated/ischemic cutaneous lesions (36% vs. 11%; p = 0.047) and a higher percentage of surgical interventions (45% vs. 0%; p < 0.001) compared with patients with SVV. In conclusion, we observed a heterogeneous presentation of vasculitides arising in the setting of SLE, with nearly 60% of cases not fulfilling the names and definitions adopted by the Chapel Hill Consensus Conference. SVV was the most frequent vasculitis, overwhelmingly cutaneous and clearly differentiated from MVV, which was less frequent but had predominantly visceral involvement (especially of the peripheral nerves). The presence of vasculitis in our patients with SLE was associated with a higher ECLAM score, livedo reticularis, hematologic parameters (anemia, high ESR), and anti-La/SS-B antibodies.

Intra-Vascular Ultrasound Findings of Diffuse Coronary Atherosclerotic Change in Systemic Lupus Erythematosus With Secondary Antiphospholipid Syndrome

Systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APS) are autoimmune inflammatory diseases associated with juvenile atherosclerosis and thrombosis, respectively. A 44-year-old woman who had SLE with secondary APS had been treated with corticosteroid therapy, however, her inflammatory marker had never been within a normal range in her clinical course, and finally acute myocardial infarction was developed. Intra-vascular ultrasound also revealed diffuse coronary atherosclerosis progression for her age, which might result from SLE and APS, including vascular inflammation.

Premature atherosclerosis and acute coronary syndrome in systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is a vasculitic disorder with potential for multisystem organ dysfunction. Among the organ systems affected is the cardiovascular system. Patients with SLE are prone to premature atherosclerosis; this premature atherosclerosis places the patient at risk for myocardial infarction with onset at a relatively young age. We present 4 patients with SLE who experienced myocardial infarction; these patients also experienced diagnostic and treatment delays because of their relatively young age at presentation. Relevant pathophysiology and diagnostic strategies are discussed.

Hydroxychloroquine cardiotoxicity in systemic lupus erythematosus: a report of 2 cases and review of the literature

BACKGROUND

Hydroxychloroquine (HCQ) is extensively used in the long-term treatment of systemic lupus erythematosus (SLE). Although considered by clinicians to be relatively safe, serious side effects have been documented in the literature. Retinotoxicity has received the most attention, whereas neuromyotoxicity and cardiotoxicity have been described in isolated case reports. We present 2 cases of potential cardiotoxicity occurring in patients with SLE while receiving long-term HCQ therapy.

OBJECTIVE

To review the incidence, presentation, and mechanism of serious antimalarial toxicity, and to discuss the impact of HCQ on cardiac health in SLE.

METHODS

The authors reviewed the English-language literature from 1948 to December 2002 using Medline databases.

RESULTS

In addition to our patients, there are 2 published cases of biopsy-proven HCQ cardiotoxicity in the English-language literature. Both occurred in patients with SLE. The literature indicates that antimalarial cardiotoxicity may be of particular importance in patients with SLE given their already increased cardiac risk due to primary heart disease and accelerated atherosclerosis. Endomyocardial biopsy reveals a constellation of findings including vacuolar myopathy, myeloid bodies, and curvilinear bodies.

CONCLUSIONS

As HCQ use among SLE patients increases, clinicians should be alert to the possibility of antimalarial cardiotoxicity. The potential severity and reversibility of this complication underscore the importance of timely diagnosis. The cases presented here, one with biopsy and one without, illustrate the utility of endomyocardial biopsy in HCQ-treated SLE patients with cardiac complaints to ensure accurate diagnosis and appropriate management.

Coronary Artery Bypass Grafting in Patients with Systemic Lupus Erythematosus

Coronary artery disease remains a major cause of mortality and morbidity with systemic lupus erythematosus (SLE). We report two cases of coronary artery bypass grafting (CABG) associated with SLE. The first patient (a 45-year-old woman) underwent CABG operation for left main and two-vessel coronary disease using cardiopulmonary bypass. Successful CABG was done using off-pump technique in the second patient (a 39-year-old woman) under hemodialysis therapy. Both patients showed good postoperative outcome without complications.

