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Carpenter K, Gilman S, French M, Shakur Y, Dunlop-Thomas C, Cullerton L, Drenkard C, Barbour KE, Lim SS. Informing Digital Programs for Lupus Self-Management Education: A Systematic Scoping Review. Arthritis Care Res (Hoboken) 2024. [PMID: 38736154 DOI: 10.1002/acr.25357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 04/13/2024] [Accepted: 04/19/2024] [Indexed: 05/14/2024]
Abstract
OBJECTIVE We describe the characteristics, content, and effectiveness of digital self-management (SM) education programs for lupus and other chronic conditions to identify gaps and inform the improvement of future programs in lupus. METHODS Three bibliographic databases were searched for articles published between May 2012 and April 2022. The search was cast to capture the breadth of digital SM education programs in the following conditions: lupus, epilepsy, fibromyalgia, multiple sclerosis, sickle cell anemia, Sjögren syndrome, psoriatic arthritis, and rheumatoid arthritis. Title and abstract screening, as well as full-text review, was conducted by two independent reviewers. Data extraction was first completed by one author charting all studies and then, a second time, by four members of the research team charting collaboratively. RESULTS Of the 1,969 articles identified through the search, 14 met inclusion criteria. Two additional articles were included following bibliography review. The 16 articles represented 12 unique digital SM education programs. Programs covered five conditions: epilepsy (n = 3), fibromyalgia (n = 2), multiple sclerosis (n = 4), lupus (n = 1), and rheumatoid arthritis (n = 2). Most programs were asynchronous and internet-based (n = 9) with a prescribed sequence of content (n = 8). Peer, technical, or specialist support was offered in seven programs. Most programs demonstrated statistically significant improvement of symptoms in the intervention group (n = 8). CONCLUSION This scoping review summarizes the current landscape for digital SM education programs in lupus and similar conditions. In lupus, further investigation will fill in the gaps around digital SM education needs, user experience, and evaluation of outcomes.
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Affiliation(s)
| | - Sarah Gilman
- Wayfinder Health Strategies, Falls Church, Virginia
| | | | | | | | | | | | - Kamil E Barbour
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - S S Lim
- Emory University, Atlanta, Georgia
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Gegenava M, Kirtava Z, Kong WKF, Gegenava T. Left ventricular systolic function assessed by standard and advanced echocardiographic techniques in patients with systemic lupus erythematosus: A systemic review and meta-analysis. Arch Rheumatol 2024; 39:149-158. [PMID: 38774698 PMCID: PMC11104758 DOI: 10.46497/archrheumatol.2024.10131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 06/11/2023] [Indexed: 05/24/2024] Open
Abstract
Objectives Aim of the study was to perform a systemic review and meta-analysis of the current case-control studies based on the assessment of the left ventricular (LV) systolic function with standard and advanced echocardiographic methods. Materials and methods Objectives of the study, methods of statisticalanalysis, literature search strategy, inclusion andexclusion criteria, and outcome measurementswere defined according to Cochrane Collaborationsteps, 13 including recommendations for metaanalysisof observational studies in epidemiology (MOOSE). Results A total of 850 papers were collected. Of those, eight papers (10 groups) including 174,442 SLE patients and 45,608,723 controls with heart failure (HF), 20 papers including 1,121 SLE patients and 1,010 controls with an evaluated LV ejection fraction (LVEF), and eight studies (nine groups) including 462 SLE patients and 356 controls with a measured LV global longitudinal strain (LVGLS) met the predefined inclusion criteria. HF rate in SLE patients was 2.39% (4,176 of 174,442 patients with HF), and SLE patients showed a 3.4 times higher risk for HF compared to controls. SLE patients had a lower LVEF compared to controls. LVGLS was more impaired in SLE patients compared to controls, irrespective of two-dimensional or three-dimensional speckle tracking echocardiography. Conclusion Heart failure rate in SLE patients is high, and SLE patients showed a 3.4 times higher risk in patients with SLE compared to controls. LV systolic function, as measured by LVEF and LVGLS, is significantly affected in SLE patients, and LVGLS potentially represents a new tool for the early assessment of LV function.
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Affiliation(s)
- Maka Gegenava
- Department of Internal Medicine №2, Tbilisi State Medical University, Tbilisi, Georgia
| | - Zviad Kirtava
- Department of Internal Medicine, Caucasus School of Medicine and Healthcare Management, Caucasus University, Tbilisi, Georgia
| | - William KF Kong
- Department of Cardiology, National University Heart Centre Singapore, National University Health System, Singapore
| | - Tea Gegenava
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Internal Medicine №1, Tbilisi State Medical University, Tbilisi, Georgia
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Han JY, Cho SK, Kim H, Jeon Y, Kang G, Jung SY, Jang EJ, Sung YK. Increased cardiovascular risk in Korean patients with systemic lupus erythematosus: a population-based cohort study. Sci Rep 2024; 14:1082. [PMID: 38212487 PMCID: PMC10784514 DOI: 10.1038/s41598-024-51546-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 01/06/2024] [Indexed: 01/13/2024] Open
Abstract
To determine the increased risk of major adverse cardiovascular events (MACE) in patients with systemic lupus erythematosus (SLE) compared to the general population in Korea. Using data from the National Health Insurance Service database spanning 2008 to 2018, incident SLE patients aged 18 years and above were selected along with a 1:4 age- and sex-matched control group. The crude incidence rate (IR) of MACE was calculated as the number of events per 1000 person-years and the IR ratio (IRR) for MACE was adjusted using generalized estimating equations. Subgroup analysis was conducted to evaluate the risk differences of overall MACE and its composites based on age and sex stratification. The study included 8568 SLE patients and 34,272 controls. The cumulative IR of MACE per 1000 person-years in SLE patients and controls were 4.08 and 1.30, respectively. After adjusting for confounders, SLE patients had a higher risk of MACE compared to the general population (adjusted IRR of 2.40 [95% confidence interval [CI] 1.88-3.05]), with no gender differences observed. The increased risk of MACE in SLE patients was highest in the 18-39 age group (IRR 11.70, 95% CI 5.95-23.01) and gradually decreased with age. The increased risk of ischemic stroke (IRR 2.41, 95% CI 1.84-3.15) and myocardial infarction (IRR 2.19, 95% CI 1.30-3.68) in SLE patients was comparable. The risk of MACE in SLE patients is 2.40 times higher than that of the general population, with a higher relative risk observed in younger individuals.
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Affiliation(s)
- Jung-Yong Han
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Republic of Korea
- Hanyang University Institute for Rheumatology Research, Seoul, Republic of Korea
| | - Soo-Kyung Cho
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Republic of Korea
- Hanyang University Institute for Rheumatology Research, Seoul, Republic of Korea
| | - Hyoungyoung Kim
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Republic of Korea
- Hanyang University Institute for Rheumatology Research, Seoul, Republic of Korea
| | - Yena Jeon
- Department of Statistics, Kyungpook National University, Daegu, Republic of Korea
| | - Gaeun Kang
- Department of Statistics, Kyungpook National University, Daegu, Republic of Korea
| | - Sun-Young Jung
- College of Pharmacy, Chung-Ang University, Seoul, Republic of Korea
| | - Eun Jin Jang
- Department of Information Statistics, Andong National University, Andong, Republic of Korea
| | - Yoon-Kyoung Sung
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Republic of Korea.
- Hanyang University Institute for Rheumatology Research, Seoul, Republic of Korea.
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Iyer P, Gao Y, Jalal D, Girotra S, Singh N, Vaughan-Sarrazin M. Hydroxychloroquine use is associated with reduced mortality risk in older adults with rheumatoid arthritis. Clin Rheumatol 2024; 43:87-94. [PMID: 37498463 PMCID: PMC10818008 DOI: 10.1007/s10067-023-06714-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 06/20/2023] [Accepted: 07/19/2023] [Indexed: 07/28/2023]
Abstract
BACKGROUND There is little robust data about the cardiovascular safety of hydroxychloroquine in patients with rheumatoid arthritis (RA), who often have cardiovascular comorbidities. We examined the association between use of hydroxychloroquine (HCQ) in patients with RA and major adverse cardiovascular events (MACE). METHODS In a retrospective cohort of Medicare beneficiaries aged ≥ 65 years with RA, we identified patients who initiated HCQ (users) and who did not initiate HCQ (non-users) between January 2015-June 2017. Each HCQ user was matched to 2 non-users of HCQ using propensity score derived from patient baseline characteristics. The primary outcome was the occurrence of MACE, defined as acute admissions for stroke, myocardial infarction, or heart failure. Secondary outcomes included all-cause mortality and the composite of MACE and all-cause mortality. Cox proportional hazards model was used to compare outcomes between HCQ users to non-users. RESULTS The study included 2380 RA patients with incident HCQ use and matched 4633 HCQ non-users over the study period. The mean follow-up duration was 1.67 and 1.63 years in HCQ non-users and users, respectively. In multivariable models, use of HCQ was not associated with the risk of MACE (hazard ratio 1.1; 95% CI: 0.832-1.33). However, use of HCQ was associated with a lower risk of all-cause mortality (HR: 0.54; 95% CI: 0.45-0.64) and the composite of all-cause mortality and MACE (HR 0.67; 95% CI: 0.58-0.78). CONCLUSION HCQ use was independently associated with a lower risk of mortality in older adults with RA but not with incidence of MACE events. Key Points • Using an incident user design (to avoid the biases of a prevalent user design) and a population-based approach, we examined the effect of hydroxychloroquine (HCQ) on the risk of major cardiovascular events (MACE) in older patients with RA. • We did not find an association between HCQ use and incident MACE. We did, however, find a significant association with the composite outcome (MACE and all-cause mortality) driven by a significant reduction in all-cause mortality with HCQ use.
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Affiliation(s)
- Priyanka Iyer
- Division of Rheumatology, University of California at Irvine, Irvine, CA, USA
| | - Yubo Gao
- Division of General Medicine, Department of Internal Medicine, Roy and Lucille Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Diana Jalal
- Division of Nephrology, Department of Internal Medicine, Roy and Lucille Carver College of Medicine, University of Iowa, and Iowa City VA Health Care System, Iowa City, IA, USA
| | - Saket Girotra
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Namrata Singh
- Division of Rheumatology, Department of Medicine, University of Washington, 1959 NE Pacific Street, Seattle, WA, 98195, USA.
| | - Mary Vaughan-Sarrazin
- Division of General Medicine, Department of Internal Medicine, Roy and Lucille Carver College of Medicine, University of Iowa, and Iowa City VA Health Care System Center for Access and Delivery Research and Evaluation (CADRE), Iowa City, IA, USA
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Mihailovic J, Ribi C, Chizzolini C, Trendelenburg M, Von Kempis J, Dahdal S, Huynh-Do U. Worse cardiovascular and renal outcome in male SLE patients. Sci Rep 2023; 13:18628. [PMID: 37903784 PMCID: PMC10616173 DOI: 10.1038/s41598-023-45171-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 10/17/2023] [Indexed: 11/01/2023] Open
Abstract
Systemic lupus erythematosus (SLE) in males is rare and poorly understood. Thus, still little is known about sex differences in SLE. We set out to identify sex differences regarding clinical manifestations as well as renal and cardiovascular outcomes of SLE. We analyzed patient data from the Swiss SLE Cohort Study. Cumulative clinical manifestations according to the updated American College of Rheumatology criteria were recorded at inclusion. Cardiovascular events were recorded within Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SLICC-SDI). Renal failure was defined as eGFR < 15 ml/min/1.73 m2, initiation of renal replacement therapy or doubling of serum creatinine which were all assessed yearly or documented as end stage renal disease in SLICC-SDI. Risk differences were calculated using logistic regression and cox regression models. We analyzed 93 men and 529 women with a median follow up time of 2 years. Males were significantly older at diagnosis (44.4 versus 33.1 years, p < 0.001) and had less often arthritis (57% versus 74%, p = 0.001) and dermatological disorders (61% versus 76%, p < 0.01). In multivariate analysis female sex remained a significantly associated with arthritis and dermatological disorders. In multivariate analysis men had a significantly higher hazard ratio of 2.3 for renal failure (95% confidence interval (95%-CI) 1.1-5.2, p < 0.04). Total SLICC-SDI Score was comparable. Men had significantly more coronary artery disease (CAD) (17% versus 4%, p < 0.001) and myocardial infarction (10% versus 2%, p < 0.01). In multivariate analysis, male sex remained a significant risk factor for CAD (odds ratio (OR) 5.6, 95%-CI 2.3-13.7, p < 0.001) and myocardial infarction (OR 8.3, 95%-CI 2.1-32.6, p = 0.002). This first sex study in a western European population demonstrates significant sex differences in SLE. Male sex is a risk factor for cardiovascular events and renal failure in SLE. Potential etiological pathomechanisms such as hormonal or X-chromosomal factors remain to be further investigated.
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Affiliation(s)
- Jelena Mihailovic
- Department of Nephrology and Hypertension Inselspital, University Hospital Bern, Freiburgstrasse 18, 3010, Bern, Switzerland
| | - Camillo Ribi
- Division of Clinical Immunology and Allergy, University Hospital Lausanne, Lausanne, Switzerland
| | - Carlo Chizzolini
- Pathology and Immunology, School of Medicine, Geneva University, Geneva, Switzerland
| | - Marten Trendelenburg
- Division of Internal Medicine and Clinical Immunology Laboratory, Department of Biomedicine, University Hospital Basel, Basel, Switzerland
| | - Johannes Von Kempis
- Division of Rheumatology and Immunology, Department of Internal Medicine, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Suzan Dahdal
- Department of Nephrology and Hypertension Inselspital, University Hospital Bern, Freiburgstrasse 18, 3010, Bern, Switzerland.
| | - Uyen Huynh-Do
- Department of Nephrology and Hypertension Inselspital, University Hospital Bern, Freiburgstrasse 18, 3010, Bern, Switzerland
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Płazak W, Drabik L. SARS-CoV-2 infection and SLE: endothelial dysfunction, atherosclerosis, and thrombosis. Clin Rheumatol 2023; 42:2691-2702. [PMID: 36622519 PMCID: PMC9827021 DOI: 10.1007/s10067-022-06497-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 12/22/2022] [Accepted: 12/26/2022] [Indexed: 01/10/2023]
Abstract
An increased risk of atherosclerotic and thrombotic complications characterizes connective tissue diseases. Endothelial dysfunction is the basis for the initiation and progression of atherosclerosis and thrombosis. We present systemic lupus erythematosus (SLE) as a model rheumatic disease with endothelial dysfunction and discuss its mechanisms, factors that influence the early onset and rapid progression of atherosclerosis, and the increased risk of thromboembolic events. We focus on established methods to improve endothelium function, including statins, antiplatelet, and antithrombotic therapy. Hypercoagulable and hypofibrinolitic states and a hyperinflammatory response characterize severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Several pathogenic mechanisms are typical for an acute phase of Covid-19 post-Covid syndrome and connective tissue diseases: endothelial dysfunction, elevated antiphospholipid antibody titer, activation of the complement system, and formation of extracellular neutrophil traps (NET). The current review discusses the mechanisms underlying SLE and the COVID-19 in the context of endothelial function, atherosclerosis, and thrombosis (Graphical abstract). Key Points • The pathophysiology of systemic lupus erythematosus (SLE) and Covid-19 shows some similarities, such as endothelial cell activation and dysfunction, the activation of complementary systems, the presence of antiphospholipid antibodies, and the formation of extracellular neutrophil traps. • Autoimmunity in both diseases creates the basis for hyperinflammatory, hypercoagulable, and hypofibrinolitic states and their thromboembolic complications. • This paper presents our perspective on the mechanisms behind the cardiovascular manifestations of SLE and COVID-19, with a particular emphasis on endothelial dysfunction. Covid-19 and systemic lupus erythematosus-potential similarities in pathophysiology. Figures of the panel illustrate the clinical manifestations of endothelial dysfunction, atherosclerosis, and thromboembolism, including coronary artery disease ([A] coronary angiography with left anterior descending artery stenosis and [B] scintigraphy with reduced perfusion in the myocardial apical segments), stroke ([C] carotid angiography, left carotid artery occlusion) and pulmonary embolism ([D]computed tomography with thrombus in the right pulmonary artery).
