Impact of Antiphospholipid Syndrome and/or Systemic Lupus Erythematosus on the Long-term Adverse Cardiovascular Outcomes in Patients After Percutaneous Coronary Intervention: A Systematic Review and Meta-analysis

Autoimmune Rheumatic Diseases and Outcomes Following Percutaneous Coronary Intervention: A Systematic Review and Meta-Analysis

Autoimmune Rheumatic Diseases (AIRDs) are associated with increased cardiovascular mortality. However, the post-percutaneous coronary intervention (PCI) outcomes in this population present a research gap, given the limited and discordant findings in existing studies. We conducted a systematic review and meta-analysis to assess the relationship between AIRDs and clinical outcomes after PCI; 9 studies with 7,027,270 patients (126,914 with AIRD, 6,900,356 without AIRD) were included. The AIRD cohort was characterized by an older age, a predominantly female demographic, and a greater prevalence of hypertension and diabetes mellitus. Over a mean follow-up period of 4.6 ± 3.5 years, AIRD patients demonstrated significantly higher odds of all-cause mortality (odds ratio (OR) 1.45, 95% CI: 1.25-1.78, P < .001) and major adverse cardiovascular events (MACE) (OR 1.63, 95% CI: 1.01-2.62, P = .04) compared with non-AIRD patients. Sensitivity analysis using adjusted estimates, confirmed the higher all-cause mortality (hazard ratio 1.32, 95% CI: 1.05-1.64, P = .01). Patients with rheumatoid arthritis had a significantly elevated odds of all-cause mortality (OR 1.50, 95% CI: 1.27-1.77) and MACE (OR 1.18, 95% CI: 1.14-1.21). Our study demonstrated an association between AIRDs and suboptimal long-term outcomes post-PCI. Prospective studies are warranted to explore the risk factors of unfavorable prognoses in patients with AIRDs.

Perivascular adipose tissue promotes vascular dysfunction in murine lupus

Introduction

Patients with systemic lupus erythematosus (SLE) are at elevated risk for Q10 cardiovascular disease (CVD) due to accelerated atherosclerosis. Compared to heathy control subjects, lupus patients have higher volumes and densities of thoracic aortic perivascular adipose tissue (PVAT), which independently associates with vascular calcification, a marker of subclinical atherosclerosis. However, the biological and functional role of PVAT in SLE has not been directly investigated.

Methods

Using mouse models of lupus, we studied the phenotype and function of PVAT, and the mechanisms linking PVAT and vascular dysfunction in lupus disease.

Results and discussion

Lupus mice were hypermetabolic and exhibited partial lipodystrophy, with sparing of thoracic aortic PVAT. Using wire myography, we found that mice with active lupus exhibited impaired endothelium-dependent relaxation of thoracic aorta, which was further exacerbated in the presence of thoracic aortic PVAT. Interestingly, PVAT from lupus mice exhibited phenotypic switching, as evidenced by "whitening" and hypertrophy of perivascular adipocytes along with immune cell infiltration, in association with adventitial hyperplasia. In addition, expression of UCP1, a brown/beige adipose marker, was dramatically decreased, while CD45-positive leukocyte infiltration was increased, in PVAT from lupus mice. Furthermore, PVAT from lupus mice exhibited a marked decrease in adipogenic gene expression, concomitant with increased pro-inflammatory adipocytokine and leukocyte marker expression. Taken together, these results suggest that dysfunctional, inflamed PVAT may contribute to vascular disease in lupus.

A Review of Systemic Hematological Manifestations and Stent Thrombosis

Stent thrombosis (ST) has significant morbidity and mortality following percutaneous coronary intervention (PCI). ST is uncommon making the identification of nonprocedural predictors challenging. Numerous case reports of ST in both benign and malignant hematological conditions exist. Given ST could be a Herald event of an undiagnosed condition and condition-specific treatment may be available, it is important to consider specialist testing in an unexplained ST. This review included a case presentation of ST in previously undiagnosed paroxysmal nocturnal hemoglobinuria (PNH) and a literature review of ST in other acquired thrombophilias including myeloproliferative disorders (MPNs), antiphospholipid syndrome, hematological malignancies, and heparin-induced thrombocytopenia (HIT). Inherited thrombophilias and common pitfalls in thrombophilia and coagulation testing are also discussed. The cardiac-hematology landscape is becoming increasingly complex and there is a paucity of how to best manage ST in these patients. There is clear variability in practice and the use of multidisciplinary input between cardiologists and hematologists is essential.

