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Altabás-González I, Rua-Figueroa I, Mouriño C, Roberts K, Jimenez N, Martinez-Barrio J, Galindo M, Calvo Alén J, Pérez VDC, Uriarte Itzazelaia E, Tomero E, Freire-González M, Martínez Taboada V, Salgado E, Vela P, Fernandez-Nebro A, Olivé A, Narváez J, Menor-Almagro R, Soler GS, Hernández-Beriain JÁ, Manero J, Aurrecoechea E, Ibarguengoitia-Barrena O, Montilla C, Bonilla G, Torrente-Segarra V, Cacheda AP, García-Villanueva MJ, Moriano-Morales C, Manteca CF, Lozano-Rivas N, Bohórquez C, Pego-Reigosa JM. Damage in a large systemic lupus erythematosus cohort from the Spanish Society of Rheumatology Lupus Registry (RELESSER) with emphasis on the cardiovascular system: a longitudinal analysis. Lupus Sci Med 2024; 11:e001064. [PMID: 39097409 DOI: 10.1136/lupus-2023-001064] [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: 10/19/2023] [Accepted: 06/18/2024] [Indexed: 08/05/2024]
Abstract
OBJECTIVE To assess organ damage, with emphasis on the cardiovascular system, over the different stages of the disease in a large SLE cohort. METHODS Multicentre, longitudinal study of a cohort of 4219 patients with SLE enrolled in the Spanish Society of Rheumatology Lupus Registry. Organ damage was ascertained using the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SDI). We longitudinally analysed SDI (globally and for each domain) over time only in the 1274 patients whose dates of damage events had been recorded. RESULTS During the first year after diagnosis of SLE, 20% of the 1274 patients presented with new damage manifestations. At years 2 and 3, new damage was recorded in 11% and 9% of patients. The annual percentage of patients with new damage after year 5 decreased to 5%. In the first year with the disease, most damage was accumulated in the musculoskeletal, neuropsychiatric and renal systems; in later stages, most damage was in the musculoskeletal, ocular and cardiovascular systems. Considering 'cerebrovascular accident' and 'claudication for 6 months' as cardiovascular items, the cardiovascular system was the second most affected system during the early stages of SLE, with 19% of the patients who presented with damage affected at first year after diagnosis. During the late stages, 20-25% of the patients presenting with new damage did so in this modified cardiovascular domain of the SDI. CONCLUSIONS New damage occurs mainly during the first year following diagnosis of SLE. Cardiovascular damage is relevant in both the early and the late stages of the disease. Strategies to prevent cardiovascular damage should be implemented early after diagnosis of SLE.
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Affiliation(s)
- Irene Altabás-González
- Rheumatology Department, Vigo University Hospital Group, Vigo, Spain
- IRIDIS Group (Investigation in Rheumatology and Immune-Diseases), Galicia Sur Health Research Institute, Vigo, Spain
| | - Iñigo Rua-Figueroa
- Rheumatology, Hospital Universitario de Gran Canaria Dr Negrin, Las Palmas de Gran Canaria, Spain
| | - Coral Mouriño
- Rheumatology Department, Vigo University Hospital Group, Vigo, Spain
| | - Karen Roberts
- Rheumatology, Instituto de Investigación, Galicia Sur, External Statistical Advisor, Rosario, Argentina
| | - Norman Jimenez
- IRIDIS Group (Investigation in Rheumatology and Immune-Diseases), Galicia Sur Health Research Institute, Vigo, Spain
| | | | - María Galindo
- Servicio de Reumatología, Instituto de Investigación Hospital 12 de Octubre, Madrid, Spain
| | - Jaime Calvo Alén
- Rheumatology, Hospital Universitario Araba, Vitoria-Gasteiz, Spain
| | - Victor Del Campo Pérez
- IRIDIS Group (Investigation in Rheumatology and Immune-Diseases), Galicia Sur Health Research Institute, Vigo, Spain
- Department of Epidemiology, Vigo University Hospital Group, Vigo, Spain
| | | | - Eva Tomero
- Rheumatology Department, Hospital Universitario de la Princesa, Madrid, Spain
| | | | | | - Eva Salgado
- Rheumatology, Complejo Hospitalario de Orense, Ourense, Spain
| | - Paloma Vela
- Department of Rheumatology, Hospital General Universitario de Alicante, Alicante, Spain
| | | | - Alejandro Olivé
- Rheumatology Department, Hospital Universitario Germans Trias i Pujol, Badalona, Spain
| | - Javier Narváez
- Rheumatology, Hospital Universitario de Bellvitge, Hospitalet de LLobregat, Spain
| | | | | | | | - Javier Manero
- Department of Rheumatology, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | | | | | | | - Gema Bonilla
- Rheumatology, La Paz University Hospital, Madrid, Spain
| | | | - Ana Paula Cacheda
- Department of Rheumatology, Hospital Son Llatzer, Palma de Mallorca, Spain
| | | | | | | | | | - Cristina Bohórquez
- Department of Rheumatology, Hospital Universitario Príncipe de Asturias, Alcala de Henares, Spain
| | - José M Pego-Reigosa
- Rheumatology Department, Vigo University Hospital Group, Vigo, Spain
- IRIDIS Group (Investigation in Rheumatology and Immune-Diseases), Galicia Sur Health Research Institute, Vigo, Spain
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Choi MY, Guan H, Yoshida K, Paudel M, Kargere BA, Li D, Ellrodt J, Stevens E, Cai T, Weber BN, Everett BM, Costenbader KH. Personalizing cardiovascular risk prediction for patients with systemic lupus erythematosus. Semin Arthritis Rheum 2024; 67:152468. [PMID: 38788567 PMCID: PMC11214838 DOI: 10.1016/j.semarthrit.2024.152468] [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: 01/07/2024] [Revised: 04/12/2024] [Accepted: 05/15/2024] [Indexed: 05/26/2024]
Abstract
OBJECTIVE Cardiovascular disease (CVD) risk is increased in SLE and underestimated by general population prediction algorithms. We aimed to develop a novel SLE-specific prediction tool, SLECRISK, to provide a more accurate estimate of CVD risk in SLE. METHODS We studied patients in the Brigham and Women's Hospital SLE cohort. We collected one-year baseline data including the presence of traditional CVD factors and SLE-related features at cohort enrollment. Ten-year follow-up for the first major adverse cardiovascular event (MACE; myocardial infarction (MI), stroke, or cardiac death) began at day +1 following the baseline period (index date). ICD-9/10 codes identified MACE were adjudicated by board-certified cardiologists. Least absolute shrinkage and selection operator regression selected SLE-related variables to add to the American College of Cardiology/American Heart Association (ACC/AHA) Pooled Cohort Risk Equations 10-year risk Cox regression model. Model fit statistics and performance (sensitivity, specificity, positive/negative predictive value, c-statistic) for predicting moderate/high 10-year risk (≥7.5 %) of MACE were assessed and compared to ACC/AHA, Framingham risk score (FRS), and modified FRS (mFRS). Optimism adjustment internal validation was performed using bootstrapping. RESULTS We included 1,243 patients with 90 MACEs (46 MIs, 36 strokes, 19 cardiac deaths) over 8946.5 person-years of follow-up. SLE variables selected for the new prediction algorithm (SLECRISK) were SLE activity (remission/mild vs. moderate/severe), disease duration (years), creatinine (mg/dL), anti-dsDNA, anti-RNP, lupus anticoagulant, anti-Ro positivity, and low C4. The sensitivity for detecting moderate/high-risk (≥7.5 %) of MACE using SLECRISK was 0.74 (95 %CI: 0.65, 0.83), which was better than the sensitivity of the ACC/AHA model (0.38 (95 %CI: 0.28, 0.48)). It also identified 3.4-fold more moderate/high-risk patients than the ACC/AHA. Patients who were moderate/high-risk according to SLECRISK but not ACC/AHA, were more likely to be young women with severe SLE and few other traditional CVD risk factors. Model performance between SLECRISK, FRS, and mFRS were similar. CONCLUSION The novel SLECRISK tool is more sensitive than the ACC/AHA for predicting moderate/high 10-year risk for MACE and may be particularly useful in predicting risk for young females with severe SLE. Future external validation studies utilizing cohorts with more severe SLE are needed.