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Affiliation(s)
- Wojciech Płazak
- Department of Cardiac and Vascular Diseases, John Paul II Hospital, Jagiellonian University Medical College, Krakow, Poland.
| | - Leszek Drabik
- Department of Cardiac and Vascular Diseases, John Paul II Hospital, Jagiellonian University Medical College, Krakow, Poland
- Department of Pharmacology, Jagiellonian University Medical College, Krakow, Poland
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7
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Farina N, Webster J, Luo W, Garelick D, Pinto SM, Isenberg D, Rahman A. Factors associated with cardiovascular events in systemic lupus erythematosus in a monocentric cohort with up to 40 years of follow-up. Semin Arthritis Rheum 2023; 61:152226. [PMID: 37201214 DOI: 10.1016/j.semarthrit.2023.152226] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 04/23/2023] [Accepted: 05/08/2023] [Indexed: 05/20/2023]
Abstract
OBJECTIVES Systemic lupus erythematosus (SLE) is associated with an increased cardiovascular risk. Several traditional and disease-specific risk factors have been shown to correlate with the occurrence of cardiovascular events (CVE) in patients with SLE. However, results of previous studies are diverse. The objectives of this study were to report number, type and those factors associated with CVE in patients with SLE in a large, single-center, ethnically diverse cohort with a long follow-up duration. METHODS Medical records of patients treated at the Lupus Clinic at University College London Hospital (UCLH) between 1979 and 2020 were retrospectively reviewed. Data about CVE, traditional cardiovascular risk factors, demographic and disease features, and treatment history were collected. Only patients with complete available information were included in the study. Regression analyses were performed to identify factors associated with CVE. RESULTS Four hundred and nineteen patients were included in the study. Maximum follow-up length was 40 years. Seventy-one (17%) patients had at least one CVE. Multivariable analysis showed that only antiphospholipid antibody positivity (p-value<0.001) was associated with CVE. When analysing different types of CVE, antiphospholipid antibodies were specifically associated with both venous thromboembolic events (p-value<0.001) and cerebrovascular events (p-value=0.007). Dedicated subanalyses revealed that cumulative glucocorticoid dose (p-value=0.010) and a diagnosis of SLE before 2000 (p-value<0.001) were significantly associated with CVE. CONCLUSIONS Cardiovascular disease is highly prevalent among patients with SLE and is associated with antiphospholipid antibodies, glucocorticoid therapy, and diagnosis before 2000.
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Affiliation(s)
- Nicola Farina
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele, Milan, Italy; Centre for Rheumatology Research, Division of Medicine, University College London, UK
| | - Jemma Webster
- Centre for Rheumatology Research, Division of Medicine, University College London, UK
| | - Weike Luo
- Centre for Rheumatology Research, Division of Medicine, University College London, UK
| | - Daniela Garelick
- Rheumatology Unit, The Zabludowicz Center for Autoimmune Diseases, Tel-Hashomer, Ramat Gan, Israel
| | - Sara Moreira Pinto
- Internal Medicine Service, Centro Hospitalar Póvoa de Varzim e Vila do Conde, Portugal
| | - David Isenberg
- Centre for Rheumatology Research, Division of Medicine, University College London, UK
| | - Anisur Rahman
- Centre for Rheumatology Research, Division of Medicine, University College London, UK.
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Matsumori A. Myocarditis and Autoimmunity. Expert Rev Cardiovasc Ther 2023. [PMID: 37243585 DOI: 10.1080/14779072.2023.2219895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 05/20/2023] [Accepted: 05/26/2023] [Indexed: 05/29/2023]
Abstract
INTRODUCTION Autoimmune myocarditis may develop due to heterogeneous causes. Myocarditis is often caused by viral infections, but it can also be caused by systemic autoimmune diseases. Immune checkpoint inhibitors and virus vaccines induce immune activation, and they can cause the development of myocarditis, as well as several immune-related adverse events. The development of myocarditis is dependent on the genetic factors of the host, and the major histocompatibility complex (MHC) may be an important determinant of the type and severity of the disease. However, non-MHC immunoregulatory genes may also play a role in determining susceptibility. AREA COVERED This review summarizes the current knowledge of the etiology, pathogenesis, diagnosis and treatment of autoimmune myocarditis with a particular focus on viral infection and autoimmunity, and biomarkers of myocarditis. EXPERT OPINION An endomyocardial biopsy may not be the gold standard for the diagnosis of myocarditis. Cardiac magnetic resonance imaging is useful in diagnosing autoimmune myocarditis. Recently identified biomarkers of inflammation and myocyte injury are promising for the diagnosis of myocarditis when measured simultaneously. Future treatments should focus on the appropriate diagnosis of the etiologic agent, as well as on the specific stage of the evolution of immune and inflammatory processes.
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Affiliation(s)
- Akira Matsumori
- Clinical Research Institute, National Hospital Organization Kyoto Medical Center, Kyoto 612-8555, Japan
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9
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du Toit R, Karamchand S, Doubell AF, Reuter H, Herbst PG. Lupus myocarditis: review of current diagnostic modalities and their application in clinical practice. Rheumatology (Oxford) 2023; 62:523-534. [PMID: 35861382 DOI: 10.1093/rheumatology/keac409] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 06/27/2022] [Accepted: 06/27/2022] [Indexed: 02/04/2023] Open
Abstract
Lupus myocarditis (LM) is a potentially fatal manifestation of SLE, occurring in 5-10% of patients. Clinical manifestations may vary from an unexplained tachycardia to fulminant congestive cardiac failure (CCF). With no single clinical or imaging modality being diagnostic, a rational and practical approach to the patient presenting with possible LM is essential. Markers of myocyte injury (including troponin I and creatine kinase) may be unelevated and do not exclude a diagnosis of LM. Findings on ECG are non-specific but remain essential to exclude other causes of CCF such as an acute coronary syndrome or conduction disorders. Echocardiographic modalities including wall motion abnormalities and speckle tracking echocardiography may demonstrate regional and/or global left ventricular dysfunction and is more sensitive than conventional echocardiography, especially early in the course of LM. Cardiac magnetic resonance imaging (CMRI) is regarded as the non-invasive diagnostic modality of choice in myocarditis. While more sensitive and specific than echocardiography, CMRI has certain limitations in the context of SLE, including technical challenges in acutely unwell and uncooperative patients, contraindications to gadolinium use in the context of renal impairment (including lupus nephritis) and limited literature regarding the application of recommended diagnostic CMRI criteria in SLE. Both echocardiography as well as CMRI may detect subclinical myocardial dysfunction and/or injury of which the clinical significance remains uncertain. Considering these challenges, a combined decision-making approach by rheumatologists and cardiologists interpreting diagnostic test results within the clinical context of the patient is essential to ensure an accurate, early diagnosis of LM.
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Affiliation(s)
| | | | | | - Helmuth Reuter
- Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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10
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Garg S, Bartels CM, Bao G, Helmick CG, Drenkard C, Lim SS. Timing and Predictors of Incident Cardiovascular Disease in Systemic Lupus Erythematosus: Risk Occurs Early and Highlights Racial Disparities. J Rheumatol 2023; 50:84-92. [PMID: 35914786 PMCID: PMC10773489 DOI: 10.3899/jrheum.220279] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/20/2022] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Systemic lupus erythematosus (SLE) affects Black people 2 to 3 times more frequently than non-Black people and is associated with higher morbidity and mortality. In total, 4 studies with predominantly non-Black SLE cohorts highlighted that cardiovascular disease (CVD) is no longer primarily a late complication of SLE. This study assessed the timing and predictors of incident CVD in a predominantly Black population-based SLE cohort. METHODS Incident SLE cases from the population-based Georgia Lupus Registry were validated as having a CVD event through review of medical records and matching with the Georgia Hospital Discharge Database and the National Death Index. The surveillance period for an incident CVD event spanned a 15-year period, starting from 2 years prior to SLE diagnosis. RESULTS Among 336 people with SLE, 253 (75%) were Black and 56 (17%) had an incident CVD event. The frequency of CVD events peaked in years 2 and 11 after SLE diagnosis. There was a 7-fold higher risk of incident CVD over the entire 15-year period; this risk was 19-fold higher in the first 12 years in Black people as compared to non-Black people with SLE. Black people with SLE (P < 0.001) and those with discoid rash (hazard ratio 3.2, 95% CI 1.4-7.1) had a higher risk of incident CVD events. CONCLUSION The frequency of incident CVD events peaked in years 2 and 11 after SLE diagnosis. Being Black or having a discoid rash were strong predictors of an incident CVD event. Surveillance for CVD and preventive interventions, directed particularly toward Black people with recent SLE diagnoses, are needed to reduce racial disparities.
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Affiliation(s)
- Shivani Garg
- S. Garg, MD, MS, Assistant Professor, C.M. Bartels, MD, MS, Associate Professor, Rheumatology Division, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin;
| | - Christie M Bartels
- S. Garg, MD, MS, Assistant Professor, C.M. Bartels, MD, MS, Associate Professor, Rheumatology Division, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Gaobin Bao
- G. Bao, MPH, Senior Statistician, Division of Rheumatology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Charles G Helmick
- C.G. Helmick, MD, Professor, Division of Population Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Cristina Drenkard
- C. Drenkard, MD, PhD, Associate Professor, S.S. Lim, MD, MPH, Professor, Division of Rheumatology, Department of Medicine, Emory University School of Medicine, and Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | - S Sam Lim
- C. Drenkard, MD, PhD, Associate Professor, S.S. Lim, MD, MPH, Professor, Division of Rheumatology, Department of Medicine, Emory University School of Medicine, and Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
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11
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Guzmán-Martínez G, Marañón C. Immune mechanisms associated with cardiovascular disease in systemic lupus erythematosus: A path to potential biomarkers. Front Immunol 2022; 13:974826. [PMID: 36420265 PMCID: PMC9677819 DOI: 10.3389/fimmu.2022.974826] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 09/13/2022] [Indexed: 10/29/2023] Open
Abstract
Systemic lupus erythematosus (SLE) patients display an increased risk of cardiovascular disease (CVD). With the improved clinical management of other classical severe manifestation of the disease, CVD is becoming one of the most relevant complications of SLE, and it is an important factor causing morbidity and mortality. Several immune constituents have been shown to be involved in the pathogenesis of atherosclerosis and endothelial damage in SLE patients, including specific circulating cell populations, autoantibodies, and inflammatory mediators. In this review, we summarize the presentation of CVD in SLE and the role of the autoimmune responses present in SLE patients in the induction of atherogenesis, endothelial impairment and cardiac disease. Additionally, we discuss the utility of these immune mediators as early CVD biomarkers and targets for clinical intervention in SLE patients.
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Affiliation(s)
- Gabriela Guzmán-Martínez
- Atrys Health, Madrid, Spain
- Department of Medicine, Faculty of Biomedical and Health Sciences, Universidad Europea de Madrid, Madrid, Spain
- Department of Cardiology, La Paz University Hospital, IdiPaz, Madrid, Spain
| | - Concepción Marañón
- Department of Genomic Medicine, Pfizer-University of Granada-Andalusian Regional Government Centre for Genomics and Oncological Research (GENYO), Granada, Spain
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12
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Arterial stiffness and atherosclerosis in systemic lupus erythematosus patients. Reumatologia 2022; 60:165-172. [PMID: 35875719 PMCID: PMC9301661 DOI: 10.5114/reum.2022.117836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 06/08/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction Systemic lupus erythematosus (SLE) is characterized by early atherothrombosis. Pulse wave velocity (PWV) is a promising tool for the diagnosis of early vascular remodelling and initial atherosclerotic plaque formation. Our objective was to evaluate PWV and its relationship with coronary atherosclerosis and thrombotic biomarkers in patients with SLE. Material and methods In 26 patients with SLE with stable clinical conditions, mean age of 39.1 ±11.7 years and without a history of coronary artery disease, multidetector computed tomography (MDCT)-based coronary calcium scoring (CACS) was performed and PWV measured. Laboratory evaluation included serum levels of anticardiolipin and anti-β2-glycoprotein antibodies (anti-β2-GPI), lupus anticoagulant (LA), D-dimers, thrombin–antithrombin complexes (TAT), and von Willebrand factor (vWF). Results Multidetector computed tomography revealed coronary calcifications in 8 (30.8%) patients and the median CACS was 52.4 HU (range 2–843.2). The mean PWV was 9.0 ±3.2 m/s and was higher in patients aged > 50 years (+33.7% vs. < 50 years), those with positive LA (+28.2% vs. LA negative), TAT ≥ 10 μg/l (+18.1% vs. < 10 μg/l), vWF ≥ 200 IU/dl (+51.8% vs. < 200 IU/dl) and with coronary atherosclerosis (CACS > 0; +21.4% vs. CACS = 0). In contrast, the duration of the disease, D-dimers, anticardiolipin, and anti-β2-GPI antibodies did not influence PWV. In the group without atherosclerosis (CACS = 0, n =18), patients with vWF ≥ 200 IU/dl had a 19.3% higher PWV compared to the rest. Conclusions In patients with SLE, PWV was associated with the presence of coronary atherosclerotic lesions in MDCT. Furthermore, arterial stiffness was higher in patients with markers of endothelial dysfunction and a prothrombotic state, suggesting their contribution to the early stages of arterial remodelling in SLE.