Cardiovascular Complications in Systemic Lupus Erythematosus

Systemic lupus erythematosus (SLE) is an auto-immune disease of a relapsing-remitting nature that can cause multiorgan damage depending on several factors, mainly the disease activity. Young age women are the most likely to be affected by the disease and the female-to-male prevalence ratio is approximately 1:10. As the number of SLE patients has been increasing in the last few decades, the annual number of deaths due to the disease and its complications has increased as well, and one of the most important systems to which high mortality is attributed is the cardiovascular system, leading to premature atherosclerosis and other events such as endocarditis and valve disease. In addition to the classical cardiovascular risk factors, studies have found a positive correlation between SLE and other cardio-harmful diseases such as metabolic syndrome and dyslipidemia. Moreover, some of the medications used in the treatment of SLE place a heavy burden on the heart. The article reviews the shared pathophysiology of SLE and cardiovascular disease along with the most common SLE- associated cardiac risks, events, and management.

Unraveling the Association Between Myocardial Infarction of Nonobstructive Coronary Arteries and Antiphospholipid Syndrome

The term "myocardial infarction with nonobstructive coronary arteries (MINOCA)" refers to a condition characterized by clinical signs and symptoms consistent with acute myocardial infarction (AMI) (as defined by the third universal definition of infarction) and coronary arteries that are angiographically normal or nearly normal. A prominent source of morbidity and mortality in patients with antiphospholipid syndrome (APS) is thrombotic events. To evaluate whether there is a relation between APS and MINOCA in this research, we did an extensive assessment of the existing research in this field. According to the data, APS was associated with microvascular thrombosis, aberrant lipid metabolism, hypertension, and abnormalities of the coagulation cascade, among other conditions. Based on the available data, we discovered evidence that suggests a relationship between MINOCA and APS patients. It is vital to raise awareness of this concern among the general public. Also required is the development and implementation of diagnostic and targeted treatment guidelines for patients with APS and MINOCA.

16th International congress on antiphospholipid antibodies task force report on clinical manifestations of antiphospholipid syndrome

The objectives of the 16th International Congress on Antiphospholipid Antibodies (aPL) Task Force on Clinical Manifestations of Antiphospholipid Syndrome (APS) were to critically analyze: a) the definition of "APS"; b) the current knowledge on non-traditional manifestations associated with aPL; and c) the risk stratification strategies in aPL-positive patients. The quality of evidence was assessed by the GRADE system. The task force concluded that: a) APS does not have a uniform definition given the heterogeneity of the clinical presentations and different aPL profiles; b) current literature supports the role for aPL testing in cases of thrombocytopenia and recurrent cardiac events but are limited by vast heterogeneity, providing an overall low-to-very low level of evidence; and c) risk stratification strategies in aPL-positive patients, such as aPL-Score and Global APS Score, can be useful in clinical practice. International multicenter studies are still highly needed to improve the quality of available evidence and consequently the strength of future recommendations.

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

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.

Cardiovascular Disease in Antiphospholipid Syndrome

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Antiphospholipid syndrome (APS) is a systemic autoimmune disease characterized by venous, arterial or microvascular thrombosis or obstetric events in the presence of persistently positive antiphospholipid antibodies and constitutes a major cause of cardiovascular events in young people. Τhis review highlights the pathophysiology of cardiovascular complications in patients with APS and possible treatment options.

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Patients with APS have endothelial dysfunction, accelerated endothelial proliferation and intimal hyperplasia, atherogenesis, platelet activation, inflammatory products secretion and coagulation-fibrinolytic dysregulation. Cardiovascular complications include accelerated atherosclerosis, acute coronary syndrome, Libman-Sacks endocarditis, cardiomyopathy and venous, arterial or intracardiac thrombi. Moreover, pulmonary hypertension and peripheral microvascular dysfunction are common findings.