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Affiliation(s)
- May Y Choi
- Division of Rheumatology, Inflammation and Immunity, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA; Division of Rheumatology, University of Calgary, Calgary, Alberta, Canada.
| | - Hongshu Guan
- Division of Rheumatology, Inflammation and Immunity, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Kazuki Yoshida
- Division of Rheumatology, Inflammation and Immunity, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Misti Paudel
- Division of Rheumatology, Inflammation and Immunity, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | | | - Daniel Li
- Division of Rheumatology, Inflammation and Immunity, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Jack Ellrodt
- Division of Rheumatology, Inflammation and Immunity, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Emma Stevens
- Division of Rheumatology, Inflammation and Immunity, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Tianrun Cai
- Division of Rheumatology, Inflammation and Immunity, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Brittany N Weber
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Brendan M Everett
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA; Division of Preventive Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Karen H Costenbader
- Division of Rheumatology, Inflammation and Immunity, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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Barozet M, Le Tilly O, Bejan-Angoulvant T, Fesler P, Roubille C. Hypertension and Cardiovascular Outcomes in Inflammatory and Autoimmune Diseases: A Systematic Review and Meta-analysis. Curr Hypertens Rep 2024:10.1007/s11906-024-01311-6. [PMID: 38819751 DOI: 10.1007/s11906-024-01311-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2024] [Indexed: 06/01/2024]
Abstract
PURPOSE This review aimed to investigate the prevalence of hypertension and cardiovascular (CV) complications in various inflammatory and autoimmune diseases (IAD). RECENT FINDINGS Despite recent improvements in the management of IAD, patients with IAD still have an increased CV mortality and CV complications, mostly related to CV risk factors such as hypertension and inflammation. We systematically searched MEDLINE and EMBASE libraries for controlled studies involving hypertension and CV complications in systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), psoriasis including psoriatic arthritis (PsA), Sjogren's syndrome (SS), or antineutrophil cytoplasmic antibody-associated vasculitis (AAV) between January 2000 and March 2022. We extracted data on the prevalence of hypertension and CV complications. Then, random-effects meta-analyses and exploratory multivariate meta-regression were performed to explore factors related to the prevalence of hypertension. Of 2726 studies screened, 122 were selected for the meta-analysis. The prevalence of hypertension was higher among patients with IAD than controls, with an overall unadjusted odds ratio (OR) [95% confidence interval] of 1.67 [1.58-1.76] and an adjusted OR of 1.36 [1.24-1.50]. All diseases were found to be associated with increased risk of hypertension: SLE, adjusted OR 3.40 [1.93-6.00]; psoriasis, OR 1.32 [1.16-1.51]; PsA, OR 1.49 [1.15-1.94]; RA, OR 1.28 [1.04-1.58]; SS, OR 2.02 [1.19-3.44]. Age and female sex were significantly associated with hypertension in patients with IAD. The risk of CV complications was increased: ischemic heart disease, adjusted OR 1.38 [1.21-1.57]; cerebrovascular disease, OR 1.37 [1.03-1.81]; heart failure, OR 1.28 [1.05-1.55]; atherosclerotic plaques presence, OR 2.46 [1.84-3.29]. The prevalence of hypertension and CV complications is higher among patients with IAD. Screening and management of hypertension appears to be of paramount importance in these patients.
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Affiliation(s)
- Marie Barozet
- Department of Internal Medicine, Montpellier University Hospital, Montpellier, France
| | - Olivier Le Tilly
- Department of Medical Pharmacology, Tours University Hospital and University of Tours, Tours, France
- UMR 1327 - ISCHEMIA Membrane Signalling and Inflammation in reperfusion injuries, INSERM, Université de Tours, Tours, France
| | - Theodora Bejan-Angoulvant
- Department of Medical Pharmacology, Tours University Hospital and University of Tours, Tours, France
- UMR 1327 - ISCHEMIA Membrane Signalling and Inflammation in reperfusion injuries, INSERM, Université de Tours, Tours, France
| | - Pierre Fesler
- Department of Internal Medicine, Montpellier University Hospital, Montpellier, France
- PhyMedExp, University of Montpellier - INSERM - CNRS - CHRU Montpellier, Montpellier, France
- University of Montpellier, Montpellier, France
| | - Camille Roubille
- Department of Internal Medicine, Montpellier University Hospital, Montpellier, France.
- PhyMedExp, University of Montpellier - INSERM - CNRS - CHRU Montpellier, Montpellier, France.
- University of Montpellier, Montpellier, France.
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Emamikia S, Gomez A, Ådahl T, von Perner G, Enman Y, Chatzidionysiou K, Arkema EV, Parodis I. Factors associated with non-adherence to medications in systemic lupus erythematosus: Results from a Swedish survey. Lupus 2024; 33:615-628. [PMID: 38545763 PMCID: PMC11015713 DOI: 10.1177/09612033241242692] [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: 10/31/2023] [Accepted: 03/05/2024] [Indexed: 04/13/2024]
Abstract
OBJECTIVE To identify determinants of medication non-adherence in a Swedish population of systemic lupus erythematosus (SLE). METHODS Patients with SLE from Karolinska and Örebro University Hospitals participated in a survey-based cross-sectional study. Demographics, disease activity, organ damage, HRQoL (LupusQol, EQ-5D-5 L), medication non-adherence (<80% on CQR-19 or MASRI) and beliefs about medicines (BMQ) were registered. MASRI was used to report adherence to different drugs/drug classes, categorised into (i) antimalarial agents (AMA), (ii) glucocorticoids and (iii) other SLE medications. Multivariable logistic regression adjusted for age, sex, disease activity and organ damage. RESULTS Among 205 respondents, the median age was 52.0 years (IQR: 34.0-70.0), 86.3% were women, 66.8% were non-adherent to their medications according to CQR-19, and 6.6% and 6.3% were non-adherent to AMA and glucocorticoids, respectively, according to MASRI. Positive beliefs about glucocorticoids (OR; 95% CI: 0.77; 0.59-0.99; p = .039) and medications overall (0.71; 0.52-0.97; p = .029) were protective against non-adherence to glucocorticoids. Anxiety/depression (3.09; 1.12-8.54; p = .029), medication concerns (1.12; 1.05-1.20; p < .001) and belief that medications are overused (1.30; 1.15-1.46; p < .001) or harmful (1.36; 1.19-1.56; p < .001) were associated with medication non-adherence (CQR-19); beliefs in the necessity of medications (0.73; 0.65-0.82; p < .001) and positive beliefs in medications were protective (0.72; 0.60-0.86; p < .001). No associations were found between other investigated factors and medication non-adherence. CONCLUSIONS Beliefs about medications were a major determinant of medication non-adherence. Patient education may help alleviate the negative impact of misinformation/unawareness on adherence.