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13
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Chang CM, Lin JR, Fu TC. Associations Between Sarcopenia, Heart Failure and Myocardial Infarction in Patients With Systemic Lupus Erythematosus and Rheumatoid Arthritis. Front Med (Lausanne) 2022; 9:882911. [PMID: 35860734 PMCID: PMC9290756 DOI: 10.3389/fmed.2022.882911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 06/07/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectivesTo evaluate associations between sarcopenia, type of autoimmune disease and risk of heart failure (HF) and myocardial infarction (MI) in patients with systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA).MethodsIn this population-based, cross-sectional study, discharge data from the 2005–2014 US Nationwide Inpatient Sample (NIS) of hospitalized patients with SLE or RA were extracted and analyzed. Univariate and multivariable regression analyses were conducted to determine associations between sarcopenia, type of autoimmune disease and risk of HF/MI.ResultsAfter exclusions, 781,199 hospitalized patients diagnosed with SLE or RA were included. Among the study cohort, 127,812 (16.4%) were hospitalized with HF, and 12,781 (1.6%) were hospitalized with MI. Sarcopenia was found in only 0.1% of HF/MI patients. Logistic regression analyses revealed that sarcopenia was not significantly associated with presence of either HF or MI. Patients with RA had significantly lower odds of HF than SLE patients (aOR = 0.77, 95%CI: 0.76, 0.79) or MI (aOR = 0.86, 95%CI: 0.82, 0.91).ConclusionIn the US, among hospitalized adults diagnosed with SLE or RA, patients with RA are significantly less likely to have HF or MI than those with SLE. Whether sarcopenia leads to increased HF or MI remains inconclusive. Further studies are warranted to investigate the pathophysiology underlying discrepancies between RA and SLE regarding risk for MI or HF.
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Affiliation(s)
- Ching-Mao Chang
- Center for Traditional Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Faculty of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- School of Medicine, Institute of Traditional Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Jr-Rung Lin
- Clinical Informatics and Medical Statistics Research Center, Graduate Institute of Clinical Medical (Joint Appointment), Chang Gung University, Taoyuan, Taiwan
| | - Tieh-Cheng Fu
- Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, Keelung, Taiwan
- Division of Cardiology, Department of Internal Medicine, Heart Failure Research Center, Chang Gung Memorial Hospital, Keelung, Taiwan
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
- *Correspondence: Tieh-Cheng Fu
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14
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Manchanda AS, Kwan AC, Ishimori M, Thomson LEJ, Li D, Berman DS, Bairey Merz CN, Jefferies C, Wei J. Coronary Microvascular Dysfunction in Patients With Systemic Lupus Erythematosus and Chest Pain. Front Cardiovasc Med 2022; 9:867155. [PMID: 35498009 PMCID: PMC9053571 DOI: 10.3389/fcvm.2022.867155] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 02/28/2022] [Indexed: 01/19/2023] Open
Abstract
Chest pain is a common symptom in patients with systemic lupus erythematosus, an autoimmune disease that is associated with increased cardiovascular morbidity and mortality. While chest pain mechanisms can be multifactorial and often attributed to non-coronary or non-cardiac cardiac etiologies, emerging evidence suggests that ischemia with no obstructive coronary arteries (INOCA) is a prevalent condition in patients with chest pain and no obstructive coronary artery disease. Coronary microvascular dysfunction is reported in approximately half of SLE patients with suspected INOCA. In this mini review, we highlight the cardiovascular risk assessment, mechanisms of INOCA, and diagnostic approach for patients with SLE and suspected CMD.
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Affiliation(s)
- Ashley S. Manchanda
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Alan C. Kwan
- Cedars-Sinai Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States
- Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States
- Department of Imaging, Mark Taper Imaging Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Mariko Ishimori
- Division of Rheumatology and Department of Biomedical Sciences, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Louise E. J. Thomson
- Department of Imaging, Mark Taper Imaging Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Debiao Li
- Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Daniel S. Berman
- Cedars-Sinai Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States
- Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States
- Department of Imaging, Mark Taper Imaging Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - C. Noel Bairey Merz
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States
- Cedars-Sinai Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Caroline Jefferies
- Division of Rheumatology and Department of Biomedical Sciences, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Janet Wei
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States
- Cedars-Sinai Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States
- Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States
- *Correspondence: Janet Wei
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15
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Jha SB, Rivera AP, Flores Monar GV, Islam H, Puttagunta SM, Islam R, Kundu S, Sange I. Systemic Lupus Erythematosus and Cardiovascular Disease. Cureus 2022; 14:e22027. [PMID: 35282557 PMCID: PMC8910778 DOI: 10.7759/cureus.22027] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2022] [Indexed: 12/14/2022] Open
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16
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Drosos GC, Vedder D, Houben E, Boekel L, Atzeni F, Badreh S, Boumpas DT, Brodin N, Bruce IN, González-Gay MÁ, Jacobsen S, Kerekes G, Marchiori F, Mukhtyar C, Ramos-Casals M, Sattar N, Schreiber K, Sciascia S, Svenungsson E, Szekanecz Z, Tausche AK, Tyndall A, van Halm V, Voskuyl A, Macfarlane GJ, Ward MM, Nurmohamed MT, Tektonidou MG. EULAR recommendations for cardiovascular risk management in rheumatic and musculoskeletal diseases, including systemic lupus erythematosus and antiphospholipid syndrome. Ann Rheum Dis 2022; 81:768-779. [PMID: 35110331 DOI: 10.1136/annrheumdis-2021-221733] [Citation(s) in RCA: 109] [Impact Index Per Article: 54.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 01/05/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To develop recommendations for cardiovascular risk (CVR) management in gout, vasculitis, systemic sclerosis (SSc), myositis, mixed connective tissue disease (MCTD), Sjögren's syndrome (SS), systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APS). METHODS Following European League against Rheumatism (EULAR) standardised procedures, a multidisciplinary task force formulated recommendations for CVR prediction and management based on systematic literature reviews and expert opinion. RESULTS Four overarching principles emphasising the need of regular screening and management of modifiable CVR factors and patient education were endorsed. Nineteen recommendations (eleven for gout, vasculitis, SSc, MCTD, myositis, SS; eight for SLE, APS) were developed covering three topics: (1) CVR prediction tools; (2) interventions on traditional CVR factors and (3) interventions on disease-related CVR factors. Several statements relied on expert opinion because high-quality evidence was lacking. Use of generic CVR prediction tools is recommended due to lack of validated rheumatic diseases-specific tools. Diuretics should be avoided in gout and beta-blockers in SSc, and a blood pressure target <130/80 mm Hg should be considered in SLE. Lipid management should follow general population guidelines, and antiplatelet use in SLE, APS and large-vessel vasculitis should follow prior EULAR recommendations. A serum uric acid level <0.36 mmol/L (<6 mg/dL) in gout, and disease activity control and glucocorticoid dose minimisation in SLE and vasculitis, are recommended. Hydroxychloroquine is recommended in SLE because it may also reduce CVR, while no particular immunosuppressive treatment in SLE or urate-lowering therapy in gout has been associated with CVR lowering. CONCLUSION These recommendations can guide clinical practice and future research for improving CVR management in rheumatic and musculoskeletal diseases.
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Affiliation(s)
- George C Drosos
- First Department of Propaedeutic Internal Medicine, Laiko Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Daisy Vedder
- Reade, Amsterdam Rheumatology and Immunology Center, Amsterdam, The Netherlands
| | - Eline Houben
- Department of Internal Medicine, Northwest Clinics, Alkmaar, The Netherlands
| | - Laura Boekel
- Reade, Amsterdam Rheumatology and Immunology Center, Amsterdam, The Netherlands
| | - Fabiola Atzeni
- Rheumatology Unit, Department of Internal Medicine, University of Messina, Messina, Italy
| | - Sara Badreh
- EULAR Patient Research Partner, Brussels, Belgium
| | - Dimitrios T Boumpas
- 4th Department of Internal Medicine, "Attikon" University Hospital, Athens, Greece.,Joint Academic Rheumatology Program, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Nina Brodin
- Division of Physiotherapy, Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Huddinge, Sweden.,Department of Orthopaedics, Danderyd Hospital Corp, Stockholm, Sweden
| | - Ian N Bruce
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, University of Manchester, Manchester, UK.,NIHR Manchester Biomedical Research Centre, Manchester University Hospitals NHS Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Miguel Ángel González-Gay
- Rheumatology Division, Hospital Universitario Marqués de Valdecilla and University of Cantabria, Santander, Spain
| | - Søren Jacobsen
- Copenhagen Lupus and Vasculitis Clinic, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - György Kerekes
- Intensive Care Unit, Department of Medicine, University of Debrecen, Debrecen, Hungary
| | | | - Chetan Mukhtyar
- Rheumatology Department, Norfolk and Norwich University Hospital, Colney Lane, UK
| | - Manuel Ramos-Casals
- Department of Autoimmune Diseases, ICMiD, University of Barcelona, Hospital Clínic, Barcelona, Spain
| | - Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Karen Schreiber
- EMEUNET member, Danish Hospital for Rheumatic Diseases, Sonderburg, Denmark
| | - Savino Sciascia
- EMEUNET member, CMID-Nephrology, San Giovanni Bosco Hospital, University of Torino, Torino, Italy
| | - Elisabet Svenungsson
- Department of Medicine, Rheumatology Unit, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Zoltan Szekanecz
- Department of Rheumatology, University of Debrecen Faculty of Medicine, Debrecen, Hungary
| | - Anne-Kathrin Tausche
- Department of Rheumatology, University Clinic Carl Gustav Carus at the TU Dresden, Dresden, Germany
| | - Alan Tyndall
- Department of Rheumatology, University of Basel, Basel, Switzerland
| | - Vokko van Halm
- Department of Cardiology, Amsterdam University Medical Center, location VU University medical center, Amsterdam, The Netherlands
| | - Alexandre Voskuyl
- Department of Rheumatology and Clinical Immunology, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | | | - Michael M Ward
- Intramural Research Program, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Michael T Nurmohamed
- Reade, Amsterdam Rheumatology and Immunology Center, Amsterdam, The Netherlands.,Amsterdam University Medical Center, location VU University Medical Centre, Amsterdam, The Netherlands
| | - Maria G Tektonidou
- First Department of Propaedeutic Internal Medicine, Laiko Hospital, National and Kapodistrian University of Athens, Athens, Greece .,Joint Academic Rheumatology Program, Medical School, National and Kapodistrian University of Athens, Athens, Greece
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17
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Cardiovascular Disease in Patients With Systemic Lupus Erythematosus: Potential for Improved Primary Prevention With Statins. Cardiol Rev 2021; 29:323-327. [PMID: 34609986 DOI: 10.1097/crd.0000000000000383] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Cardiovascular disease (CVD) is a significant cause of morbidity and mortality in patients with systemic lupus erythematosus (SLE). This is especially true in SLE patients with traditional CVD risk factors (eg, hypertension, hyperlipidemia, obesity) and disease-related risk factors (eg, increased SLE disease activity, elevated C-reactive protein levels, and antiphospholipid antibodies). The only guidelines in the primary prevention of CVD in SLE patients involve reducing traditional risk factors, but there are additional therapies that may be beneficial, including statin use. Current data on statin use for prevention of CVD in SLE patients are limited, but there have been some promising results. Statin use has been shown to be especially important in SLE patients for decreasing low-density lipoprotein levels and preventing CVD in hyperlipidemic patients. In addition, there is evidence suggesting that it may be beneficial to use statins in SLE patients with chronically elevated high-sensitivity C-reactive protein levels and antiphospholipid antibodies. It is important to continue to investigate the impact of statins on CVD in SLE patients, as they could significantly improve outcomes in patients with this disease.
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18
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Cardiovascular disease in systemic lupus erythematosus. RHEUMATOLOGY AND IMMUNOLOGY RESEARCH 2021; 2:157-172. [PMID: 35880242 PMCID: PMC9242526 DOI: 10.2478/rir-2021-0022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 09/08/2021] [Indexed: 11/21/2022]
Abstract
There is a well-known increased risk for cardiovascular disease that contributes to morbidity and mortality in systemic lupus erythematosus (SLE). Major adverse cardiovascular events and subclinical atherosclerosis are both increased in this patient population. While traditional cardiac risk factors do contribute to the increased risk that is seen, lupus disease-related factors, medications, and genetic factors also impact the overall risk. SLE-specific inflammation, including oxidized lipids, cytokines, and altered immune cell subtypes all are likely to play a role in the pathogenesis of atherosclerotic plaques. Research is ongoing to identify biomarkers that can help clinicians to predict which SLE patients are at the greatest risk for cardiovascular disease (CVD). While SLE-specific treatment regimens for the prevention of cardiovascular events have not been identified, current strategies include minimization of traditional cardiac risk factors and lowering of overall lupus disease activity.
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19
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Choi MY, Li D, Feldman CH, Yoshida K, Guan H, Kim SC, Everett BM, Costenbader KH. Comparative risks of cardiovascular disease events among SLE patients receiving immunosuppressive medications. Rheumatology (Oxford) 2021; 60:3789-3798. [PMID: 33369672 DOI: 10.1093/rheumatology/keaa862] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 11/18/2020] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES SLE patients have elevated cardiovascular disease (CVD) risk, but it is unclear whether this risk is affected by choice of immunosuppressive drug. We compared CVD risks among SLE patients starting MMF, CYC or AZA. METHODS Using Medicaid Analytic eXtract (2000-2012), adult SLE patients starting MMF, CYC or AZA were identified and propensity scores (PS) were estimated for receipt of MMF vs CYC and MMF vs AZA. We examined rates of first CVD event (primary outcome), all-cause mortality, and a composite of first CVD event and all-cause mortality (secondary outcomes). After 1:1 PS-matching, Fine-Gray regression models estimated subdistribution hazard ratios (HRs.d.) for risk of CVD events. Cox regression models estimated HRs for all-cause mortality. The primary analysis was as-treated; 6- and 12-month intention-to-treat (ITT) analyses were secondary. RESULTS We studied 680 PS-matched pairs of patients with SLE initiating MMF vs CYC and 1871 pairs initiating MMF vs AZA. Risk of first CVD event was non-significantly reduced for MMF vs CYC [HRs.d 0.72 (95% CI: 0.37, 1.39)] and for MMF vs AZA [HRs.d 0.88 (95% CI: 0.59, 1.32)] groups. In the 12-month ITT, first CVD event risk was lower among MMF than AZA new users [HRs.d 0.68 (95% CI: 0.47, 0.98)]. CONCLUSION In this head-to-head PS-matched analysis, CVD event risks among SLE patients starting MMF vs CYC or AZA were not statistically reduced except in one 12-month ITT analysis of MMF vs AZA, suggesting longer-term use may convey benefit. Further studies of potential cardioprotective benefit of MMF are necessary.