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Management of these patients is not well documented. The role of primary thrombosis prevention remains controversial in individuals with positive antiphospholipid antibodies. Treatment of traditional cardiovascular risk factors according to current guidelines for the prevention of cardiovascular disease in the general population is recommended for primary prevention of APS. Anticoagulation therapy with unfractionated or low-molecular-weight heparin overlapped with a vitamin K antagonist remains the mainstay of the treatment for APS patients with venous thrombosis, whereas direct oral anticoagulants are not yet recommended. Data are scarce regarding the secondary arterial thrombosis prevention and it is not clear whether dual or triple antithrombotic therapy is necessary. To date, it is recommended to follow current guidelines for the management of acute coronary syndrome in the general population. New treatment targets are promising options for patients with catastrophic APS.

Acute coronary syndrome leading to revision of a co-morbid condition in a young man with arthritis

Although patients with rheumatoid arthritis (RA) may have an increased incidence of cardiovascular events, the development of coronary artery disease and of myocardial infarction at young age is rather uncommon. Herein, we report a case of a 26-year-old man without classical cardiovascular risk factors, but with a 2-year history of RA, who experienced recurrent episodes of angina-like chest pain. His electrocardiogram showed ST-elevation and T-wave inversion in anterior chest leads, and the patient was sent for coronary angiography, which revealed multivessel coronary artery disease. Subsequently, the patient underwent coronary artery bypass grafting. Closer analysis of the patient’s history and of the laboratory findings led to revision of the diagnosis of RA: the patient was found to meet the classification criteria for systemic lupus erythematosus. Pitfalls of the classification criteria and the impact of the revised diagnosis on the patient’s care are discussed.

Outcomes of Coronary Artery Revascularization Procedures in Patients with Antiphospholipid Syndrome

BACKGROUND

Published data on the outcome of coronary artery revascularization in patients with antiphospholipid syndrome (APS) are limited. Because APS is associated with a high rate of arterial thrombosis, there is concern that coronary revascularization in this group may be complicated by increased need for repeat revascularization. We aimed to determine the incidence and timing of repeat revascularization performed in patients with APS undergoing percutaneous coronary interventions (PCI) or coronary artery bypass grafting (CABG).

METHODS

Our institutional database was queried for individuals (n = 575) testing positive for antiphospholipid antibodies between 2000 and 2012. From this group, 46 patients underwent cardiac catheterization. Charts were reviewed to identify subsequent revascularization procedures.

RESULTS

The study sample consisted of 15 patients (67 ± 11 years, 11 females) who underwent revascularization. All of the study subjects had prior history of arterial (stroke, TIA n = 7) or venous (n = 10) thrombosis. Ten of the subjects had initial revascularization (6 CABG, 4 PCI) at an outside facility, while another five underwent initial PCI at our hospital. Repeat revascularization occurred in five patients (33%) at a median of 6 years (range 4, 13) following the initial revascularization. The median follow-up for patients who did not require repeat revascularization (n = 10) was 10 years (range 2, 15).

CONCLUSION

Amongst patients with APS who underwent CABG or PCI the need for repeat revascularization was infrequent and occurred several years after initial procedure. Based on this small sample size the periprocedural risk associated with coronary artery revascularization in subjects with APS is not prohibitively high.

Increased circulating interleukin-8 levels in systemic lupus erythematosus patients: a meta-analysis

AIM

We performed this meta-analysis in order to evaluate circulating interleukin-8 (IL-8) levels in systemic lupus erythematosus (SLE) patients more accurately and explore its related influencing factors.

METHODS

The related literature was systematically searched in PubMed, Embase and The Cochrane Library database (up to 28 March 2018). All data analysis was performed by Stata 12.0 software.

RESULTS

The results showed SLE patients had a higher circulating IL-8 levels than normal controls (pooled standardized mean difference = 0.963; 95% CI: 0.416-1.511). Subgroup analyses indicated SLE patients with age <40 years, Asia group and disease duration <10 years had higher IL-8 levels.

CONCLUSION

Compared with normal controls, circulating IL-8 levels in SLE patients are elevated and affected by age, region and disease duration.

Autoimmune Diseases May Increase Adverse Cardiovascular Events After Percutaneous Coronary Intervention: A Systematic Review and Meta-Analysis

BACKGROUND

Outcomes of patients with autoimmune diseases after percutaneous coronary intervention (PCI), as compared to those without autoimmune disease, remain unclear.