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Affiliation(s)
- Sharzad Emamikia
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Alvaro Gomez
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Theodor Ådahl
- Department of Rheumatology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Gunilla von Perner
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Yvonne Enman
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Katerina Chatzidionysiou
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Elizabeth V. Arkema
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Ioannis Parodis
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
- Department of Rheumatology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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Roubille C. [Management of cardiovascular comorbidities in immune-mediated inflammatory diseases]. Rev Med Interne 2024; 45:194-199. [PMID: 37981509 DOI: 10.1016/j.revmed.2023.11.001] [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: 10/30/2023] [Accepted: 11/05/2023] [Indexed: 11/21/2023]
Abstract
Patients with chronic inflammatory and autoimmune diseases are at increased cardiovascular risk, which is the cause of persistent excess mortality despite increasingly effective specific treatment of the inflammatory and/or autoimmune disease. This increased cardiovascular risk is multifactorial, associated with accelerated atherosclerosis related to systemic inflammation, but also secondary to traditional cardiovascular risk factors and to the therapies used to control systemic inflammation. This justifies a coordinated, personalized management of cardiovascular risk in patients with chronic inflammatory and autoimmune diseases, based not only on the treatment of their disease to achieve the lowest level of activity, but also on the screening and management of their cardiovascular comorbidities and modifiable cardiovascular risk factors.
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Affiliation(s)
- C Roubille
- Département de médecine interne, CHU de Lapeyronie, Montpellier, France; Inserm, PhyMedExp, CNRS, CHRU Montpellier, université de Montpellier, Montpellier, France; Université de Montpellier, Montpellier, France.
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6
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Hsu UH, Lin YT, Chiang BL. The characteristics and risk factors of cerebrovascular events in young systemic lupus erythematosus patients: A case-control study. J Formos Med Assoc 2024; 123:478-486. [PMID: 37813767 DOI: 10.1016/j.jfma.2023.09.018] [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: 04/28/2023] [Revised: 08/10/2023] [Accepted: 09/28/2023] [Indexed: 10/11/2023] Open
Abstract
OBJECTIVES We clarified the characteristics and risk factors of CVEs in young SLE patients. METHOD We retrospectively reviewed the medical records of patients younger than 50 years of age diagnosed with SLE and first CVEs from 1995 to 2020 in a tertiary medical center in Taiwan. We collected data on the patient characteristics before the CVE and reviewed the laboratory data obtained during the period. At a ratio of 1:3, cases and controls were matched with sex, SLE diagnosis age, diagnosis year, and SLE duration. RESULTS We enrolled 43 CVE SLE patients and matched 129 non-CVE SLE controls. The median age at the time of the CVE was 39 years. Around 70% of young-aged CVE involved the cerebral lobes of frontal (∼30%), parietal (∼20%), occipital (∼10%), and temporal (∼10%). The peak incidence period for hemorrhagic CVE was within 1st year of SLE diagnosis (37%); in contrast, during the 2nd to 5th year of SLE diagnosis (25%) for ischemia CVEs. Hyperlipidemia (odds ratio [OR] = 19.36, p = 0.002), anti-phospholipid syndrome (APS) (OR = 41.9, p = 0.0068), a lower hemoglobin level (OR = 0.66, p = 0.0192), and a higher SLE Disease Activity Index (SLEDAI-2k) score (OR = 1.22, p = 0.0019) were independent risk factors for CVEs in young SLE patients. CONCLUSION Hyperlipidemia, APS, low Hb level, and high SLEDAI-2k significantly increase the risk of young-aged SLE patients developing CVE.
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Affiliation(s)
- Uei-Hsiang Hsu
- Department of Pediatrics, National Taiwan University Hospital Hsin-Chu Branch, Taiwan
| | - Yu-Tsan Lin
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Bor-Luen Chiang
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan; Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.
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Huang JA, Lin CH, Wu MJ, Chen YH, Chang KC, Hou CW. Ten-year follow-up investigation of stroke risk in systemic lupus erythematosus. Stroke Vasc Neurol 2024; 9:1-7. [PMID: 37169398 PMCID: PMC10956114 DOI: 10.1136/svn-2022-001499] [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: 01/11/2022] [Accepted: 05/02/2023] [Indexed: 05/13/2023] Open
Abstract
BACKGROUND AND PURPOSE To analyse the long-term risk of ischaemic stroke and the clinical effects of antithrombotics on the risk of haemorrhagic stroke in patients with systemic lupus erythematosus (SLE). METHODS A retrospective cohort study was conducted using a population-based database taken from Taiwan National Health Insurance Research Database. Patients with SLE between 2000 and 2008 were registered and matched with two controls by the index date, age, gender and Charlson Comorbidity Index (CCI). These subjects were followed until either stroke event or 31 December 2013. Adjusted HRs (aHRs) for strokes were estimated with Cox regression models, and the cumulative incidence of ischaemic stroke was analysed by log-rank test and Kaplan-Meier survival analysis. RESULTS In total, 8310 patients with SLE and 16 620 patients without SLE were included. In general, patients with SLE had higher rates of ischaemic stroke (5.4% vs 3.3%) and haemorrhagic stroke (1.5% vs 0.6%) than in controls. In multivariate analysis adjusted to age, gender, CCI, urbanisation level and antithrombotics uses, aHRs of all strokes, ischaemic stroke and haemorrhagic stroke were 1.73 (95% CI: 1.54 to 1.94), 1.65 (95% CI: 1.45 to 1.87) and 2.24 (95% CI: 1.71 to 2.95), respectively, in patients with SLE. Patients with SLE were significantly more likely to suffer ischaemic stroke than patients without SLE, even 10 years after SLE diagnosis (6.12% vs 3.50%, p<0.001). Antiplatelet use increased the risk of haemorrhagic stroke in SLE group (aHR=1.74, 95% CI: 1.18 to 2.57). CONCLUSIONS Patients with SLE are at greater risk of developing ischaemic stroke that lasts for 10 years. Antiplatelets should be carefully administered to prevent cardiovascular events in patients with SLE due to the risk of haemorrhagic stroke.
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Affiliation(s)
- Jin-An Huang
- Division of Neurology, Neurological Institute, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Health Business Administration, Hungkuang University, Taichung,Taiwan
| | - Ching-Heng Lin
- Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Ming-Ju Wu
- Division of Nephrology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan
- College of Medicine, National Chung Hsing University, Taichung, Taiwan
| | - Yi-Hsing Chen
- Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- School of Medicine, National Yang-Ming Chiao Tung University, Taichung, Taiwan
| | - Kuo-Cheng Chang
- Division of Neurology, Neurological Institute, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Chung-Wei Hou
- Division of Neurology, Neurological Institute, Taichung Veterans General Hospital, Taichung, Taiwan
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Muñoz-Grajales C, Yilmaz EB, Svenungsson E, Touma Z. Systemic lupus erythematosus and damage: What has changed over the past 20 years? Best Pract Res Clin Rheumatol 2023; 37:101893. [PMID: 37993371 DOI: 10.1016/j.berh.2023.101893] [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: 10/16/2023] [Accepted: 10/27/2023] [Indexed: 11/24/2023]
Abstract
The young age of onset and chronic/relapsing nature of systemic lupus erythematosus (SLE) make SLE patients prone to develop and accrue organ damage as a result of long-standing disease activity and side effects of treatment. There is a growing interest in objectifying damage and identifying its risk factors. Still, the lack of therapeutic alternatives has led to difficulties in avoiding immunosuppressives particularly corticosteroids, which have been implicated in a large spectrum of organ damage in SLE patients. Moreover, it continues to be very challenging to determine what actually causes damage in different organ-systems. Cardiovascular disease continues to be one of the leading types of damage in patients with SLE, reported as early as 1976. Since then, many researchers have focused on identifying SLE or treatment-related and traditional risk factors. The same considerations are valid for other conditions, such as the occurrence of metabolic syndrome, osteoporosis, avascular necrosis, susceptibility to infections, etc. On the other hand, diverse risk factors contribute to the development of chronic kidney disease (CKD) in SLE. Most evidence suggests that high initial levels of serum creatinine, hypocomplementemia, nephrotic range proteinuria, concomitant uncontrolled hypertension, Black and Hispanic ancestry, non-adherence to treatment, and biopsy findings such as diffuse proliferative lupus nephritis (LN), a high chronicity index, tubular atrophy, and tubulointerstitial inflammation are risk factors for progression to end stage renal disease (ESRD) in LN. While cardiovascular disease, CKD and infections are leading causes of mortality in patients with SLE, hospitalizations are caused mostly by SLE disease flares and infections. Cognitive impairment and mood disorders are common in SLE but continue to impose a challenge on how to measure, manage and decipher the underlying pathogenesis. Nevertheless, they have a great impact on SLE patients' health-related quality of life (HRQoL) and social functioning. Also, skin manifestations, such as alopecia and scaring, cataracts, and sicca symptoms result in a significant decrease in HRQoL. In light of recent developments in SLE treatment, we can expect to enter a period of new-age targeted therapies that will enable us to reduce disease activity and glucocorticoid usage further and positively alter the trajectory of damage development and accrual in SLE.