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Affiliation(s)
- May Y Choi
- Division of Rheumatology, Immunology, and Allergy, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.,Division of Rheumatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Daniel Li
- Division of Rheumatology, Immunology, and Allergy, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Candace H Feldman
- Division of Rheumatology, Immunology, and Allergy, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Kazuki Yoshida
- Division of Rheumatology, Immunology, and Allergy, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Hongshu Guan
- Division of Rheumatology, Immunology, and Allergy, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Seoyoung C Kim
- Division of Rheumatology, Immunology, and Allergy, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.,Division of Pharmacoepidemiology and Pharmacoeconomics Department of Medicine Brigham and Women's Hospital and Harvard Medical School Boston, Boston, MA, USA
| | - Brendan M Everett
- Divisions of Cardiovascular and Preventive Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Karen H Costenbader
- Division of Rheumatology, Immunology, and Allergy, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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20
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Quevedo-Abeledo JC, Caceres L, Palazuelos C, Llorca J, González-Gay MÁ, Ferraz-Amaro I. QRISK3 Relation to Carotid Plaque is Higher than that of SCORE In Patients with Systemic Lupus Erythematosus. Rheumatology (Oxford) 2021; 61:1408-1416. [PMID: 34240117 DOI: 10.1093/rheumatology/keab531] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 04/01/2021] [Accepted: 04/19/2021] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Systemic lupus erythematosus (SLE) has been described as an independent risk factor for the development of cardiovascular (CV) disease. Recently, the QRESEARCH risk estimator version 3 (QRISK3) calculator has been launched for CV risk assessment in the general population. QRISK3 now includes the presence of SLE as one of its variables for calculating CV risk. Our objective was to compare the predictive capacity between QRISK3 and the Systematic Coronary Risk Assessment (SCORE) for the presence of subclinical carotid atherosclerosis in patients with SLE. METHODS 296 patients with SLE were recruited. The presence of subclinical atherosclerosis was evaluated by carotid ultrasound to identify carotid plaque and the thickness of the carotid intima media (cIMT). QRISK3 and SCORE were calculated. The relationship of QRISK3 and SCORE with each other and with the presence of subclinical carotid atherosclerosis (both carotid plaque and cIMT) was studied. RESULTS There was no correlation between SCORE and QRISK3 in patients with SLE (Rho Spearman r= -0.008, p= 0.90). Although QRISK3 showed a statistically significant correlation with cIMT (Rho Spearman r = 0.420, p= 0.000), this relationship was not found between SCORE and cIMT (Rho Spearman r= -0.005, p= 0.93). The discrimination capacity of QRISK3 for the presence of carotid plaque was statistically significant and superior to that of SCORE (AUC 0.765 [95% CI 0.711-0.820] vs 0.561 [95% CI 0.494-0.629], p= 0.000). CONCLUSION QRISK3 discrimination for subclinical atherosclerosis is higher than that of SCORE. QRISK3, and not SCORE, should be used for the calculation of CV risk in patients with SLE.
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Affiliation(s)
| | - Laura Caceres
- Division of Rheumatology, Hospital Doctor Negrín, Las Palmas de Gran Canaria, Spain
| | | | - Javier Llorca
- University of Cantabria, Santander, Spain.,CIBER Epidemiología y Salud Pública (CIBERESP), Santander, Spain
| | - Miguel Á González-Gay
- Division of Rheumatology, Hospital Universitario Marqués de Valdecilla, Universidad de Cantabria, Santander, Spain.,Epidemiology, Genetics and Atherosclerosis Research Group on Systemic Inflammatory Diseases, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain.,Cardiovascular Pathophysiology and Genomics Research Unit, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Iván Ferraz-Amaro
- Division of Rheumatology, Hospital Universitario de Canarias, Tenerife, Spain
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21
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Wirestam L, Saleh M, Svensson C, Compagno M, Zachrisson H, Wetterö J, Sjöwall C. Plasma osteopontin versus intima media thickness of the common carotid arteries in well-characterised patients with systemic lupus erythematosus. Lupus 2021; 30:1244-1253. [PMID: 33957796 PMCID: PMC8209759 DOI: 10.1177/09612033211013898] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Objective The progress of accelerated atherosclerosis in systemic lupus erythematosus (SLE) is incompletely understood. Circulating osteopontin (OPN) is increased in autoimmune conditions, e.g. SLE, and its serum concentration was recently reported to associate with subclinical atherosclerosis in SLE, as measured by carotid intima-media thickness. The aim of this study was to investigate whether OPN may be used as a surrogate biomarker of subclinical atherosclerosis in SLE patients with different disease phenotypes. Methods We recruited 60 well-characterised SLE cases and 60 age- and sex-matched healthy controls. The SLE cases were divided into three different disease phenotypes: SLE with antiphospholipid syndrome (APS), lupus nephritis, and isolated skin and joint involvement. Plasma OPN was detected by ELISA (Quantikine®, R&D Systems). Common carotid arteries intima media thickness was compared between the studied groups in relation to OPN levels and risk factors for vascular changes. Intima media thickness of common carotid arteries was measured by using a sensitive ultrasound technique (LOGIQ™ E9 ultrasound, GE Healthcare). Results OPN levels were significantly higher among the entire SLE group (n = 60) compared to the healthy controls (P = 0.03). SLE cases with concomitant APS (n = 20) showed higher OPN levels than the controls (P = 0.004), whereas none of the other two subgroups differed significantly from the healthy controls. OPN and intima media thickness were correlated to several traditional risk factors of atherosclerosis, as well as to SLE-related factors. Yet, no significant correlation was observed between OPN levels and ultrasound findings of the common carotid arteries. Conclusions In line with previous studies, we observed increased OPN levels among SLE patients as compared to matched controls. However, the OPN concentrations did not correlate with intima media thickness of the common carotid arteries. Based on our findings, the use of OPN as a surrogate biomarker of subclinical atherosclerosis in SLE subjects, regardless of clinical phenotypes, cannot be recommended.
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Affiliation(s)
- Lina Wirestam
- Division of Inflammation and Infection/Rheumatology, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Muna Saleh
- Division of Inflammation and Infection/Rheumatology, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Christina Svensson
- Department of Clinical Physiology, University Hospital and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Michele Compagno
- Department of Clinical Sciences Lund, Rheumatology, Lund University, Lund, Sweden
| | - Helene Zachrisson
- Department of Clinical Physiology, University Hospital and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Jonas Wetterö
- Division of Inflammation and Infection/Rheumatology, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Christopher Sjöwall
- Division of Inflammation and Infection/Rheumatology, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
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22
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Denegri A, Boriani G. High Sensitivity C-reactive Protein (hsCRP) and its Implications in Cardiovascular Outcomes. Curr Pharm Des 2021; 27:263-275. [PMID: 32679014 DOI: 10.2174/1381612826666200717090334] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 05/20/2020] [Indexed: 11/22/2022]
Abstract
Atherosclerosis and its fearsome complications represent the first cause of morbidity and mortality worldwide. Over the last two decades, several pieces of evidence have been accumulated, suggesting a central role of inflammation in atheroma development. High sensitivity C-reactive protein (hsCRP) is a well-established marker of cardiovascular (CV) disease; high levels of hsCRP have been associated with adverse CV outcome after acute coronary syndrome (ACS) and, despite some controversy, an active role for hsCRP in initiation and development of the atherosclerotic plaque has been also proposed. Randomized clinical trials focusing on hsCRP have been crucial in elucidating the anti-inflammatory effects of statin therapy. Thus, hsCRP has been progressively considered a real CV risk factor likewise to low-density lipoprotein cholesterol (LDL-C), expanding the concept of residual CV inflammatory risk. Subsequent research has been designed to investigate potential new targets of atherothrombotic protection. Despite the fact that the clinical usefulness of hsCRP is widely recognized, hsCRP may not represent the ideal target of specific anti-inflammatory therapies. Clinical investigations, therefore, have also focused on other inflammatory mediators, restricting hsCRP to an indicator rather than a therapeutic target. The aim of the present review is to provide an illustrative overview of the current knowledge of atherosclerosis and inflammation, highlighting the most representative clinical studies of lipid-lowering and antiinflammatory therapies focused on hsCRP in CV diseases.
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Affiliation(s)
- Andrea Denegri
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria di Modena, Largo del Pozzo, 71, 41125, Modena, Italy
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria di Modena, Largo del Pozzo, 71, 41125, Modena, Italy
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23
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Ajeganova S, Hafström I, Frostegård J. Patients with SLE have higher risk of cardiovascular events and mortality in comparison with controls with the same levels of traditional risk factors and intima-media measures, which is related to accumulated disease damage and antiphospholipid syndrome: a case-control study over 10 years. Lupus Sci Med 2021; 8:8/1/e000454. [PMID: 33547230 PMCID: PMC7871345 DOI: 10.1136/lupus-2020-000454] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 01/02/2021] [Accepted: 01/06/2021] [Indexed: 01/31/2023]
Abstract
OBJECTIVE SLE is a strong risk factor for premature cardiovascular (CV) disease and mortality. We investigated which factors could explain poor prognosis in SLE compared with controls. METHODS Patients with SLE and population controls without history of clinical CV events who performed carotid ultrasound examination were recruited for this study. The outcome was incident CV event and death. Event-free survival rates were compared using Kaplan-Meier curves. Relative HR (95% CI) was used to estimate risk of outcome. RESULTS Patients (n=99, 87% female), aged 47 (13) years and with a disease duration of 12 (9) years, had mild disease at inclusion, Systemic Lupus Erythematosus Diseases Activity Index score of 3 (1-6) and Systemic Lupus International Collaborating Clinics (SLICC) Damage Index score of 0 (0-1). The controls (n=109, 91% female) were 49 (12) years old. Baseline carotid intima-media thickness (cIMT) did not differ between the groups, but plaques were more prevalent in patients (p=0.068). During 10.1 (9.8-10.2) years, 12 patients and 4 controls reached the outcome (p=0.022). Compared with the controls, the risk of the adverse outcome in patients increased threefold to fourfold taking into account age, gender, history of smoking and diabetes, family history of CV, baseline body mass index, waist circumference, C reactive protein, total cholesterol, high-density lipoprotein, low-density lipoprotein, dyslipidaemia, cIMT and presence of carotid plaque. In patients, higher SLICC score and SLE-antiphospholipid syndrome (SLE-APS) were associated with increased risk of the adverse outcome, with respective HRs of 1.66 (95% CI 1.20 to 2.28) and 9.08 (95% CI 2.71 to 30.5), as was cIMT with an HR of 1.006 (95% CI 1.002 to 1.01). The combination of SLICC and SLE-APS with cIMT significantly improved prediction of the adverse outcome (p<0.001). CONCLUSION In patients with mild SLE of more than 10 years duration, there is a threefold to fourfold increased risk of CV events and death compared with persons who do not have SLE with similar pattern of traditional CV risk factors, cIMT and presence of carotid plaque. SLICC, SLE-APS and subclinical atherosclerosis may indicate a group at risk of worse outcome in SLE.
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Affiliation(s)
- Sofia Ajeganova
- 1Division of Gastroenterology and Rheumatology, Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden .,Department of Clinical Sciences, Rheumatology Division, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Ingiäld Hafström
- 1Division of Gastroenterology and Rheumatology, Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden.,Rheumatology Unit, Karolinska University Hospital, Stockholm, Sweden
| | - Johan Frostegård
- Section of Immunology and Chronic Disease, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
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24
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Sánchez-Pérez H, Quevedo-Abeledo JC, de Armas-Rillo L, Rua-Figueroa Í, Tejera-Segura B, Armas-González E, Machado JD, García-Dopico JA, Jimenez-Sosa A, Rodríguez-Lozano C, Díaz-González F, González-Gay MA, Ferraz-Amaro I. Impaired HDL cholesterol efflux capacity in systemic lupus erythematosus patients is related to subclinical carotid atherosclerosis. Rheumatology (Oxford) 2021; 59:2847-2856. [PMID: 32065639 DOI: 10.1093/rheumatology/keaa038] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 01/11/2020] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES Lipid profiles appear to be altered in SLE patients due to disease activity and inflammation. Cholesterol efflux capacity (CEC) is the ability of high-density lipoprotein cholesterol to accept cholesterol from macrophages. CEC has been linked to cardiovascular events in the general population and is impaired in SLE patients. The aim of this study was to establish whether CEC is related to subclinical carotid atherosclerosis in SLE patients. METHODS The present report is of a cross-sectional study that encompassed 418 individuals: 195 SLE patients and 223 controls. CEC, using an in vitro assay, and lipoprotein serum concentrations were assessed in patients and controls. Carotid intima-media thickness and carotid plaques were evaluated in SLE patients. A multivariable analysis was performed to study the relationship of CEC to SLE-related data, lipid profile and subclinical carotid atherosclerosis. RESULTS CEC was downregulated in SLE patients [8.1 (4.2) % vs 16.9 (10.4) %, P = 0.004). This occurred independently of traditional cardiovascular risk factors, statin use or other variations in the lipid profile related to the disease. Traditional cardiovascular risk factors, both in patients and controls, and SLE-related data such as activity, severity or damage were not associated with CEC. After multivariable regression analysis including lipid profile-related molecules, CEC was inversely and independently associated with the presence of carotid plaques in SLE patients [odds ratio 0.87 (95% CI: 0.78, 0.97), P = 0.014]. CONCLUSION CEC is impaired in SLE patients independently of other inflammation-related lipid profile modifications that occur during the disease. CEC is associated with carotid plaques in SLE patients.