METHODS

We searched Medline, EMBASE, and the Cochrane Library from their inception to 1 April 2017. All studies comparing the following outcomes of patients with and without autoimmune diseases after PCI were included: long-term mortality, major adverse cardiovascular events (MACE), repeat revascularisation, myocardial ischaemia or myocardial infarction (MI), restenosis, and in-hospital mortality. The Newcastle-Ottawa Quality Assessment Scale (NOS) and the quality assessment form of the Agency for Healthcare Research and Quality (USA) (AHRQ) were used for assessing the risk of bias, and the certainty of evidence was rated by the Grading of Recommendations Assessment, Development, and Evaluation (GRADE).

RESULTS

A total of 11 studies were included in our analysis. Compared with patients without autoimmune diseases, those with autoimmune diseases carried an increased risk of MACEs (relative risk (RR): 2.24, 95% confidence interval (CI): 1.20-4.16; heterogeneity: p=0.128, I²=56.9%), repeat revascularisation (RR: 1.66, 95% CI 95%: 1.01-2.72; heterogeneity: p=0.057, I²=65.1%), ischaemia or MI (RR: 2.80, 95% CI: 1.38-5.65; heterogeneity: p=0.871, I²=0.0%), and restenosis (RR: 2.06, 95% CI: 1.39-3.07; heterogeneity: p=0.665, I²=0.0%) during the one-year follow-up after PCI, and carried an increased risk of MACEs (RR: 1.10, 95% CI: 1.04-1.17) and death (RR: 1.38, 95% CI: 1.25-1.51) during the 11-year follow-up after PCI.

CONCLUSIONS

Evidence of very low quality showed that during the one-year follow-up period, patients with autoimmune diseases after PCI were more likely to experience MACEs, repeat revascularisation, myocardial ischaemia or MI, and restenosis. During the 11-year follow-up period, patients with autoimmune diseases after PCI were more likely to die. It is therefore important to watch for restenosis, repeat ischaemia or MI and other adverse events more carefully in patients with autoimmune diseases after PCI.

An unusual case of heart attack

We reported a patient with antiphospholipid syndrome (APS) secondary to systemic lupus erythematosus (SLE) who suffered from myocardial infarction and graft occlusion after coronary artery bypass surgery. Our patient illustrates the impact of accelerated atherosclerosis in patients with SLE and APS and the importance of early institution of antithrombotic therapies. In this article, the treatment of APS is summarized. Although the main stay of treatment is anticoagulation, there is emerging evidence to support rituximab as an option for “refractory” cases of APS.

Assessment of subclinical atherosclerosis in systemic lupus erythematosus: A systematic review and meta-analysis

OBJECTIVES

To determine whether subclinical atherosclerosis is increased in patients with systemic lupus erythematosus (SLE) compared to healthy individuals, using carotid intima-media thickness (CIMT), carotid plaque (CP) presence or flow-mediated dilatation (FMD).

METHODS

A systematic literature search was performed using MedLine, Embase and Cochrane databases. Two reviewers independently screened the articles to identify studies that compared the rates of atherosclerosis in SLE patients versus healthy controls. The results were pooled in a meta-analysis. Factors influencing the CIMT, CP or FMD results were collected.

RESULTS

Of the 203 articles initially identified, 68 were selected for the meta-analysis. Compared to healthy controls, SLE patients had a significantly increased CIMT (mean difference [MD] of 0.08mm, 95% CI [0.06-0.09], P<0.05), more CP (odds ratio 2.01, 95% CI [1.63-2.47], P<0.05) and decreased FMD (MD -3.96%, 95% CI [-5.37 to -2.54)], P<0.05). There was marked heterogeneity among the studies. However, the results of the meta-analysis that included only the CIMT per new international recommendations also showed an increased CIMT in SLE patients, but the heterogeneity was low (MD 0.04mm, 95% CI [0.02-0.06], P<0.05; I²=23%).

CONCLUSION

SLE patients exhibit increased subclinical atherosclerosis compared to healthy controls. CIMT is a promising measure for cardiovascular risk evaluations because non-invasive, non-radiation-based, reproducible. Thus, CIMT can be proposed as an alternative to the reliable CP evaluation and to FMD, which is influenced by independent factors such as smoking. Future studies should focus on reducing the heterogeneity of these measures using standardized procedures.