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Affiliation(s)
- Carolina Muñoz-Grajales
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network, Division of Rheumatology, University of Toronto, Toronto, Canada; University of Toronto Lupus Clinic, Centre for Prognosis Studies in Rheumatic Diseases, Toronto Western Hospital Lupus Clinic, Toronto, Canada
| | - Esin Beste Yilmaz
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Elisabet Svenungsson
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Zahi Touma
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network, Division of Rheumatology, University of Toronto, Toronto, Canada; University of Toronto Lupus Clinic, Centre for Prognosis Studies in Rheumatic Diseases, Toronto Western Hospital Lupus Clinic, Toronto, Canada.
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Liu F, Xie Y, Wu C, Liu H, Zhang J, Lian Y, Xie N. A nested case-control study investigating short-term prognosis, clinical and imaging features in acute ischemic stroke patients with systemic lupus erythematosus. Acta Neurol Belg 2023; 123:2177-2184. [PMID: 36719615 DOI: 10.1007/s13760-023-02189-y] [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: 04/10/2022] [Accepted: 01/16/2023] [Indexed: 02/01/2023]
Abstract
OBJECTIVES To investigate acute ischemic stroke (AIS) patients with systemic lupus erythematosus (SLE) clinical and imaging features, and to explore the impact of SLE on the short-term prognosis of AIS patients. METHODS A nested case-control study was conducted in The First Affiliated Hospital of Zhengzhou University between October 1, 2019, and May 31, 2021. The case group consisted of 28 AIS patients diagnosed with SLE, and 112 AIS patients without SLE were selected by incidence density sampling as a control group. RESULTS Among 140 patients, the mean age was (48.4 ± 15.6) years, and 130 (92.9%) were females. Higher levels in low-density lipoprotein cholesterol (LDL-C) (2.5 mmol/L vs. 2.1 mmol/L; P = 0.049), D-dimer (DDi) (0.7 mg/L vs. 0.3 mg/L; P = 0.02), and C-reactive protein (CRP) (13.2 mg/L vs. 6.3 mg/L; P = 0.002) were observed in the case group. On imaging, the case group was more prevalent in simultaneous involvement of the anterior and posterior circulation (42.9% vs. 17.0%; P = 0.004), multiple infarcts (46.4% vs. 20.5%; P = 0.008) and stroke of other undetermined etiologies (SUE) (28.6% vs. 6.3%; P = 0.002) than the control group. SLE (OR 5.94, 95%CI [1.04-34.39]; P = 0.045) was an independent risk factor for a poor short-term prognosis of AIS patients. CONCLUSIONS Higher levels of LDL-C, CRP, and DDi, multiple infarcts and simultaneous involvement of the anterior, and posterior circulation were more prevalent in the AIS patients with SLE. Further, SLE was also found as an independent risk factor for AIS patients' poor short-term prognosis.
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Affiliation(s)
- Fengxia Liu
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, 1 Jianshe East Road, Zhengzhou, 450052, Henan, China
| | - Yinyin Xie
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, 1 Jianshe East Road, Zhengzhou, 450052, Henan, China
| | - Chuanjie Wu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
| | - Hongbo Liu
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, 1 Jianshe East Road, Zhengzhou, 450052, Henan, China
| | - Jiwei Zhang
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, 1 Jianshe East Road, Zhengzhou, 450052, Henan, China
| | - Yajun Lian
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, 1 Jianshe East Road, Zhengzhou, 450052, Henan, China
| | - Nanchang Xie
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, 1 Jianshe East Road, Zhengzhou, 450052, Henan, China.
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Frostegård J. Antibodies against Phosphorylcholine-Implications for Chronic Inflammatory Diseases. Metabolites 2023; 13:720. [PMID: 37367878 DOI: 10.3390/metabo13060720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 05/22/2023] [Accepted: 05/25/2023] [Indexed: 06/28/2023] Open
Abstract
Atherosclerosis and its main consequence, cardiovascular disease (CVD) are nowadays regarded as chronic inflammatory disease conditions, and CVD is the main cause of death in the world. Other examples of chronic inflammation are rheumatic and other autoimmune conditions, but also diabetes, obesity, and even osteoarthritis among others. In addition, infectious diseases can have traits in common with these conditions. Systemic lupus erythematosus (SLE) is a prototypical autoimmune disease, where atherosclerosis is increased and the risk of CVD is very high. This is a clinical problem but could also shed light on the role of the immune system in atherosclerosis and CVD. Underlying mechanisms are of major interest and these are only partially known. Phosphorylcholine (PC) is a small lipid-related antigen, which is both a danger associated molecular pattern (DAMP), and a pathogen associated molecular pattern (PAMP). Antibodies against PC are ubiquitous and 5-10% of circulating IgM is IgM anti-PC. Anti-PC, especially IgM and IgG1 anti-PC, has been associated with protection in the chronic inflammatory conditions mentioned above, and develops during the first years of life, while being present at very low levels at birth. Animal experiments with immunization to raise anti-PC ameliorate atherosclerosis and other chronic inflammatory conditions. Potential mechanisms include anti-inflammatory, immune modulatory, clearance of dead cells and protection against infectious agents. An intriguing possibility is to raise anti-PC levels through immunization, to prevent and/or ameliorate chronic inflammation.
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Affiliation(s)
- Johan Frostegård
- IMM, Nobels Väg 13, Karolinska Institutet, 17165 Stockholm, Sweden
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11
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Abstract
Cerebrovascular accidents (CVAs) or strokes are part of the common thrombotic manifestations of Systemic Lupus Erythematosus (SLEs) and Antiphospholipid syndrome (APS). Such neurological thrombotic events tend to occur in patients with SLE at a higher frequency when Antiphospholipid antibodies (aPLs) are present, and tend to involve the large cerebral vessels. The mechanism of stroke in SLE can be driven by complement deposition and neuroinflammation involving the blood-brain barrier although the traditional cardiovascular risk factors remain major contributing factors. Primary prevention with antiplatelet therapy and disease activity controlling agent is the basis of the management. Anticoagulation via warfarin had been a tool for secondary prevention, especially in stroke recurrence, although the debate continues regarding the target international normalized ratio (INR). The presence of either of the three criteria antiphospholipid antibodies (aPLs) and certain non-criteria aPL can be an independent risk factor for stroke. The exact mechanism for the involvement of the large cerebral arteries, especially in lupus anticoagulant (LAC) positive cases, is still to be deciphered. The data on the role of non-criteria aPL remain very limited and heterogenous, but IgA antibodies against β2GPI and the D4/5 subunit as well as aPS/PT IgG might have a contribution. Anticoagulation with warfarin has been recommended although the optimal dosing or the utility of combination with antiplatelet agents is still unknown. Minimal data is available for direct oral anticoagulants (DOACs).