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Affiliation(s)
| | | | | | - Íñigo Rua-Figueroa
- Division of Rheumatology, Hospital Doctor Negrín, Las Palmas de Gran Canaria
| | - Beatriz Tejera-Segura
- Division of Rheumatology, Hospital Insular de Gran Canaria, Las Palmas de Gran Canaria
| | | | - José David Machado
- Department of Pharmacology, Faculty of Medicine, Universidad de La Laguna
| | | | | | | | - Federico Díaz-González
- Division of Rheumatology, Hospital Universitario de Canarias, Tenerife.,Department of Internal Medicine, Faculty of Medicine, Universidad de La Laguna, La Laguna
| | - Miguel A González-Gay
- Division of Rheumatology, Hospital Universitario Marqués de Valdecilla, Universidad de Cantabria.,Epidemiology, Genetics and Atherosclerosis Research Group on Systemic Inflammatory Diseases, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain.,Cardiovascular Pathophysiology and Genomics Research Unit, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Iván Ferraz-Amaro
- Division of Rheumatology, Hospital Universitario de Canarias, Tenerife
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25
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Fasano S, Iacono D, Riccardi A, Ciccia F, Valentini G. The role of aspirin in the primary prevention of accelerated atherosclerosis in systemic autoimmune rheumatic diseases. Rheumatology (Oxford) 2020; 59:3593-3602. [DOI: 10.1093/rheumatology/keaa335] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 05/17/2020] [Indexed: 01/04/2023] Open
Abstract
Abstract
Aspirin is the most commonly used medication worldwide. Beside its well-known anti-inflammatory effects, a role has emerged in the prevention of cardiovascular events. However, a significant benefit has been demonstrated in secondary cardiovascular prevention only, while there is limited evidence supporting a role in primary prevention. This discrepancy might depend on the that so far, the high-risk populations that will achieve the greatest benefits yet experiencing minimal harmful side effects have not been identified. Patients with autoimmune systemic rheumatic diseases have an increased risk of cardiovascular complications compared with the general population, which makes aspirin of potential value in these subjects. Moving from general aspects of aspirin pharmacology and specific issues in general population, the aim of this study is to review the evidence about the role of low-dose aspirin in primary cardiovascular prevention in autoimmune systemic rheumatic diseases.
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Affiliation(s)
- Serena Fasano
- Rheumatology Unit, University of Campania ‘Luigi Vanvitelli’, Naples, Italy
| | - Daniela Iacono
- Rheumatology Unit, University of Campania ‘Luigi Vanvitelli’, Naples, Italy
| | - Antonella Riccardi
- Rheumatology Unit, University of Campania ‘Luigi Vanvitelli’, Naples, Italy
| | - Francesco Ciccia
- Rheumatology Unit, University of Campania ‘Luigi Vanvitelli’, Naples, Italy
| | - Gabriele Valentini
- Rheumatology Unit, University of Campania ‘Luigi Vanvitelli’, Naples, Italy
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26
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Lim SS, Drenkard C. Understanding Lupus Disparities Through a Social Determinants of Health Framework. Rheum Dis Clin North Am 2020; 46:613-621. [DOI: 10.1016/j.rdc.2020.07.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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27
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González LA, Pons-Estel GJ, Toloza SMA, Ugarte-Gil MF, Alarcón GS. Understanding Risk Factors for Poor Outcomes in a Multiethnic Longitudinal Cohort: The LUMINA (Lupus in Minorities: Nature vs. Nurture) Experience (LUMINA LXXXII). Rheum Dis Clin North Am 2020; 47:55-64. [PMID: 34042054 DOI: 10.1016/j.rdc.2020.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The Lupus in Minorities: Nature Vs Nurture (LUMINA) cohort has placed Hispanics on the lupus map in the United States. Texan Hispanic and African American patients experience, overall, worse outcomes than the Caucasian and Puerto Rican Hispanic patients. The genetic component of ethnicity is important early in the disease course whereas socioeconomic factors become more important subsequently. The role of hydroxychloroquine in preventing damage accrual and reducing mortality in lupus patients is a major contribution of LUMINA.
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Affiliation(s)
- Luis Alonso González
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, Universidad de Antioquia, Hospital Universitario de San Vicente Fundación, Medellín, Colombia
| | - Guillermo J Pons-Estel
- Centro Regional de Enfermedades Autoinmunes y Reumáticas (GO-CREAR). Rosario, Argentina; Rheumatology Department, Hospital Provincial de Rosario, Rosario, Argentina
| | - Sergio M A Toloza
- Department of Medicine, Rheumatology Unit, Hospital San Juan Bautista, San Fernando del Valle de Catamarca, Catamarca, Argentina
| | - Manuel Francisco Ugarte-Gil
- Rheumatology Department, Hospital Guillermo Almenara Irigoyen, EsSalud, Lima, Perú; Facultad de Ciencias de la Salud, Universidad Científica del Sur, Lima, Perú
| | - Graciela S Alarcón
- Division of Clinical Immunology and Rheumatology, Department of Medicine, School of Medicine, The University of Alabama at Birmingham, USA; Department of Medicine, School of Medicine, Universidad Peruana Cayetano Heredia. Lima, Perú.
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28
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Mavrogeni S, Koutsogeorgopoulou L, Dimitroulas T, Markousis-Mavrogenis G, Boki K, Katsifis G, Vartela V, Kallenberg CG, Kolovou G, Kitas G. Combined Brain/Heart Magnetic Resonance Imaging in Systemic Lupus Erythematosus. Curr Cardiol Rev 2020; 16:178-186. [PMID: 31368877 PMCID: PMC7536815 DOI: 10.2174/1573403x15666190801122105] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 07/08/2019] [Accepted: 07/19/2019] [Indexed: 12/27/2022] Open
Abstract
Cardiovascular Disease (CVD) in Systemic Lupus Erythematosus (SLE) and Neuropsychiatric SLE (NPSLE) has an estimated prevalence of 50% and 40%, respectively and both constitute major causes of death among SLE patients. In this review, a combined brain/heart Magnetic Resonance Imaging (MRI) for SLE risk stratification has been proposed. The pathophysiologic background of NPSLE includes microangiopathy, macroscopic infarcts and accelerated atherosclerosis. Classic brain MRI findings demonstrate lesions suggestive of NPSLE in 50% of the NPSLE cases, while advanced MRI indices can detect pre-clinical lesions in the majority of them, but their clinical impact still remains unknown. Cardiac involvement in SLE includes myo-pericarditis, valvular disease/endocarditis, Heart Failure (HF), coronary macro-micro-vascular disease, vasculitis and pulmonary hypertension. Classic and advanced Cardiovascular Magnetic Resonance (CMR) indices allow function and tissue characterization for early diagnosis and treatment follow-up of CVD in SLE. Although currently, there are no clinical data supporting the combined use of brain/heart MRI in asymptomatic SLE, it may have a place in cases with clinical suspicion of brain/heart involvement, especially in patients at high risk for CVD/stroke such as SLE with antiphospholipid syndrome (SLE/APS), in whom concurrent cardiac and brain lesions have been identified. Furthermore, it may be of value in SLE with multi-organ involvement, NPSLE with concurrent cardiac involvement, and recent onset of arrhythmia and/or heart failure.
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Affiliation(s)
| | | | - Theodoros Dimitroulas
- 4th Department of Internal Medicine, School of Medicine, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | | | | | | | - Cees G Kallenberg
- Department of Rheumatology and Clinical Immunology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | | | - George Kitas
- Arthritis Research UK Epidemiology Unit, Manchester University, Manchester, M13 9PL, United Kingdom
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29
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Kostopoulou M, Nikolopoulos D, Parodis I, Bertsias G. Cardiovascular Disease in Systemic Lupus Erythematosus: Recent Data on Epidemiology, Risk Factors and Prevention. Curr Vasc Pharmacol 2020; 18:549-565. [DOI: 10.2174/1570161118666191227101636] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 11/20/2019] [Accepted: 12/12/2019] [Indexed: 12/22/2022]
Abstract
Systemic Lupus Erythematosus (SLE) is associated with increased risk for accelerated atherosclerosis
and cardiovascular (CV) events including coronary heart disease, cerebrovascular and peripheral
artery disease. CV events occur both early and late during the disease course, with younger
patients being at much higher risk than age-matched counterparts. The risk cannot be fully accounted for
by the increased prevalence of traditional atherosclerotic factors and may be due to pathophysiologic
intermediates such as type I interferons and other inflammatory cytokines, oxidative stress, activated
granulocytes and production of extracellular chromatin traps, antiphospholipid and other autoantibodies
causing dysfunction of lipoproteins, altogether resulting in endothelial injury and pro-atherogenic
dyslipidaemia. These mechanisms may be further aggravated by chronic intake of prednisone (even at
doses <7.5 mg/day), whereas immunomodulatory drugs, especially hydroxychloroquine, may exert antiatherogenic
properties. To date, there is a paucity of randomized studies regarding the effectiveness of
preventative strategies and pharmacological interventions specifically in patients with SLE. Nevertheless,
both the European League Against Rheumatism recommendations and extrapolated evidence from
the general population emphasize that SLE patients should undergo regular monitoring for atherosclerotic
risk factors and calculation of the 10-year CV risk. Risk stratification should include diseaserelated
factors and accordingly, general (lifestyle modifications/smoking cessation, antihypertensive and
statin treatment, low-dose aspirin in selected cases) and SLE-specific (control of disease activity, minimization
of glucocorticoids, use of hydroxychloroquine) preventive measures be applied as appropriate.
Further studies will be required regarding the use of non-invasive tools and biomarkers for CV assessment
and of risk-lowering strategies tailored to SLE.
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Affiliation(s)
- Myrto Kostopoulou
- 4th Department of Internal Medicine, Attikon University Hospital, Joint Rheumatology Program, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Dionysis Nikolopoulos
- 4th Department of Internal Medicine, Attikon University Hospital, Joint Rheumatology Program, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Ioannis Parodis
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet and Rheumatology, Karolinska University Hospital, Stockholm, Sweden
| | - George Bertsias
- Department of Rheumatology, Clinical Rheumatology and Allergy, University of Crete Medical School, Iraklio, Greece
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30
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Sandhu VK, Wei J, Thomson LEJ, Berman DS, Schapira J, Wallace D, Weisman MH, Merz CNB, Ishimori ML. Five-Year Follow-Up of Coronary Microvascular Dysfunction and Coronary Artery Disease in Systemic Lupus Erythematosus: Results From a Community-Based Lupus Cohort. Arthritis Care Res (Hoboken) 2020; 72:882-887. [PMID: 31058466 PMCID: PMC6832763 DOI: 10.1002/acr.23920] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 04/30/2019] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The present study was undertaken to investigate prospective change in the prevalence of coronary microvascular dysfunction (CMD) and obstructive coronary artery disease (CAD) in a cohort of subjects with systemic lupus erythematosus (SLE) initially evaluated for anginal chest pain (CP). Prior work documented a relatively high prevalence of CMD in the absence of obstructive CAD in subjects with SLE. METHODS Twenty female SLE subjects with CP who underwent stress cardiac magnetic resonance imaging (CMRI) and coronary computed tomography angiography at baseline were reevaluated at 5 years. RESULTS Seventeen subjects (85%) were available and reenrolled, of which 11 (65%) had persistent CP at follow-up. Fourteen subjects had complete follow-up CMRI, of which 36% (n = 5) demonstrated CMD at follow-up. Further, 25% (1 of 4) of the originally abnormal myocardial perfusion reserve index (MPRI) findings at baseline were lower at follow-up, while 2 additional abnormal MPRI findings at follow-up were noted in previously normal MPRI results. The prevalence of CMD and nonobstructive/obstructive CAD both was unchanged between baseline and follow-up, respectively (both P values not significant). During follow-up, 33% of subjects (5 of 15) had adverse cardiac outcomes, including pericarditis, unstable angina, or intracranial aneurysm clipping procedure. CONCLUSION At the 5-year follow-up of SLE subjects with CP who were evaluated at baseline and follow-up, a majority had persistent CP, and nearly one-half had similar or worse myocardial perfusion consistent with CMD without obstructive CAD. These findings propose an alternative explanation for CP in SLE subjects compared to the more common SLE-related accelerated obstructive CAD accounting for CP and adverse outcomes. These findings support further studies of CMD as an etiology for cardiac morbidity and mortality in SLE.
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Affiliation(s)
- Vaneet K. Sandhu
- Division of Rheumatology, Department of Medicine, Loma Linda University, Loma Linda, CA
| | - Janet Wei
- Barbra Streisand Women’s Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center
| | | | - Daniel S. Berman
- S. Mark Taper Foundation Imaging Center, Cedars-Sinai Medical Center
| | - Jay Schapira
- Department of Cardiology, Cedars-Sinai Medical Center
| | - Daniel Wallace
- Division of Rheumatology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Michael H. Weisman
- Division of Rheumatology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
| | - C. Noel Bairey Merz
- Barbra Streisand Women’s Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center
| | - Mariko L. Ishimori
- Division of Rheumatology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
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31
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Di Minno MND, Forte F, Tufano A, Buonauro A, Rossi FW, De Paulis A, Galderisi M. Speckle tracking echocardiography in patients with systemic lupus erythematosus: A meta-analysis. Eur J Intern Med 2020; 73:16-22. [PMID: 31911023 DOI: 10.1016/j.ejim.2019.12.033] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Revised: 12/17/2019] [Accepted: 12/30/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND Systemic lupus erythematosus (SLE), is characterized by a systemic involvement including myocardial dysfunction. Being standard echocardiography not able at fully detecting subclinical alterations, speckle tracking echocardiography (STE) has recently emerged as a quantitative ultrasound technique to accurately estimate myocardial function. METHODS We conducted a systematic review with meta-analysis of studies reporting STE parameters in patients with SLE. RESULTS A total of 9 studies were included in the analysis. Left ventricle global longitudinal strain (GLS) was significantly lower in SLE patients than in non-SLE controls (MD: -2.331, 95% CI: -3.083, -1.580, p < 0.001). In addition, we found significant differences between SLE patients and non-SLE controls in left ventricle GLS rate (MD: -0.115, 95% CI: -0.177 to 0.063, p < 0.001), left ventricle circumferential strain(MD: -1.841, 95% CI: -3.160 to 0.521, p = 0.006) and left ventricle radial strain(MD: -11.03, 95% CI: -13.819 to 8.241, p < 0.001). Right ventricle strain was significantly lower in SLE patients than in non-SLE controls (MD: -5.814, 95% CI: -7.347, -4.281, p < 0.001). Meta-regression models showed a lower difference in left ventricle GLS between SLE cases and controls for studies with a higher prevalence of female gender and higher prevalence of hypertension. CONCLUSIONS SLE patients have lower STE parameters than controls, thus suggesting the presence of an impaired myocardial function involving both left and right ventricle.