A teenager with mixed connective tissue disease presenting with an acute coronary syndrome

Mixed connective tissue disease (MCTD) manifests as a number of cardiovascular diseases; however, myocardial infarction secondary to coronary artery disease has not been well documented. We present a case of a teenager with MCTD and known cardiac risk factors who developed an acute coronary syndrome.

Endothelial cell apoptosis in systemic lupus erythematosus: a common pathway for abnormal vascular function and thrombosis propensity

Women with systemic lupus erythematosus (SLE) are at risk for premature atherothrombosis independent of Framingham risk factors. We investigated whether endothelial cell (EC) apoptosis predicts abnormal vasomotor tone and contributes to circulating tissue factor (TF) levels in this disease. Brachial artery flow-mediated dilation (FMD) and nitroglycerin-mediated dilation were determined in women with SLE, healthy control subjects, and subjects with coronary artery disease (CAD) (n = 43/group). Quantification of circulating apoptotic ECs was performed by flow cytometry (CD146+ cells that stained for Annexin V [CD146AnnV+]) and immunofluorescent microscopy. Plasma TF was measured by enzyme-linked immunosorbent assay (ELISA). Compared with healthy control and CAD subjects, patients with SLE had higher numbers of circulating CD146AnnV+ cells (10 ± 3, 18 ± 5, and 89 ± 32 cells/mL, respectively, mean ± SEM; P &lt; .01). Increased CD146AnnV+ cells correlated strongly with abnormal vascular function (P = .037). After adjusting for known predictors of endothelial function, CD146AnnV+ was the only variable that predicted FMD (β = –4.5, P &lt; .001). Increased CD146AnnV+ was strongly associated with elevated levels of circulating TF (r = .46, P = .002). Circulating apoptotic ECs are elevated in young women with SLE and strongly correlate with markedly abnormal vascular function and elevated TF levels. Heightened endothelial apoptosis may represent an important mechanism for development of atherothrombosis in SLE.

Coronary and valvular syndromes and antiphospholipid antibodies

Since the recognition of the antiphospholipid syndrome (APS), a large number of cardiac manifestations have been reported in association with these antibodies, including coronary artery and valvular disease, cardiomyopathy, and intracardiac thrombosis. Most of these manifestations are explicable on the basis of thrombotic lesions either in the coronary circulation or on the valves and may mimic other similar conditions, such as rheumatic fever or infectious endocarditis. The APS coagulopathy in these patients requires the careful and judicious use of appropriate antiaggregant and anticoagulant therapy. In this review article, the focus will be on the main cardiac features related to the presence of antiphospholipid antibodies (aPLs), which may be of interest to clinicians.

Endothelial nitric oxide synthase gene polymorphisms in Behçet's disease and rheumatic diseases with vasculitis

OBJECTIVE

To assess potential associations between Korean Behçet's disease (BD) or other rheumatic diseases with vasculitis and two polymorphisms of the endothelial nitric oxide synthase (eNOS) gene, which include the Glu298Asp polymorphism in exon 7 and a variable number of tandem repeats (VNTR) polymorphism in intron 4.

METHODS

65 patients with BD, 27 with rheumatic diseases with vasculitis, and 80 controls were studied. Analyses of the Glu298Asp polymorphism in exon 7 and VNTR polymorphism in intron 4 of the eNOS gene were made by the polymerase chain reaction (PCR)-restriction fragment length polymorphism technique and PCR genotyping, respectively. Additionally, HLA-B51 typing was performed in the BD group and controls by a two step PCR sequence-specific primers method.