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Affiliation(s)
- Georges El Hasbani
- Department of Internal Medicine, St Vincent's Medical Center, Bridgeport, CT, USA
| | - Imad Uthman
- Department of Internal Medicine, 11238American University of Beirut Medical Center, Beirut, Lebanon
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12
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Bello N, Meyers KJ, Workman J, Hartley L, McMahon M. Cardiovascular events and risk in patients with systemic lupus erythematosus: Systematic literature review and meta-analysis. Lupus 2023; 32:325-341. [PMID: 36547368 PMCID: PMC10012401 DOI: 10.1177/09612033221147471] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Systemic lupus erythematosus (SLE) is an autoimmune disease that typically affects women aged 16-55 years. Cardiovascular disease (CVD) is a well-recognized complication of SLE. This systematic literature review and meta-analysis evaluated the relative risk (RR; compared with non-SLE controls), absolute risk (AR; as incidence proportion, n/N), and incidence rate (IR) of CVD events (including stroke, myocardial infarction [MI], and CVD [composite or undefined]) in adult patients with SLE. The RR of CV risk factors (including hypertension, diabetes, and metabolic syndrome [MetS]) was also examined. METHODS PubMed and Embase were searched on September 10, 2020. Observational studies published between January 2010 and September 2020 that reported RR, AR, and/or IR of CVD events, or RR of CV risk factors, were eligible. Pooled risk estimates were calculated using a random-effects model. RESULTS Forty-six studies (16 cross-sectional, 15 retrospective cohort, 14 prospective cohort, and 1 case-control) were included in meta-analyses. Most studies were considered high quality (Critical Appraisal Skills Programme checklists). Compared with adults without SLE, patients with SLE had statistically significantly higher RRs (95% CIs) of stroke (2.51 [2.03-3.10]; 12 studies), MI (2.92 [2.45-3.48]; 11 studies), CVD (2.24 [1.94-2.59]; 8 studies), and hypertension (2.70 [1.48-4.92]; 7 studies). RRs of diabetes (1.24 [0.78-1.96]; 3 studies) and MetS (1.49 [0.95-2.33]; 7 studies) were elevated but not significant. RRs of stroke and MI were generally higher in younger versus older patients with SLE. In patients with SLE, the pooled estimate of AR (95% CI) was 0.03 (0.02-0.05), 0.01 (0.00-0.02), and 0.06 (0.03-0.10) for stroke (7 studies), MI (6 studies), and CVD (8 studies), respectively. The pooled estimate of IR per 1000 person-years (95% CI) was 4.72 (3.35-6.32), 2.81 (1.61-4.32), and 11.21 (8.48-14.32) for stroke (10 studies), MI (6 studies), and CVD (8 studies), respectively. Although heterogeneity (based on I2 value) was high in most analyses, sensitivity analyses confirmed the robustness of the pooled estimates. CONCLUSIONS This meta-analysis found an increased risk of stroke, MI, CVD, and hypertension in patients with SLE compared with the general population, despite substantial heterogeneity across the included studies.
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Affiliation(s)
| | | | | | | | - Maureen McMahon
- Division of Rheumatology, Department of Medicine, David Geffen School of Medicine, 8783University of California Los Angeles, Los Angeles, CA, USA
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13
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Central nervous system involvement in systemic lupus erythematosus: Data from the Spanish Society of Rheumatology Lupus Register (RELESSER). Semin Arthritis Rheum 2023; 58:152121. [PMID: 36375359 DOI: 10.1016/j.semarthrit.2022.152121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 09/15/2022] [Accepted: 10/19/2022] [Indexed: 11/13/2022]
Abstract
OBJECTIVES To analyze the prevalence, incidence, survival and contribution on mortality of major central nervous system (CNS) involvement in systemic lupus erythematosus (SLE). METHODS Patients fulfilling the SLE 1997 ACR classification criteria from the multicentre, retrospective RELESSER-TRANS (Spanish Society of Rheumatology Lupus Register) were included. Prevalence, incidence and survival rates of major CNS neuropsychiatric (NP)-SLE as a group and the individual NP manifestations cerebrovascular disease (CVD), seizure, psychosis, organic brain syndrome and transverse myelitis were calculated. Furthermore, the contribution of these manifestations on mortality was analysed in Cox regression models adjusted for confounders. RESULTS A total of 3591 SLE patients were included. Of them, 412 (11.5%) developed a total of 522 major CNS NP-SLE manifestations. 61 patients (12%) with major CNS NP-SLE died. The annual mortality rate for patients with and without ever major CNS NP-SLE was 10.8% vs 3.8%, respectively. Individually, CVD (14%) and organic brain syndrome (15.5%) showed the highest mortality rates. The 10% mortality rate for patients with and without ever major CNS NP-SLE was reached after 12.3 vs 22.8 years, respectively. CVD (9.8 years) and organic brain syndrome (7.1 years) reached the 10% mortality rate earlier than other major CNS NP-SLE manifestations. Major CNS NP-SLE (HR 1.85, 1.29-2.67) and more specifically CVD (HR 2.17, 1.41-3.33) and organic brain syndrome (HR 2.11, 1.19-3.74) accounted as independent prognostic factors for poor survival. CONCLUSION The presentation of major CNS NP-SLE during the disease course contributes to a higher mortality, which may differ depending on the individual NP manifestation. CVD and organic brain syndrome are associated with the highest mortality rates.
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14
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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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15
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Abstract
The prognosis in systemic lupus erythematosus (SLE) has improved due to better treatment and care, but cardiovascular disease (CVD) still remains an important clinical problem, since the risk of CVD in SLE is much higher than among controls. Atherosclerosis is the main cause of CVD in the general population, and in SLE, increased atherosclerosis, especially the prevalence of atherosclerotic plaques, has been demonstrated. Atherosclerosis is an inflammatory condition, where immunity plays an important role. Interestingly, oxidized low-density lipoprotein, defective clearance of dead cells, and inflammation, with a pro-inflammatory T-cell profile are characteristics of both atherosclerosis and SLE. In addition to atherosclerosis as an underlying cause of CVD in SLE, there are also other non-mutually exclusive mechanisms, and the most important of these are antiphospholipid antibodies (aPL) leading to the antiphospholipid antibody syndrome with both arterial and venous thrombosis. aPL can cause direct pro-inflammatory and prothrombotic effects on endothelial and other cells and also interfere with the coagulation, for example, by inhibiting annexin A5 from its antithrombotic and protective effects. Antibodies against phosphorylcholine (anti-PC) and other small lipid-related epitopes, sometimes called natural antibodies, are negatively associated with CVD and atherosclerosis in SLE. Taken together, a combination of traditional risk factors such as hypertension and dyslipidemia, and nontraditional ones, especially aPL, inflammation, and low anti-PC are implicated in the increased risk of CVD in SLE. Close monitoring of both traditional risk factors and nontraditional ones, including treatment of disease manifestations, not lest renal disease in SLE, is warranted.
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Affiliation(s)
- Johan Frostegård
- Section of Immunology and Chronic Disease, Karolinska Institutet, Stockholm, Sweden
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16
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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: 5] [Impact Index Per Article: 2.5] [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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Richter P, Cardoneanu A, Rezus C, Burlui AM, Rezus E. Non-Traditional Pro-Inflammatory and Pro-Atherosclerotic Risk Factors Related to Systemic Lupus Erythematosus. Int J Mol Sci 2022; 23:ijms232012604. [PMID: 36293458 PMCID: PMC9604037 DOI: 10.3390/ijms232012604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 10/16/2022] [Accepted: 10/17/2022] [Indexed: 11/23/2022] Open
Abstract
Cardiovascular diseases (CVD) are one of the leading causes of high mortality in patients with systemic lupus erythematosus (SLE). The Framingham risk score and other traditional risk factors do not fully reflect the CVD risk in SLE patients. Therefore, in order to stratify these high-risk patients, additional biomarkers for subclinical CVD are needed. The mechanisms of atherogenesis in SLE are still being investigated. During the past decades, many reports recognized that inflammation plays a crucial role in the development of atherosclerosis. The aim of this report is to present novel proinflammatory and pro-atherosclerotic risk factors that are closely related to SLE inflammation and which determine an increased risk for the occurrence of early cardiovascular events.