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Affiliation(s)
| | - Francesco Forte
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Antonella Tufano
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Agostino Buonauro
- Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | - Francesca Wanda Rossi
- Department of Translational Medical Sciences, Federico II University, Via S. Pansini 5, 80131 Naples, Italy
| | - Amato De Paulis
- Department of Translational Medical Sciences, Federico II University, Via S. Pansini 5, 80131 Naples, Italy
| | - Maurizio Galderisi
- Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
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Twumasi AA, Shao A, Dunlop-Thomas C, Drenkard C, Cooper HL. Exploring the Perceived Impact of the Chronic Disease Self-Management Program on Self-Management Behaviors among African American Women with Lupus: A Qualitative Study. ACR Open Rheumatol 2020; 2:147-157. [PMID: 32037683 PMCID: PMC7077773 DOI: 10.1002/acr2.11117] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Accepted: 12/20/2019] [Indexed: 01/11/2023] Open
Abstract
Objective To qualitatively explore the processes through which the Chronic Disease Self‐Management Program (CDSMP)—a peer‐led, group‐based educational intervention for people with chronic conditions—affects self‐management behaviors among African American women with systemic lupus erythematosus (SLE). Methods Using a longitudinal pre‐ and postintervention design, we conducted two waves of one‐on‐one, semistructured interviews with 24 purposefully sampled participants. Wave 1 interviews explored self‐management behaviors at baseline; wave 2 interviews focused on changes in these behaviors postintervention. Transcripts were analyzed using thematic analysis methods. Results Study participants perceived the CDSMP to be a valuable resource that helped them improve fundamental self‐management behaviors, including exercise, relaxation, diet, and medication adherence. We found, with few exceptions, that in this sample, women's reported changes in self‐management behaviors did not vary by participant age, education, SLE disease severity, or depression status. Our analysis suggests that the CDSMP had the most widespread perceived effects on relaxation and exercise. Strategies that generated improvements in relaxation and exercise included goal setting, action planning, encouragement to pursue low‐impact physical activity, and introduction of mindfulness techniques to better manage SLE symptoms. Conclusion Our findings suggest that African American women with SLE perceived the CDSMP as an effective educational self‐management intervention. The program can potentially catalyze improvements in self‐management behaviors in this population, regardless of demographic or disease characteristics.
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Affiliation(s)
- Abena A Twumasi
- Emory University Rollins School of Public Health, Atlanta, Georgia
| | - Anna Shao
- Emory University Rollins School of Public Health, Atlanta, Georgia
| | | | | | - Hannah L Cooper
- Emory University Rollins School of Public Health, Atlanta, Georgia
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33
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Fernández-Garcés M, Haro G, Micó ML. Predisposing factors to nonfatal cardiovascular events in women with systemic lupus erythematosus. An observational, cross-sectional, multicenter study in Spain from the risk/systemic lupus erythematosus thematic network. Medicine (Baltimore) 2019; 98:e17489. [PMID: 31651851 PMCID: PMC6824671 DOI: 10.1097/md.0000000000017489] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Very few studies have been published on cardiovascular morbidity in Spanish patients diagnosed with systemic lupus erythematosus (SLE). Moreover, knowledge of the predictive factors for the occurrence of nonfatal events in this group of patients is scarce.This was a multicenter, observational, cross-sectional study designed to ascertain the prevalence of nonfatal cardiovascular risk factors and cardiovascular events (CVEs) in 335 Spanish women diagnosed with SLE between 2003 and 2013.The average patient age was 36.0 years (range: 26.4-45.6); 35 patients (10.7%) experienced at least 1 CVE, which most frequently affected the brain, followed by the heart, and finally, the peripheral vasculature. Both the number of admissions because of SLE (95% confidence interval [CI] odds ratio [OR] = 1.024-1.27, P = .017) and the systemic lupus international collaborating clinics (SLICC) chronicity index score (95% CI OR = 1.479-2.400, P = .000) resulted in an increase in the OR of these patients presenting a CVE. Regarding the classic risk factors, only the interaction between hypertension (HT) and treatment with antihypertensive drugs influenced the presence of CVEs (95% CI OR = 2.165-10.377, P = .000). The presence of a family history of early cardiovascular disease was also related to CVEs (95% CI OR = 2.355-40.544, P = .002). Binary logistic regression including the above factors resulted in a model in which the 3 main variables in each group persisted, implying that they must be independent of each other. However, the weight of the interaction between the family history of early cardiovascular disease and the interaction between HT and the use of antihypertensives was higher than for the number of admissions for SLE.The SLE disease activity over time (measured using the SLICC) and the number of hospital admissions due to the disease itself, both increase the risk of women with SLE presenting a CVE. Classic cardiovascular risk factors, especially HT and its treatment, as well as a family history of early CVEs, should be considered when assessing the risk of nonfatal CVEs in women with SLE.
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Affiliation(s)
| | - Gonzalo Haro
- TXP Research Group, Department of Medicine, Universidad Cardenal Herrera-CEU, CEU Universities, Castellón
- Provincial Hospital of Castellón
| | - María Luisa Micó
- Internal Medicine Service, Hospital Universitario y Politécnico La Fe, Valencia, Spain
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Lim SS, Kan H, Pobiner BF, Bao G, Drenkard C. Patient perceptions and preferences of biologic therapies in SLE. Lupus Sci Med 2019; 6:e000322. [PMID: 31478010 PMCID: PMC6703291 DOI: 10.1136/lupus-2019-000322] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Revised: 05/30/2019] [Accepted: 06/29/2019] [Indexed: 11/15/2022]
Abstract
Objective To evaluate patient perceptions of biologic therapies from a large, population-based cohort of patients with SLE with significant numbers of blacks and whites and across the full spectrum of socioeconomic strata and disease severity. Methods This was a cross-sectional study of validated patients with SLE enrolled in the Georgians Organized Against Lupus Cohort between September 2014 and August 2015. The survey instrument was developed ad hoc by the authors and contained an introduction on biologics. Results A total of 676 participants were on average 48.4 years old with 15.9 years of disease; 93.2% were female and 80.6% were black; 34.2% had private health insurance and 9.8% had no insurance; and 26.8% and 27.5% had Medicare or Medicaid, respectively. Of all respondents, 30.8% had heard of biologics, with a significant difference between blacks and whites (25.2% vs 53.4%, respectively). There were no significant differences, however, between blacks and whites with respect to ever having been on biologics (7.6% and 11.5%, respectively) or where they got their information about biologics. Out of 202 individuals who had heard of biologics, 102 (51.3%) were familiar with potential benefits or side effects, and most (n=129, 66.5%) had a neutral perception to risks associated with biologic use. There was no perception of biologics working differently between races/ethnicities. More (n=76, 62.8%) blacks preferred intravenous over subcutaneous modalities compared with whites (n=12, 37.5%) but were not as willing to pay as much out of pocket for it. Individuals with Medicare were significantly more likely to have been on biologics. Conclusions There are important similarities and differences between blacks and whites with lupus with respect to their perceptions of biologic therapies and their impact. There are opportunities to increase patient exposure to information about biologics and improve their understanding in order for them to make the best informed decision possible.
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Affiliation(s)
- S Sam Lim
- Department of Medicine, Division of Rheumatology, Emory University School of Medicine, Atlanta, Georgia, USA.,Department of Epidemiology, Emory University School of Public Health, Atlanta, Georgia, USA
| | - Hong Kan
- Johns Hopkins University, Baltimore, Maryland, USA
| | - Bonnie F Pobiner
- GlaxoSmithKline USA, Research Triangle Park, North Carolina, USA
| | - Gaobin Bao
- Department of Medicine, Division of Rheumatology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Cristina Drenkard
- Department of Medicine, Division of Rheumatology, Emory University School of Medicine, Atlanta, Georgia, USA.,Department of Epidemiology, Emory University School of Public Health, Atlanta, Georgia, USA
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Chen SK, Barbhaiya M, Fischer MA, Guan H, Yoshida K, Feldman CH, Costenbader KH, Everett BM. Heart failure risk in systemic lupus erythematosus compared to diabetes mellitus and general medicaid patients. Semin Arthritis Rheum 2019; 49:389-395. [PMID: 31280938 DOI: 10.1016/j.semarthrit.2019.06.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 05/24/2019] [Accepted: 06/05/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Patients with systemic lupus erythematosus (SLE) have a similar risk of myocardial infarction as those with diabetes mellitus (DM). Whether the risk of heart failure (HF) in SLE is similar to the elevated risk in DM is unknown. We sought to estimate the rates and risks for HF hospitalization among US Medicaid patients with SLE and to compare them to those for DM and the general Medicaid population. METHODS Using U.S. Medicaid data from 2007-2010, we identified patients with SLE or DM, and a matched cohort from the general Medicaid population and calculated incidence rates (IR), incidence rate ratios (IRR) and adjusted hazard ratios (HR) of a first HF hospitalization. RESULTS We identified 37,902 SLE (93% female, mean age 40.1 ± 12.1), 76,657 DM (93% female, mean age 40.0 ± 12.1), and 158,695 general Medicaid patients (93% female, mean age 40.2 ± 12.1). The IR per 1000-person years was 6.9 (95% CI 6.3-7.5) for SLE, 6.6 (95% CI 6.2-7.0) for DM, and 1.6 (95% CI 1.5-1.8) for general Medicaid patients. The highest IRR compared to general Medicaid was seen among SLE patients in age group 18-39 (14.7, 95% CI 13.9-15.5). Multivariable-adjusted HRs for HF compared to general Medicaid population were similar for SLE (2.7, 95% CI 2.3-3.1) and DM (3.0, 95% CI 2.6-3.4). CONCLUSION The incidence of HF among SLE patients was 2.7-fold higher than general Medicaid patients, and similar to DM. Further investigation into the biologic mechanism of HF among SLE compared to non-SLE and DM patients may shed light on the findings of this study.
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Affiliation(s)
- Sarah K Chen
- Division of Rheumatology, Immunology and Allergy, Department of Medicine, Brigham and Women's Hospital, 60 Fenwood Road, Boston, MA 02115, USA.
| | - Medha Barbhaiya
- Division of Rheumatology, Department of Medicine, Hospital for Special Surgery, New York, NY, USA
| | - Michael A Fischer
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Hongshu Guan
- Division of Rheumatology, Immunology and Allergy, Department of Medicine, Brigham and Women's Hospital, 60 Fenwood Road, Boston, MA 02115, USA
| | - Kazuki Yoshida
- Division of Rheumatology, Immunology and Allergy, Department of Medicine, Brigham and Women's Hospital, 60 Fenwood Road, Boston, MA 02115, USA
| | - Candace H Feldman
- Division of Rheumatology, Immunology and Allergy, Department of Medicine, Brigham and Women's Hospital, 60 Fenwood Road, Boston, MA 02115, USA
| | - Karen H Costenbader
- Division of Rheumatology, Immunology and Allergy, Department of Medicine, Brigham and Women's Hospital, 60 Fenwood Road, Boston, MA 02115, USA
| | - Brendan M Everett
- Divisions of Cardiovascular and Preventive Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
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Sanghera C, Wong LM, Panahi M, Sintou A, Hasham M, Sattler S. Cardiac phenotype in mouse models of systemic autoimmunity. Dis Model Mech 2019; 12:dmm036947. [PMID: 30858306 PMCID: PMC6451423 DOI: 10.1242/dmm.036947] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Patients suffering from systemic autoimmune diseases are at significant risk of cardiovascular complications. This can be due to systemically increased levels of inflammation leading to accelerated atherosclerosis, or due to direct damage to the tissues and cells of the heart. Cardiac complications include an increased risk of myocardial infarction, myocarditis and dilated cardiomyopathy, valve disease, endothelial dysfunction, excessive fibrosis, and bona fide autoimmune-mediated tissue damage by autoantibodies or auto-reactive cells. There is, however, still a considerable need to better understand how to diagnose and treat cardiac complications in autoimmune patients. A range of inducible and spontaneous mouse models of systemic autoimmune diseases is available for mechanistic and therapeutic studies. For this Review, we systematically collated information on the cardiac phenotype in the most common inducible, spontaneous and engineered mouse models of systemic lupus erythematosus, rheumatoid arthritis and systemic sclerosis. We also highlight selected lesser-known models of interest to provide researchers with a decision framework to choose the most suitable model for their study of heart involvement in systemic autoimmunity.
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Affiliation(s)
- Chandan Sanghera
- National Heart and Lung Institute, Imperial College London, London, W12 0NN, UK
| | - Lok Man Wong
- National Heart and Lung Institute, Imperial College London, London, W12 0NN, UK
| | - Mona Panahi
- National Heart and Lung Institute, Imperial College London, London, W12 0NN, UK
| | - Amalia Sintou
- National Heart and Lung Institute, Imperial College London, London, W12 0NN, UK
| | - Muneer Hasham
- The Jackson Laboratory, 600 Main Street, Bar Harbor, ME 04609, USA
| | - Susanne Sattler
- National Heart and Lung Institute, Imperial College London, London, W12 0NN, UK
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Sun L, Wang Y, Dong Y, Song S, Luo R, Li G. Assessment of Right Atrium Function in Patients With Systemic Lupus Erythematosus With Different Pulmonary Artery Systolic Pressures by 2-Dimensional Speckle-Tracking Echocardiography. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2018; 37:2345-2351. [PMID: 29480580 DOI: 10.1002/jum.14582] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 12/13/2017] [Accepted: 12/15/2017] [Indexed: 06/08/2023]
Abstract
OBJECTIVES To assess right atrium (RA) function of patients with systemic lupus erythematosus (SLE) and pulmonary artery hypertension (PAH) by 2-dimensional speckle-tracking echocardiography. METHODS Thirty matched healthy adults were selected as group A. Then, 102 patients with SLE were divided into 3 groups according to the severity of PAH. Group B included 37 patients without PAH (pulmonary artery [PA] systolic pressure ≤ 30 mm Hg); group C included 34 patients with PAH (PA systolic pressure of 30-50 mm Hg); and group D included 31 patients with PAH (PA systolic pressure ≥ 50 mm Hg). Parameters evaluated included RA maximum volume, minimum volume, preatrial contraction volume, passive ejection fraction (EF), and active EF. The global peak longitudinal systolic strain rate and early and late diastolic strain rates of the RA were obtained by 2-dimensional speckle-tracking echocardiography. RESULTS No significant differences were found in all parameters between groups B and A (P > .05). The RA maximum volume, minimum volume, preatrial contraction volume, active EF, and late diastolic strain rate in groups C and D were significantly increased compared with those in groups A and B, and the parameters in group D were significantly higher than those in group C (P < .05). Although the RA passive EF, early diastolic strain rate, and systolic strain rate in groups C and D were significantly decreased compared with those in groups A and B, those in group D were significantly lower than those in group C (P < .05). CONCLUSIONS Two-dimensional speckle-tracking echocardiography could effectively assess RA function in patients with SLE who have different severities of PAH.