RESULTS

Significant differences in Glu298Asp genotype frequencies were found between the BD or vasculitis groups and the controls (BD group v controls: p(corr)=0.006; vasculitis group v controls: p<0.001). The Asp298 frequency was much higher in the BD and vasculitis groups than in the controls. Even after stratification of the BD group based on the results of HLA-B51 testing, a significant association of the Glu298Asp polymorphism was still found (p=0.002, Mantel-Haenszel weighted odds ratio 4.3, 95% confidence interval 1.7 to 10.9). Distribution of the genotype frequencies in two eNOS gene polymorphisms was similar in connective tissue diseases-associated vasculitis and primary vasculitic syndromes. In contrast, distribution of alleles and genotypes of VNTR polymorphism did not differ between BD or vasculitis groups and the controls.

CONCLUSION

The Glu298Asp polymorphism in exon 7 of the eNOS gene seems to be a susceptibility gene for Korean BD and other rheumatic diseases.

Acute myocardial infarction caused by delayed heparin-induced thrombocytopenia and acute immunoreaction due to re-exposure to heparin in a systemic lupus erythematosus patient with HIT antibodies

A patient with systemic lupus erythematosus and anticardiolipin antibodies and antibodies to platelet factor 4/heparin complexes suffered an acute myocardial infarction caused by delayed heparin-induced thrombocytopenia after heparin administration given to treat pulmonary hypertension. Furthermore, additional heparin administration for emergency coronary angiography appeared to have led to an acute immunoreaction, which might have resulted in acute coronary occlusion during coronary angiography and to a decreased platelet count. The present findings suggest that one must suspect delayed-type HIT in rare cases of induction of thrombosis after the cessation of heparin treatment, and avoid re-exposure to heparin in such cases.

Food restriction and fish oil suppress atherogenic risk factors in lupus-prone (NZB x NZW) F1 mice

Atherosclerosis-mediated coronary artery disease is a significant cause of mortality in lupus patients. Both an activated immune system and hyperlipidemia are implicated in the pathogenesis of the atherosclerotic lesions of lupus. In this study, the increases in anticardiolipin antibodies, total cholesterol, and LDL cholesterol with age were significantly lowered by fish oil and food restriction, either alone or in combination. Food restriction also significantly decreased the elevation in anti-dsDNA antibody production seen with age in ad libitum groups. Interestingly, effects of food restriction and fish oil on both lipid profile and autoantibody production were seen from a young age. Accumulation of leukocytes in the blood vessels and deposition of IgG in the glomerular mesangium also were suppressed by food restriction. Thus, beneficial effects of fish oil and food restriction on lupus nephritis and survival could be, at least in part, due to their selective effect on atherogenic risk factors.

Systemic lupus erythematosus in the intensive care unit

SLE causes significant morbidity and mortality by multisystem organ involvement. Infections are the leading cause of morbidity and mortality in patients with SLE. Meticulous exclusion of infection is mandatory in patients with SLE, because infections may masquerade as exacerbation of underlying disease; and the immunosuppression used to treat severe forms of exacerbation of lupus can have catastrophic consequences in patients with infections. Corticosteroids are the first-line therapy for most noninfectious complications of SLE, with various adjuvant immunosuppressive agents such as cyclophosphamide being increasingly used in combination with plasmapheresis. Some recent series have shown an improved survival rate, but this improvement needs to be confirmed by further studies. Controlled trials comparing various therapeutic options are lacking, and optimal therapy has not been defined.

How does one assess and monitor patients with systemic lupus erythematosus in daily clinical practice?

Systemic lupus erythematosus (SLE) is a multisystem autoimmune rheumatic disease (ARD) characterized by flares and remissions. SLE has protean and often complex manifestations, necessitating careful clinical assessment. However, it is important to remember that not all clinical problems reported by a lupus patient are due to the disease. Some may be a consequence of therapy and others may be unrelated to lupus. Therefore it is important to understand the totality of the effect of the disease on the patient. In order to do this measures are needed which distinguish current, potentially reversible disease activity, permanent organ damage and the effect of the disease on the patients' health status. Several measures are in current use in clinical trials, but not all are suitable for use in the routine clinical setting. This chapter discusses the current measures available to assess disease activity and damage in SLE.