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Affiliation(s)
- Patricia Richter
- Department of Rheumatology, University of Medicine and Pharmacy “Grigore T Popa”, 700115 Iasi, Romania
- Clinical Rehabilitation Hospital, 700661 Iasi, Romania
| | - Anca Cardoneanu
- Department of Rheumatology, University of Medicine and Pharmacy “Grigore T Popa”, 700115 Iasi, Romania
- Clinical Rehabilitation Hospital, 700661 Iasi, Romania
- Correspondence: (A.C.); (C.R.); Tel.: +40232301615 (A.C. & C.R.)
| | - Ciprian Rezus
- Department of Internal Medicine, University of Medicine and Pharmacy “Grigore T Popa”, 700115 Iasi, Romania
- “Sfantul Spiridon” Emergency Hospital, 700111 Iasi, Romania
- Correspondence: (A.C.); (C.R.); Tel.: +40232301615 (A.C. & C.R.)
| | - Alexandra Maria Burlui
- Department of Rheumatology, University of Medicine and Pharmacy “Grigore T Popa”, 700115 Iasi, Romania
- Clinical Rehabilitation Hospital, 700661 Iasi, Romania
| | - Elena Rezus
- Department of Rheumatology, University of Medicine and Pharmacy “Grigore T Popa”, 700115 Iasi, Romania
- Clinical Rehabilitation Hospital, 700661 Iasi, Romania
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Su L, Qi Z, Guan S, Wei L, Zhao Y. Exploring the risk factors for ischemic cerebrovascular disease in systemic lupus erythematosus: A single-center case-control study. Front Immunol 2022; 13:978910. [PMID: 36238309 PMCID: PMC9552613 DOI: 10.3389/fimmu.2022.978910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 08/22/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectivesIschemic cerebrovascular disease (ICVD) is one of the most common and severe complications in systemic lupus erythematosus (SLE). We aim to explore the risk factors for ICVD in SLE and to assess their associated clinical characteristics.MethodsIn this study, 44 lupus patients with ICVD (ICVD-SLE) and 80 age- and sex-matched lupus patients without ICVD (non-ICVD-SLE) who were hospitalized in our center between 2014 and 2021 were enrolled. A comprehensive set of clinical and socio-demographic data was recorded. In the ICVD-SLE group, the modified Rankin score (mRS) at 90 days after the occurrence of ICVD, the brain MRI, and arterial ultrasonography findings were collected. Group comparisons were made with continuous variables using an independent t-test or the Mann–Whitney test, and with categorical variables using the chi-square test or Fisher exact test. Multivariate logistic regression analysis was performed to identify the risk factors for ICVD in SLE. Patients with ICVD-SLE were divided into three subgroups according to the gradations of intracranial arterial stenosis (ICAS). The subgroup comparisons were performed by one-way ANOVA test or Kruskal–Wallis test.ResultsOf the 44 patients with ICVD, 45% had a large-vessel ischemic stroke, 50% had a symptomatic lacunar stroke, and 9% had a transient ischemic attack. 2 (4.5%) had both large-vessel ischemic stroke and symptomatic lacunar stroke. Multivariate logistic regression analysis showed that cutaneous vasculitis (OR=7.36, 95% CI=2.11–25.65), anticardiolipin antibody (aCL) (OR=4.38, 95% CI=1.435–13.350), and lupus anticoagulant (LA) (OR=7.543,95% CI=1.789–31.808) were the risk factors, and hydroxychloroquine (HCQ) therapy (OR=0.198, 95% CI=0.078–0.502) was the protective factor, after controlling for confounders. During the analysis of the subgroups, no significant difference was observed between the patients in the group without internal carotid arterial occlusion (ICAS) and those with severe ICAS except for diagnostic delay. However, patients in the moderate ICAS group were older when SLE occurred (P<0.01), had a longer diagnostic delay (P<0.01), a lower percentage of hypocomplementemia (P=0.05) and steroids and HCQ therapy (P=0.01, P=0.05, respectively), a trend toward lower mRS score, but a higher incidence of carotid atherosclerotic plaque (P<0.01), when compared with the other two subgroups.ConclusionCutaneous vasculitis and antiphospholipid antibodies (aPLs) are associated with an increased risk of ICVD, while HCQ therapy may provide protection against ICVD in SLE. The ICVD in younger lupus patients is associated with complement-mediated inflammation and poorer outcome, and require immunosuppressive therapy, whereas the ICVD in elderly patients are characterized by moderate ICAS and carotid atherosclerotic plaques.
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Affiliation(s)
- Li Su
- Department of Rheumatology and Allergy, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Zhigang Qi
- Department of Radiology and Nuclear Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Shaochen Guan
- Evidence-Based Medical Center, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Lian Wei
- Department of Rheumatology and Allergy, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yi Zhao
- Department of Rheumatology and Allergy, Xuanwu Hospital, Capital Medical University, Beijing, China
- *Correspondence: Yi Zhao,
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Myhr KA, Zinglersen AH, Hermansen MLF, Jepsen MM, Iversen KK, Ngo AT, Pecini R, Jacobsen S. Left ventricular size and function in patients with systemic lupus erythematosus associate with lupus anticoagulant: An echocardiographic follow-up study. J Autoimmun 2022; 132:102884. [PMID: 36029716 DOI: 10.1016/j.jaut.2022.102884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 07/20/2022] [Accepted: 07/20/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Systemic lupus erythematosus (SLE) is a chronic autoimmune disease with increased risk of cardiac dysfunction. The pathophysiological mechanisms are poorly understood, and prognostic markers are warranted. PURPOSE We aimed to identify SLE-characteristics associated with measures of cardiac size and function during a five-year follow-up. METHODS We included 108 patients with SLE: 90% females, mean age 46 ± 13 years, median disease duration 14 (range 7-21) years. We performed blood sampling for potential biomarkers as well as a standard echocardiography at baseline and at a 5-year follow-up. To investigate associations with baseline and prospective 5-year changes in echocardiographic parameters, we performed multivariate regression analyses of SLE-related baseline variables (clinical disease activity, lupus nephritis, chronic kidney disease, anti-cardiolipin and/or anti-beta-2 glycoprotein I antibodies, and lupus anticoagulant (LAC)) and adjusted for traditional risk factors. RESULTS During follow-up, diastolic function regressed in two out of five echocardiographic measures (E/A ratio 1.4 ± 0.5 vs. 1.3 ± 0.5, p = 0.002; tricuspid regurgitation peak velocity 2.0 ± 0.6 vs. 2.2 ± 0.4 mmHg, p < 0.001). Left ventricular (LV) end-diastolic volume index increased (43.7 ± 13.9 vs. 52.5 ± 15.7 mL/m2, p < 0.001). Left and right ventricular systolic function remained stationary. LAC was associated with inferior diastolic function: lower E/A ratio (p = 0.04) and higher E/e' ratio at baseline (p = 0.04) and increased left ventricular atrial volume index during follow-up (p = 0.01). LAC was further associated with LV dilatation during follow-up (p = 0.01). CONCLUSION Presence of LAC was associated with measures of diastolic function as well as progressive LV dilatation during the 5-year follow-up. Thus, LAC might be a predictor of cardiac dysfunction in SLE patients. LAC is known to have implications for the microvascular circulation, but the clinical significance of the present findings is yet to be elucidated.