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Affiliation(s)
- Lihua Sun
- Department of Ultrasound, Second Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Ying Wang
- Department of Ultrasound, Second Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Yu Dong
- Department of Ultrasound, Second Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Shengda Song
- Department of Ultrasound, Second Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Runlan Luo
- Department of Ultrasound, Second Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Guangsen Li
- Department of Ultrasound, Second Affiliated Hospital of Dalian Medical University, Dalian, China
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Liu D, Li X, Zhang Y, Kwong JSW, Li L, Zhang Y, Xu C, Li Q, Sun X, Tian H, Li S. Chloroquine and hydroxychloroquine are associated with reduced cardiovascular risk: a systematic review and meta-analysis. Drug Des Devel Ther 2018; 12:1685-1695. [PMID: 29928112 PMCID: PMC6001837 DOI: 10.2147/dddt.s166893] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Background and aims Chloroquine (CQ) and hydroxychloroquine (HCQ) are widely used in patients with rheumatic diseases, but their effects on the cardiovascular system remain unclear. We aimed to assess whether CQ/HCQ could reduce the risk of cardiovascular disease (CVD). Materials and methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, Embase, and the ClinicalTrials.gov for studies investigating the association between CQ/HCQ and the risk of CVD from inception to 20 December 2017. We carried out the quality assessment using the Newcastle-Ottawa Quality Assessment Scale (NOS). Random-effects model was used to pool the risk estimates relative ratio (RR), hazard ratio (HR) or odds ratio (OR) with 95% confidence interval (CI) for the outcomes. Results A total of 19 studies (7 case-control studies, 12 cohort studies, and no clinical trials) involving 19,679 participants were included in the meta-analysis. Pooled results for HRs or RRs showed that CQ/HCQ was associated with a significantly reduced risk of CVD (pooled RR 0.72, 95% CI 0.56–0.94, p=0.013). Results based on ORs showed a similar tendency towards a reduced risk of CVD with CQ/HCQ (pooled OR 0.41, 95% CI 0.25–0.69, p=0.001). Conclusion Our results suggested that CQ/HCQ was associated with a reduced risk of CVD in patients with rheumatic diseases. Randomized trials are needed to confirm the potential of CQ/HCQ in cardiovascular prevention in patients with and without rheumatic diseases.
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Affiliation(s)
- Dan Liu
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Xiaodan Li
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Yonggang Zhang
- Center for Stem Cell Research and Application, Institute of Blood Transfusion, Chinese Academy of Medical Sciences & Peking Union Medical College, Chengdu 610052, China
| | - Joey Sum-Wing Kwong
- Jockey Club School of Public Health and Primary Care, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong.,Department of Clinical Epidemiology and Department of Health Policy, National Center for Child Health and Development, Tokyo, Japan
| | - Ling Li
- Chinese Evidence-based Medicine Center, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Yiyi Zhang
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Chang Xu
- Chinese Evidence-based Medicine Center, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Qianrui Li
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Xin Sun
- Chinese Evidence-based Medicine Center, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Haoming Tian
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Sheyu Li
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu 610041, China.,Division of Molecular & Clinical Medicine, Ninewells Hospital, University of Dundee, Dundee, Scotland, UK
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McCormick N, Marra CA, Sadatsafavi M, Aviña-Zubieta JA. Incremental direct medical costs of systemic lupus erythematosus patients in the years preceding diagnosis: A general population-based study. Lupus 2018; 27:1247-1258. [PMID: 29665755 DOI: 10.1177/0961203318768882] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective We estimated the incremental (extra) direct medical costs of a population-based cohort of newly diagnosed systemic lupus erythematosus (SLE) for five years before and after diagnosis, and the impact of sex and socioeconomic status (SES) on pre-index costs for SLE. Methods We identified all adults newly diagnosed with SLE over 2001-2010 in British Columbia, Canada, and obtained a sample of non-SLE individuals from the general population, matched on sex, age, and calendar-year of study entry. We captured costs for all outpatient encounters, hospitalisations, and dispensed medications each year. Using generalised linear models, we estimated incremental costs of SLE each year before/after diagnosis (difference in costs between SLE and non-SLE, controlling for covariates). Similar models were used to examine the impact of sex and SES on costs within SLE. Results We included 3632 newly diagnosed SLE (86% female, mean age 49.6 ± 15.9) and 18,060 non-SLE individuals. Over the five years leading up to diagnosis, per-person healthcare costs for SLE patients increased year-over-year by 35%, on average, with the biggest increases in the final two years by 39% and 97%, respectively. Per-person all-cause medical costs for SLE the year after diagnosis (Year + 1) averaged C$12,019 (2013 Canadian) with 58% from hospitalisations, 24% outpatient, and 18% from prescription medications; Year + 1 costs for non-SLE averaged C$2412. Following adjustment for age, sex, urban/rural residence, socioeconomic status, and prior year's comorbidity score, SLE was associated with significantly greater hospitalisation, outpatient, and medication costs than non-SLE in each year of study. Altogether, adjusted incremental costs of SLE rose from C$1131 per person in Year -5 (fifth year before diagnosis) to C$2015 (Year -2), C$3473 (Year -1) and C$6474 (Year + 1). In Years -2, -1 and +1, SLE patients in the lowest SES group had significantly greater costs than the highest SES. Unlike the non-SLE cohort, male patients with SLE had higher costs than females. Annual incremental costs of SLE males (vs. SLE females) rose from C$540 per person in Year -2, to C$1385 in Year -1, and C$2288 in Year + 1. Conclusion Even years before diagnosis, SLE patients incur significantly elevated direct medical costs compared with the age- and sex-matched general population, for hospitalisations, outpatient care, and medications.
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Affiliation(s)
- N McCormick
- 1 Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, BC, Canada.,2 Arthritis Research Canada, Richmond, BC, Canada
| | - C A Marra
- 1 Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, BC, Canada.,2 Arthritis Research Canada, Richmond, BC, Canada.,3 School of Pharmacy, University of Otago, Dunedin, New Zealand
| | - M Sadatsafavi
- 1 Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, BC, Canada
| | - J A Aviña-Zubieta
- 2 Arthritis Research Canada, Richmond, BC, Canada.,4 Division of Rheumatology, Department of Medicine, The University of British Columbia, Vancouver, BC, Canada
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Long A, Long B, Koyfman A. Non-traditional risk factors for atherosclerotic disease: A review for emergency physicians. Am J Emerg Med 2017; 36:494-497. [PMID: 29269163 DOI: 10.1016/j.ajem.2017.12.036] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 12/01/2017] [Accepted: 12/13/2017] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Acute coronary syndrome (ACS) is a life-threatening disease frequently managed in the Emergency Department (ED). Risk factors such as age, hypertension, diabetes mellitus, obesity, and smoking are classically associated with atherosclerosis and ACS. OBJECTIVE This review evaluates non-traditional risk factors for atherosclerotic disease and seeks to inform physicians of their potential danger, particularly in vulnerable patient populations. DISCUSSION Traditional risk factors are commonly utilized in the evaluation of patients with concern for ACS and acute myocardial infarction (AMI), though these may not be as useful for individual patient assessment. Heart disease accounts for a significant number of deaths in the U.S. Awareness of disease presentation and risk factors is important; however, several non-traditional risk factors are associated with atherosclerosis. Vasculitides, as well as immunologic medications used to treat these patients, increase atherosclerosis. Specific types of cancer and some therapies used to treat cancer are associated with atherosclerosis development and cardiovascular disease (CVD). Heavy alcohol use increases atherosclerosis and risk of AMI. Pregnancy also increases risk of AMI. Patients with HIV develop atherosclerosis at higher rates, and antiretroviral therapy predisposes patients to early development of coronary disease. Infections such as pneumonia and sepsis, associated with elevated inflammation, increase rate of ACS events during illness and throughout the one-year period after diagnosis of infection. CONCLUSIONS Several non-traditional factors are associated with increased risk of atherosclerosis and ACS. Knowledge of these risk factors is important in the ED to minimize the potential of missing ACS.
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Affiliation(s)
- Adrianna Long
- Winn Army Community Hospital, Department of Emergency Medicine, 1061 Harmon Avenue, Fort Stewart, GA 31314, United States
| | - Brit Long
- San Antonio Military Medical Center, Department of Emergency Medicine, 3841 Roger Brooke Dr, Fort Sam Houston, TX 78234, United States.
| | - Alex Koyfman
- The University of Texas Southwestern Medical Center, Department of Emergency Medicine, 5323 Harry Hines Boulevard, Dallas, TX 75390, United States
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Tselios K, Gladman DD, Su J, Ace O, Urowitz MB. Evolution of Risk Factors for Atherosclerotic Cardiovascular Events in Systemic Lupus Erythematosus: A Longterm Prospective Study. J Rheumatol 2017; 44:1841-1849. [DOI: 10.3899/jrheum.161121] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/28/2017] [Indexed: 01/13/2023]
Abstract
Objective.We previously reported the effect of certain factors on cardiovascular disease (CVD) in 250 women with systemic lupus erythematosus (SLE) followed for 8 years. The aim of this study was to delineate their evolution after 15 years of followup.Methods.There were 210 women with SLE and 138 age-matched healthy women available for analysis after 15 years. Cardiovascular events (CVE) included angina pectoris, myocardial infarction (fatal and nonfatal), transient ischemic attack, and stroke (fatal and nonfatal). Analysis was performed with SAS 9.3 software; p < 0.05 was considered significant.Results.CVE occurred in 41/210 patients (19.5%) and 9/138 controls (6.5%), most of them in the second part (2008–2015) of the study (24/210, 11.4% vs 17/241, 7.1% in SLE group). Coronary artery disease was more common in patients (32/210, 15.2% vs 5/138, 3.6%, p = 0.0041). There was no significant difference for cerebrovascular disease (10/210, 4.8% vs 3/138, 2.2%, p = 0.213). SLE was the most prominent CVE predictor in the first 8 years (HR 2.8, 95% CI 1.3–6.3). Hypertension and diabetes were more frequent in patients who developed CVE during the second half of the study. Thirty-one deaths occurred in patients with SLE (10 because of CVD) and 6 in controls (none because of CVD).Conclusion.The relative importance of atherosclerotic risk factors is significantly differentiated over time in SLE. Disease-related factors seem to dominate CV risk during the early stages while traditional factors, partially related to corticosteroid treatment, play a significant role later in the disease course.
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Dhakal BP, Kim CH, Al-Kindi SG, Oliveira GH. Heart failure in systemic lupus erythematosus. Trends Cardiovasc Med 2017; 28:187-197. [PMID: 28927572 DOI: 10.1016/j.tcm.2017.08.015] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2017] [Revised: 08/22/2017] [Accepted: 08/28/2017] [Indexed: 11/19/2022]
Abstract
Systemic lupus erythematosus (SLE) is an autoimmune disorder characterized by a constellation of cardiovascular (CV) and non-CV manifestations. Even though CV complications such as accelerated atherosclerosis and elevated risk of myocardial infarction (MI) have been recognized for many years, there is limited evidence regarding SLE and its association with heart failure (HF). Traditional risk factors of atherosclerotic CV disease, as well as various SLE manifestations and therapies, independently or together, increase the risk of HF in this population. There is a need for sufficiently powered intervention studies focusing on specific risk factors to improve CV outcomes in SLE patients.
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Affiliation(s)
- Bishnu P Dhakal
- Division of Heart Failure and Cardiac Transplant, Department of Medicine, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Case Western Reserve University, 11100 Euclid Avenue, Mailstop LKS 5038, Cleveland, OH 44106
| | - Chang H Kim
- Division of Heart Failure and Cardiac Transplant, Department of Medicine, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Case Western Reserve University, 11100 Euclid Avenue, Mailstop LKS 5038, Cleveland, OH 44106
| | - Sadeer G Al-Kindi
- Division of Heart Failure and Cardiac Transplant, Department of Medicine, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Case Western Reserve University, 11100 Euclid Avenue, Mailstop LKS 5038, Cleveland, OH 44106
| | - Guilherme H Oliveira
- Division of Heart Failure and Cardiac Transplant, Department of Medicine, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Case Western Reserve University, 11100 Euclid Avenue, Mailstop LKS 5038, Cleveland, OH 44106.
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Fasano S, Margiotta DP, Navarini L, Pierro L, Pantano I, Riccardi A, Afeltra A, Valentini G. Primary prevention of cardiovascular disease in patients with systemic lupus erythematosus: case series and literature review. Lupus 2017; 26:1463-1472. [DOI: 10.1177/0961203317722847] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background Systemic lupus erythematosus is associated with an increased risk of cardiovascular disease. Low-dose aspirin, hydroxychloroquine and statins have been suggested to play a prophylactic role of cardiovascular events. This study is devoted to reviewing the literature on the topic and assessing the effects of these drugs in preventing a first cardiovascular event in a two-centre Italian series. Methods A PubMed search on cardiovascular prevention in systemic lupus erythematosus was performed. Moreover, systemic lupus erythematosus patients admitted to two centres from 2000–2015, who at admission had not experienced any cardiovascular event, were investigated. Aspirin, hydroxychloroquine and statin use, and the occurrence of any cardiovascular event, were recorded at each visit. Kaplan-Meier and Cox regression analyses were performed to evaluate the role of traditional, disease-related cardiovascular risk factors and of each of the three drugs in the occurrence of new cardiovascular events. Results The literature search produced conflicting results. Two hundred and ninety-one systemic lupus erythematosus patients were included in the study and followed for a median of eight years. During follow-up, 16 cardiovascular events occurred. At multivariate analysis, taking aspirin (hazard ratio: 0.24) and hydroxychloroquine for more than five years (hazard ratio: 0.27) reduced, while antiphospholipid antibody positivity (hazard ratio: 4.32) increased, the risk of a first cardiovascular event. No effect of statins emerged. Conclusion Our study confirms an additive role of aspirin and hydroxychloroquine in the primary prophylaxis of cardiovascular events in Italian patients with systemic lupus erythematosus. The lack of any detected effect in previous reports may depend on the design of studies and their short follow-up period.