[Involvement of thrombophilia in coronary thrombosis]

This review of thrombophilia and coronary thrombosis takes into account the "classical" thrombophilia commonly found in venous pathology and the conditions under which their research may be useful in certain forms of arterial thrombosis especially coronary thrombosis. In addition to the classical thrombophilia, exceptional thrombophilia are evoked, which are both factors of venous thrombosis but also arterial thrombosis. There are also thrombophilia that are more specific to the arterial system such as - homocystein which is potentially both a thrombosis factor but also an agent of arterial parietal lesion or - serotonin which is a factor of arterial spasm and especially coronary spasm. Finally, under the term thrombophilia, it is possible to include thrombophilic conditions, in particular cancers and inflammatory conditions.

Biodegradable polymer drug-eluting stents versus first-generation durable polymer drug-eluting stents: A systematic review and meta-analysis of 12 randomized controlled trials

BACKGROUND

Even if drug-eluting stents (DES) showed beneficial effects in patients with coronary artery diseases (CADs), limitations have been observed with the first-generation durable polymer DES (DP-DES). Recently, biodegradable polymer DES (BP-DES) have been approved to be used as an alternative to DP-DES, with potential benefits. We aimed to systematically compare BP-DES with the first-generation DP-DES using a large number of randomized patients.

METHODS

Electronic databases were searched for randomized controlled trials (RCTs) comparing BP-DES with first-generation DP-DES. The main endpoints were the long-term (≥2 years) adverse clinical outcomes that were reported with these 2 types of DES. We calculated odds ratios (ORs) with 95% confidence intervals (CIs) and the analysis was carried out by RevMan 5.3 software.

RESULTS

Twelve trials with a total number of 13,480 patients (7730 and 5750 patients were treated by BP-DES and first-generation DP-DES, respectively) were included. During a long-term follow-up period of ≥2 years, mortality, myocardial infarction (MI), target lesion revascularization (TLR), and major adverse cardiac events (MACEs) were not significantly different between these 2 groups with OR: 0.84, 95% CI: 0.66-1.07; P = .16, I = 0%, OR: 1.01, 95% CI: 0.45-2.27; P = .98, I = 0%, OR: 0.91, 95% CI: 0.75-1.11; P = .37, I = 0% and OR: 0.86, 95% CI: 0.44-1.67; P = .65, I = 0%, respectively. Long-term total stent thrombosis (ST), definite ST, and probable ST were also not significantly different between BP-DES and the first-generation DP-DES with OR: 0.77, 95% CI: 0.50-1.18; P = .22, I = 0%, OR: 0.71, 95% CI: 0.43-1.18; P = .19, I = 0% and OR: 1.31, 95% CI: 0.56-3.08; P = .53, I = 6%, respectively.

CONCLUSION

Long-term mortality, MI, TLR, MACEs, and ST were not significantly different between BP-DES and the first-generation DP-DES. However, the follow-up period was restricted to only 3 years in this analysis.

The pulse-mass index as a predictor of cardiovascular events in women with systemic lupus erythematosus

BACKGROUND

Patients with systemic lupus erythematosus (SLE) have 3times the risk of death compared to the rest of the population, with cardiovascular events (CVD) being one of the main causes. Índices such as waist-height (W-Ht I), waist-hip (W-Hp I) and pulse-mass (PMI) predict CVD, though the behaviour is unknown in patients with SLE. The aim of this study was to determine the prognostic value of PMI in the development of CVD in premenopausal women with SLE.

METHODOLOGY

Cohort study. Included were premenopausal women with SLE without prior CVD; excluded were those patients with antiphospholipid syndrome (APS), pregnancy, thyroid disease, recent liposuction, and chronic kidney disease. Exposure variables were: PMI, W-Ht I, W-Hp I and metabolic syndrome at onset of the cohort. Considered confounding variables were time of evolution, disease activity, cumulative damage and treatment. Through semi-annual appointments, accident and emergency admittance and hospitalisation records the CVD were screened. Analysis was performed with Cox for proportional hazards and survival with Kaplan Meier.

RESULTS

We included 238 women with a median age of 31 (18-52) years, with a follow-up of 8years. We identified 22 (9.6%) cases of CVD. In the Cox proportional hazards analysis, the prognostic variables were: PMI with HR=8.1 (95% CI: 1.1-65), metabolic syndrome with 2.4 (95% CI: 1-5.8), cumulative damage with HR=1.5 (95% CI: 1.1-2.2) and body fat percentage HR=2.8 (95% CI: 1.1-6.9) CONCLUSIONS: The PMI is a better predictor factor of CVD in women with SLE.