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Affiliation(s)
- Katrine A Myhr
- Department of Cardiology, Rigshospitalet, Inge Lehmanns Vej 7, 2100, Copenhagen, Denmark.
| | - Amanda H Zinglersen
- Copenhagen Research Center for Autoimmune Connective Tissue Diseases, Center for Rheumatology and Spine Diseases, Rigshospitalet, Juliane Maries Vej 10, 2100, Copenhagen, Denmark.
| | - Marie-Louise F Hermansen
- Copenhagen Research Center for Autoimmune Connective Tissue Diseases, Center for Rheumatology and Spine Diseases, Rigshospitalet, Juliane Maries Vej 10, 2100, Copenhagen, Denmark.
| | - Mathies M Jepsen
- Department of Cardiology, Rigshospitalet, Inge Lehmanns Vej 7, 2100, Copenhagen, Denmark.
| | - Katrine K Iversen
- Copenhagen Research Center for Autoimmune Connective Tissue Diseases, Center for Rheumatology and Spine Diseases, Rigshospitalet, Juliane Maries Vej 10, 2100, Copenhagen, Denmark.
| | - Anh T Ngo
- Department of Cardiology, Rigshospitalet, Inge Lehmanns Vej 7, 2100, Copenhagen, Denmark.
| | - Redi Pecini
- Department of Cardiology, Rigshospitalet, Inge Lehmanns Vej 7, 2100, Copenhagen, Denmark.
| | - Søren Jacobsen
- Copenhagen Research Center for Autoimmune Connective Tissue Diseases, Center for Rheumatology and Spine Diseases, Rigshospitalet, Juliane Maries Vej 10, 2100, Copenhagen, Denmark.
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Chen Y, Fu L, Pu S, Xue Y. Systemic lupus erythematosus increases risk of incident atrial fibrillation: A systematic review and meta-analysis. Int J Rheum Dis 2022; 25:1097-1106. [PMID: 35906745 DOI: 10.1111/1756-185x.14403] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 07/08/2022] [Accepted: 07/13/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVES Patients with systemic lupus erythematosus (SLE) might have increased risk of atrial fibrillation (AF) as a result of initiating chronic and systematic inflammation. However, the prevalence of AF in patients with SLE have not been well quantified. The aim of this systematic review and meta-analysis was to collect and identify available clinical data to explore this possible correlation. METHODS Articles were searched based on electronic databases (PubMed, Scopus, ScienceDirect, Cochrane Library, Web of Science). Review Manager 5.4 was used to perform meta-analysis of all selected studies and subgroup analyses (pooled separately by geographical distribution). Pooled risk ratio (RR) and 95% confidence intervals (95% CI) were calculated by random-effect model or fix-effect model. RESULTS Six cohort studies were involved in this meta-analysis, including 311 844 participants, 78 134 cases of SLE and 347 883 non-SLE controls. Pooled studies indicated increased risk of AF development in patients with SLE compared to participants without SLE (I2 = 96%, RR = 1.85; 95% CI: 1.23-2.79; P = .003). Four clinical trials including only European/ American populations were analyzed in subgroups. Heterogeneity analysis showed that I2 = 9% and there was an increase in the risk of AF development in European/ American patients with SLE (RR = 1.79; 95% CI: 1.61-1.98; P < .001), while in 2 Korean studies, the heterogeneity was 98% and there was no correlation between AF and SLE (RR = 1.81, 95% CI: 0.39-8.43). Five clinical studies were involved in subgroup analysis after excluding the Beak study, with I2 = 96% and they suggested that SLE increased the risk of AF development (RR = 2.13, 95% CI: 1.42-3.21, P = .002). CONCLUSION This meta-analysis suggested that SLE may be a risk factor for AF development and the results may vary with geographic distribution.
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Affiliation(s)
- Yanlin Chen
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Lu Fu
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Sijia Pu
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Yumei Xue
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
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21
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Liu Y, Yu X, Zhang W, Zhang X, Wang M, Ji F. Mechanistic insight into premature atherosclerosis and cardiovascular complications in systemic lupus erythematosus. J Autoimmun 2022; 132:102863. [PMID: 35853760 DOI: 10.1016/j.jaut.2022.102863] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 07/02/2022] [Indexed: 12/12/2022]
Abstract
Systemic lupus erythematosus (SLE) is associated with a significant risk of cardiovascular disease (CVD), which substantially increases disease mortality and morbidity. The overall mechanisms associated with the development of premature atherosclerosis and CVD in SLE remain unclear, but has been considered as a result of an intricate interplay between the profound immune dysregulation and traditional CVD risk factors. Aberrant systemic inflammation in SLE may lead to an abnormal lipid profile and dysfunction, which can further fuel the pro-atherosclerotic environment. The existence of a strong imbalance between endothelial damage and vascular repair/angiogenesis promotes vascular injury, which is the early step in the progression of atherosclerotic CVD. Profound innate and adaptive immune dysregulation, characterized by excessive type I interferon burden, aberrant macrophage, platelet and complements activation, neutrophil dysregulation and neutrophil extracellular traps formation, uncontrolled T cell activation, and excessive autoantibody production and immune complex formation, have been proposed to promote accelerated CVD in SLE. While designing targeted therapies to correct the dysregulated immune activation may be beneficial in the treatment of SLE-related CVD, much additional work is needed to determine how to translate these findings into clinical practice. Additionally, a number of biomarkers display diagnostic potentials in improving CVD risk stratification in SLE, further prospective studies will help understand which biomarker(s) will be the most impactful one(s) in assessing SLE-linked CVD. Continued efforts to identify novel mechanisms and to establish criteria for assessing CVD risk as well as predicting CVD progression are in great need to improve CVD outcomes in SLE.
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Affiliation(s)
- Yudong Liu
- Department of Rheumatology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, 100730, PR China; The Key Laboratory of Geriatrics, Beijing Institute of Geriatrics, Beijing Hospital, National Center of Gerontology, National Health Commission, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, 100730, PR China
| | - Xue Yu
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, 100730, PR China
| | - Wenduo Zhang
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, 100730, PR China
| | - Xuan Zhang
- Department of Rheumatology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, 100730, PR China
| | - Min Wang
- Department of Rheumatology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, 100730, PR China
| | - Fusui Ji
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, 100730, PR China.
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22
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Gao N, Kong M, Li X, Wei D, Zhu X, Hong Z, Ni M, Wang Y, Dong A. Systemic Lupus Erythematosus and Cardiovascular Disease: A Mendelian Randomization Study. Front Immunol 2022; 13:908831. [PMID: 35734181 PMCID: PMC9207262 DOI: 10.3389/fimmu.2022.908831] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 05/13/2022] [Indexed: 12/27/2022] Open
Abstract
Background Previous studies have shown that patients with systemic lupus erythematosus (SLE) tend to have a higher risk of cardiovascular disease (CVD), but the potential causal relationship between genetic susceptibility to SLE and CVD risk is not clear. This study systematically investigated the potential association between genetically determined SLE and the risk of CVD. Methods The genetic tools were obtained from genome-wide association studies of SLE and CVD, with no overlap between their participating populations. Mendelian randomization (MR) analysis was performed using inverse variance weighting as the primary method. Simultaneously, a series of repeated analyses, sensitivity analyses, and instrumental variable strength evaluations were performed to verify the reliability of our results. Results MR analysis showed that genetic susceptibility to SLE was associated with a higher risk of heart failure (OR=1.025, 95% CI [1.009-1.041], P=0.002), ischemic stroke (OR=1.020, 95% CI [1.005-1.034], P=0.009), and venous thromboembolism (OR=1.001, 95% CI [1.000-1.002], P=0.014). However, genetic susceptibility to SLE was negatively correlated with the risk of type 2 diabetes (OR=0.968, 95% CI [0.947-0.990], P=0.004). Sensitivity analysis found no evidence of horizontal pleiotropy or heterogeneity. Conclusion Our MR study explored the causal role of SLE in the etiology of CVD, which would help improve our understanding of the basic disease mechanisms of SLE and provide comprehensive CVD assessment and treatment for SLE patients.