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Affiliation(s)
- S Fasano
- Department of Clinical and Experimental Medicine, University of Campania ‘Luigi Vanvitelli’, Naples, Italy
| | - D P Margiotta
- Unit of Allergology, Immunology and Rheumatology, Campus Bio-Medico University, Rome, Italy
| | - L Navarini
- Unit of Allergology, Immunology and Rheumatology, Campus Bio-Medico University, Rome, Italy
| | - L Pierro
- Department of Clinical and Experimental Medicine, University of Campania ‘Luigi Vanvitelli’, Naples, Italy
| | - I Pantano
- Department of Clinical and Experimental Medicine, University of Campania ‘Luigi Vanvitelli’, Naples, Italy
| | - A Riccardi
- Department of Clinical and Experimental Medicine, University of Campania ‘Luigi Vanvitelli’, Naples, Italy
| | - A Afeltra
- Unit of Allergology, Immunology and Rheumatology, Campus Bio-Medico University, Rome, Italy
| | - G Valentini
- Department of Clinical and Experimental Medicine, University of Campania ‘Luigi Vanvitelli’, Naples, Italy
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Soh MC, Nelson-Piercy C, Westgren M, McCowan L, Pasupathy D. Do adverse pregnancy outcomes contribute to accelerated cardiovascular events seen in young women with systemic lupus erythematosus? Lupus 2017; 26:1351-1367. [PMID: 28728509 DOI: 10.1177/0961203317719146] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Cardiovascular events (CVEs) are prevalent in patients with systemic lupus erythematosus (SLE), and it is the young women who are disproportionately at risk. The risk factors for accelerated cardiovascular disease remain unclear, with multiple studies producing conflicting results. In this paper, we aim to address both traditional and SLE-specific risk factors postulated to drive the accelerated vascular disease in this cohort. We also discuss the more recent hypothesis that adverse pregnancy outcomes in the form of maternal-placental syndrome and resultant preterm delivery could potentially contribute to the CVEs seen in young women with SLE who have fewer traditional cardiovascular risk factors. The pathophysiology of how placental-mediated vascular insufficiency and hypoxia (with the secretion of placenta-like growth factor (PlGF) and soluble fms-tyrosine-like kinase-1 (sFlt-1), soluble endoglin (sEng) and other placental factors) work synergistically to damage the vascular endothelium is discussed. Adverse pregnancy outcomes ultimately are a small contributing factor to the complex pathophysiological process of cardiovascular disease in patients with SLE. Future collaborative studies between cardiologists, obstetricians, obstetric physicians and rheumatologists may pave the way for a better understanding of a likely multifactorial aetiological process.
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Affiliation(s)
- M C Soh
- 1 Women's Health Academic Centre, King's College London, United Kingdom.,3 Faculty of Medical and Health Science, University of Auckland, New Zealand
| | - C Nelson-Piercy
- 1 Women's Health Academic Centre, King's College London, United Kingdom
| | - M Westgren
- 2 Department of Clinical Science, Karolinska Institutet, Sweden
| | - L McCowan
- 3 Faculty of Medical and Health Science, University of Auckland, New Zealand.,4 National Women's Health, South Auckland Clinical School of Medicine and Counties Manukau Health, Auckland, New Zealand
| | - D Pasupathy
- 1 Women's Health Academic Centre, King's College London, United Kingdom.,5 Biomedical Research Centre at Guy's & St Thomas's NHS Foundation Trust and King's College London, United Kingdom
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Fernández-Gutiérrez B, Perrotti PP, Gisbert JP, Domènech E, Fernández-Nebro A, Cañete JD, Ferrándiz C, Tornero J, García-Sánchez V, Panés J, Fonseca E, Blanco F, Rodríguez-Moreno J, Carreira P, Julià A, Marsal S, Rodriguez-Rodriguez L. Cardiovascular disease in immune-mediated inflammatory diseases: A cross-sectional analysis of 6 cohorts. Medicine (Baltimore) 2017; 96:e7308. [PMID: 28658137 PMCID: PMC5500059 DOI: 10.1097/md.0000000000007308] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
To analyze in several immune-mediated inflammatory diseases (IMIDs) the influence of demographic and clinical-related variables on the prevalence of cardiovascular disease (CVD), and compare their standardized prevalences.Cross-sectional study, including consecutive patients diagnosed with rheumatoid arthritis, psoriatic arthritis, psoriasis, systemic lupus erythematosus, Crohn disease, or ulcerative colitis, from rheumatology, gastroenterology, and dermatology tertiary care outpatient clinics located throughout Spain, between 2007 and 2010. Our main outcome was defined as previous diagnosis of angina, myocardial infarction, peripheral vascular disease, and/or stroke. Bivariate and multivariate logistic and mixed-effects logistic regression models were performed for each condition and the overall cohort, respectively. Standardized prevalences (in subjects per 100 patients, with 95% confidence intervals) were calculated using marginal analysis.We included 9951 patients. For each IMID, traditional cardiovascular risk factors had a different contribution to CVD. Overall, older age, longer disease duration, presence of traditional cardiovascular risk factors, and male sex were independently associated with a higher CVD prevalence. After adjusting for demographic and traditional cardiovascular risk factors, systemic lupus erythematosus exhibited the highest CVD standardized prevalence, followed by rheumatoid arthritis, psoriasis, Crohn disease, psoriatic arthritis, and ulcerative colitis (4.5 [95% confidence interval (CI): 2.2, 6.8], 1.3 [95% CI: 0.8, 1.8], 0.9 [95% CI: 0.5, 1.2], 0.8 [95% CI: 0.2, 1.3], 0.6 [95% CI: 0.2, 1.0], and 0.5 [95% CI: 0.1, 0.8], respectively).Systemic lupus erythematosus, rheumatoid arthritis, and psoriasis are associated with higher prevalence of CVD compared with other IMIDs. Specific prevention programs should be established in subjects affected with these conditions to prevent CVD.
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Affiliation(s)
- Benjamín Fernández-Gutiérrez
- Rheumatology Department and Instituto de Investigación Sanitaria San Carlos (IdISSC), Hospital Clínico San Carlos, Madrid
| | - Pedro P. Perrotti
- Rheumatology Research Group, Vall d’Hebron Hospital Research Institute
- Department of Medicine, University of Barcelona, Barcelona
| | - Javier P. Gisbert
- Gastroenterology Department, Hospital Universitario de la Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Madrid
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD)
| | - Eugeni Domènech
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD)
- Gastroenterology and Hepatology Department, Hospital Universitari Germans Trias i Pujol, Badalona
| | - Antonio Fernández-Nebro
- UGC Reumatología, Instituto de Investigación Biomédica de Málaga, Hospital Regional Universitario de Málaga, Universidad de Málaga, Málaga
| | | | - Carlos Ferrándiz
- Dermatology Department, Hospital Universitari Germans Trias i Pujol, Badalona
- Universidad Autónoma de Barcelona, Barcelona
| | - Jesús Tornero
- Rheumatology Department, Hospital General Universitario de Guadalajara, Guadalajara
| | - Valle García-Sánchez
- Hospital Universitario Reina Sofía, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Universidad de Córdoba, Córdoba
| | - Julián Panés
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD)
- Hospital Clínic de Barcelona and IDIBAPS, Barcelona
| | | | - Francisco Blanco
- Rheumatology Department, Complejo Hospitalario Universitario A Coruña, INIBIC, A Coruña
| | | | - Patricia Carreira
- Rheumatology Department, Hospital Universitario Doce de Octubre, Madrid, Spain
| | - Antonio Julià
- Rheumatology Research Group, Vall d’Hebron Hospital Research Institute
| | - Sara Marsal
- Rheumatology Research Group, Vall d’Hebron Hospital Research Institute
| | - Luis Rodriguez-Rodriguez
- Rheumatology Department and Instituto de Investigación Sanitaria San Carlos (IdISSC), Hospital Clínico San Carlos, Madrid
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Affiliation(s)
- Luis Alonso González
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, Universidad de Antioquia, Medellín, Colombia
| | - Graciela S. Alarcón
- Department of Medicine, Division of Clinical Immunology and Rheumatology, School of Medicine, The University of Alabama at Birmingham, Birmingham, AL, USA
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Mavrogeni S, Koutsogeorgopoulou L, Dimitroulas T, Markousis-Mavrogenis G, Kolovou G. Complementary role of cardiovascular imaging and laboratory indices in early detection of cardiovascular disease in systemic lupus erythematosus. Lupus 2017; 26:227-236. [DOI: 10.1177/0961203316671810] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
Background Cardiovascular disease (CVD) has been documented in >50% of systemic lupus erythematosus (SLE) patients, due to a complex interplay between traditional risk factors and SLE-related factors. Various processes, such as coronary artery disease, myocarditis, dilated cardiomyopathy, vasculitis, valvular heart disease, pulmonary hypertension and heart failure, account for CVD complications in SLE. Methods Electrocardiogram (ECG), echocardiography (echo), nuclear techniques, cardiac computed tomography (CT), cardiovascular magnetic resonance (CMR) and cardiac catheterization (CCa) can detect CVD in SLE at an early stage. ECG and echo are the cornerstones of CVD evaluation in SLE. The routine use of cardiac CT and nuclear techniques is limited by radiation exposure and use of iodinated contrast agents. Additionally, nuclear techniques are also limited by low spatial resolution that does not allow detection of sub-endocardial and sub-epicardial lesions. CCa gives definitive information about coronary artery anatomy and pulmonary artery pressure and offers the possibility of interventional therapy. However, it carries the risk of invasive instrumentation. Recently, CMR was proved of great value in the evaluation of cardiac function and the detection of myocardial inflammation, stress-rest perfusion defects and fibrosis. Results An algorithm for CVD evaluation in SLE includes clinical, laboratory, ECG and echo assessment as well as CMR evaluation in patients with inconclusive findings, persistent cardiac symptoms despite normal standard evaluation, new onset of life-threatening arrhythmia/heart failure and/or as a tool to select SLE patients for CCa. Conclusions A non-invasive approach including clinical, laboratory and imaging evaluation is key for early CVD detection in SLE.
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Affiliation(s)
- S Mavrogeni
- Onassis Cardiac Surgery Center, Athens, Greece
| | - L Koutsogeorgopoulou
- Department of Pathophysiology, School of Medicine, University of Athens, Athens, Greece
| | - T Dimitroulas
- 4th Department of Internal Medicine, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - G Kolovou
- Onassis Cardiac Surgery Center, Athens, Greece
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Nightingale AL, Davidson JE, Molta CT, Kan HJ, McHugh NJ. Presentation of SLE in UK primary care using the Clinical Practice Research Datalink. Lupus Sci Med 2017; 4:e000172. [PMID: 28243454 PMCID: PMC5307373 DOI: 10.1136/lupus-2016-000172] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 12/19/2016] [Accepted: 12/30/2016] [Indexed: 01/01/2023]
Abstract
OBJECTIVES To describe the presenting symptoms of SLE in primary care using the Clinical Practice Research Database (CPRD) and to calculate the time from symptom presentation to SLE diagnosis. METHODS Incident cases of SLE were identified from the CPRD between 2000 and 2012. Presenting symptoms were identified from the medical records of cases in the 5 years before diagnosis and grouped using the British Isles Lupus Activity Group (BILAG) symptom domains. The time from the accumulation of one, two and three BILAG domains to SLE diagnosis was investigated, stratified by age at diagnosis (<30, 30-49 and ≥50 years). RESULTS We identified 1426 incident cases (170 males and 1256 females) of SLE. The most frequently recorded symptoms and signs prior to diagnosis were musculoskeletal, mucocutaneous and neurological. The median time from first musculoskeletal symptom to SLE diagnosis was 26.4 months (IQR 9.3-43.6). There was a significant difference in the time to diagnosis (log rank p<0.01) when stratified by age and disease severity at baseline, with younger patients <30 years and those with severe disease having the shortest times and patients aged ≥50 years and those with mild disease having the longest (6.4 years (IQR 5.8-6.8)). CONCLUSIONS The time from symptom onset to SLE diagnosis is long, especially in older patients. SLE should be considered in patients presenting with flaring or chronic musculoskeletal, mucocutaneous and neurological symptoms.
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Affiliation(s)
| | - Julie E Davidson
- Worldwide Epidemiology, GlaxoSmithKline R&D, Stockley Park , London , UK
| | - Charles T Molta
- U.S. Health Outcomes, GlaxoSmithKline, Research Triangle Park , North Carolina , USA
| | - Hong J Kan
- U.S. Medical Affairs, GlaxoSmithKline , Philadelphia, Pennsylvania , USA
| | - Neil J McHugh
- Department of Pharmacy & Pharmacology, University of Bath, Bath, UK; Royal National Hospital for Rheumatic Diseases, Bath, UK
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Kim CH, Al-Kindi SG, Jandali B, Askari AD, Zacharias M, Oliveira GH. Incidence and risk of heart failure in systemic lupus erythematosus. Heart 2016; 103:227-233. [DOI: 10.1136/heartjnl-2016-309561] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 07/14/2016] [Accepted: 07/16/2016] [Indexed: 01/20/2023] Open
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50
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Tselios K, Sheane BJ, Gladman DD, Urowitz MB. Optimal Monitoring For Coronary Heart Disease Risk in Patients with Systemic Lupus Erythematosus: A Systematic Review. J Rheumatol 2015; 43:54-65. [DOI: 10.3899/jrheum.150460] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/28/2015] [Indexed: 01/11/2023]
Abstract
Objective.Premature coronary heart disease (CHD) significantly affects morbidity and mortality in systemic lupus erythematosus (SLE). Several studies have detected factors influencing the atherosclerotic process, as well as methods to quantify the atherosclerotic burden in subclinical stages. The aim of this systematic review was to identify the minimum investigations to optimally monitor CHD risk in SLE.Methods.English-restricted literature review was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines through Ovid Medline, Embase, and Cochrane Central databases, from inception until May 2014 (Medline until October 2014). Specific search terms included, among others, “SLE,” “atherosclerosis,” “CHD,” “myocardial ischemia,” “acute coronary syndrome,” “myocardial infarction,” and “angina pectoris.” We identified 101 eligible articles, 23 with cardiovascular events (CVE) as endpoints and 78 with measures of subclinical atherosclerosis. The Newcastle-Ottawa scale was used for quality assessment.Results.Certain traditional and disease-specific factors were identified as independent predictors for CHD. Among the former were age (particularly postmenopausal state), male sex, arterial hypertension, dyslipidemia, and smoking. Disease activity and duration, cumulative damage, antiphospholipid antibodies, high sensitivity C-reactive protein, and renal disease were the most consistent disease-related factors. Corticosteroids were linked to increased CHD risk whereas antimalarials were protective. Concerning imaging techniques, carotid ultrasonography (intima-media thickness and plaque) was shown to independently predict CVE.Conclusion.Premature CHD in SLE is multifactorial; modifiable variables should be monitored at frequent intervals to ensure prompt management. Disease-specific factors also affect the atherogenic process and should be evaluated regularly. Carotid ultrasonography may hold promise in predicting CVE in selected high-risk patients.
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