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23
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Mrak D, Bonelli M, Radner H. Neuropsychiatric Systemic Lupus Erythematosus: a remaining challenge. Curr Pharm Des 2022; 28:881-891. [PMID: 35549864 DOI: 10.2174/1381612828666220512102824] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 04/13/2022] [Indexed: 11/22/2022]
Abstract
Systemic Lupus Erythematosus (SLE) is an autoimmune disease, which affects a wide range of organs with variable clinical features. Involvement of the nervous system is a challenging and multifaceted manifestation of the disease, presenting with a broad range of symptoms. Neuropsychiatric lupus (NPSLE) encompasses seven syndromes of the peripheral and 12 of the central nervous system, associated with a high disease burden. Despite advances in the management of SLE, NP manifestations still pose a challenge to clinicians. First, diagnosis and attribution to SLE is difficult due to the lack of specific biomarkers or imaging modalities. Second, therapeutic options are limited, and evidence is mainly based on case reports and expert consensus, as clinical trials are sparse. Moreover, no validated outcome measure on disease activity exists. Current recommendations for treatment include supportive as well as immunosuppressive medication, depending on the type and severity of manifestations. As NPSLE manifestations are increasingly recognized, a broader spectrum of therapeutic options can be expected.
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Affiliation(s)
- Daniel Mrak
- Medical University of Vienna, Vienna, Austria
| | - Michael Bonelli
- Division of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Helga Radner
- Division of Rheumatology, Medical University of Vienna, Vienna, Austria
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24
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Moran CA, Collins LF, Beydoun N, Mehta PK, Fatade Y, Isiadinso I, Lewis TT, Weber B, Goldstein J, Ofotokun I, Quyyumi A, Choi MY, Titanji K, Lahiri CD. Cardiovascular Implications of Immune Disorders in Women. Circ Res 2022; 130:593-610. [PMID: 35175848 PMCID: PMC8869407 DOI: 10.1161/circresaha.121.319877] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Immune responses differ between men and women, with women at higher risk of developing chronic autoimmune diseases and having more robust immune responses to many viruses, including HIV and hepatitis C virus. Although immune dysregulation plays a prominent role in chronic systemic inflammation, a key driver in the development of atherosclerotic cardiovascular disease (ASCVD), standard ASCVD risk prediction scores underestimate risk in populations with immune disorders, particularly women. This review focuses on the ASCVD implications of immune dysregulation due to disorders with varying global prevalence by sex: autoimmune disorders (female predominant), HIV (male-female equivalent), and hepatitis C virus (male predominant). Factors contributing to ASCVD in women with immune disorders, including traditional risk factors, dysregulated innate and adaptive immunity, sex hormones, and treatment modalities, are discussed. Finally, the need to develop new ASCVD risk stratification tools that incorporate variables specific to populations with chronic immune disorders, particularly in women, is emphasized.
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Affiliation(s)
- Caitlin A. Moran
- Emory University School of Medicine, Department of Medicine, Division of Infectious Diseases, Atlanta, GA, USA
| | - Lauren F. Collins
- Emory University School of Medicine, Department of Medicine, Division of Infectious Diseases, Atlanta, GA, USA
| | - Nour Beydoun
- Emory University School of Medicine, Department of Medicine, Center for Heart Disease Prevention, Division of Cardiology and Emory Women’s Heart Center, Atlanta, GA, USA
| | - Puja K. Mehta
- Emory University School of Medicine, Department of Medicine, Center for Heart Disease Prevention, Division of Cardiology and Emory Women’s Heart Center, Atlanta, GA, USA
| | - Yetunde Fatade
- Emory University School of Medicine, Department of Medicine, Atlanta, GA, USA
| | - Ijeoma Isiadinso
- Emory University School of Medicine, Department of Medicine, Center for Heart Disease Prevention, Division of Cardiology and Emory Women’s Heart Center, Atlanta, GA, USA
| | - Tené T Lewis
- Emory University, Rollins School of Public Health, Department of Epidemiology, Atlanta, GA, USA
| | - Brittany Weber
- Harvard Medical School, Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Jill Goldstein
- Massachusetts General Hospital, Department of Psychiatry, and Harvard Medical School, Departments of Psychiatry and Medicine, Boston, MA, USA
| | - Igho Ofotokun
- Emory University School of Medicine, Department of Medicine, Division of Infectious Diseases, Atlanta, GA, USA
| | - Arshed Quyyumi
- Emory University School of Medicine, Department of Medicine, Center for Heart Disease Prevention, Division of Cardiology and Emory Women’s Heart Center, Atlanta, GA, USA
| | - May Y. Choi
- Cumming School of Medicine, University of Calgary, Calgary, AB Canada
| | - Kehmia Titanji
- Emory University, Department of Medicine, Division of Endocrinology, Metabolism, and Lipids, Atlanta, GA, USA
| | - Cecile D. Lahiri
- Emory University School of Medicine, Department of Medicine, Division of Infectious Diseases, Atlanta, GA, USA
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25
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Huang X, Zhang Q, Zhang H, Lu Q. A Contemporary Update on the Diagnosis of Systemic Lupus Erythematosus. Clin Rev Allergy Immunol 2022; 63:311-329. [DOI: 10.1007/s12016-021-08917-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2021] [Indexed: 12/11/2022]
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Sairam S, Sureen A, Gutierrez J, Dang TQ, Mishra K. Cardiovascular Outcomes in Systemic Lupus Erythematosus. Curr Cardiol Rep 2022; 24:75-83. [PMID: 35028818 DOI: 10.1007/s11886-021-01626-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/05/2021] [Indexed: 12/23/2022]
Abstract
PURPOSE OF THE REVIEW To review cardiovascular outcomes (CVE) in systemic lupus erythematosus (SLE) that evolves over time. RECENT FINDINGS Inception cohorts now report long-term data, and large population registries add to our knowledge. Mortality and cardiovascular morbidity remain high with a risk ratio of 2-3. SLE disease activity-related inflammation accounts for higher CVE incidence ratio in the first year following diagnosis with accelerated atherosclerosis contributing to CVE in about a quarter to a third of the patients later in the disease course. Immunomodulation and disease control are associated with improved cardiovascular outcomes. Validation of modified risk stratification tools and studies evaluating primary prevention with aspirin and hydroxychloroquine are reported. Increased awareness of high mortality associated with cardiac inflammation, improved outcomes with early disease control, aggressive management of risk factors, hypertension, obesity, and high cholesterol with modifying risk stratification will result in more favorable outcomes in SLE patients.
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Affiliation(s)
- Shrilekha Sairam
- Division of Rheumatology, Department of Internal Medicine, Paul L. Foster School of Medicine, Texas Tech Health Sciences Center El Paso, El Paso, TX, USA.
| | - Amit Sureen
- Department of Internal Medicine, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, 4800 Alberta Ave, El Paso, TX, 79905, USA
| | - Jesus Gutierrez
- Department of Internal Medicine, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, 4800 Alberta Ave, El Paso, TX, 79905, USA
| | - The Q Dang
- Department of Internal Medicine, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, 4800 Alberta Ave, El Paso, TX, 79905, USA
| | - Kunal Mishra
- Department of Internal Medicine, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, 4800 Alberta Ave, El Paso, TX, 79905, USA
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27
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Kitano T, Hirano T, Okazaki S, Itotagawa E, Yagita Y, Morita Y, Watanabe A, Takahashi D, Sakaguchi M, Fujiwara H, Todo K, Sasaki T, Kumanogoh A, Mochizuki H. Heterogeneity of Stroke in Patients with Systemic Lupus Erythematosus. Intern Med 2022; 61:3045-3052. [PMID: 36244734 PMCID: PMC9646340 DOI: 10.2169/internalmedicine.9228-21] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Objective The underlying pathophysiology varies according to stroke subtype. However, stroke heterogeneity among patients with systemic lupus erythematosus (SLE) remains unstudied. We hypothesized that the contribution of SLE to stroke might vary according to its subtype and investigated the associations of SLE and various stroke subtypes. Methods Diagnostic codes and electronic medical records were used to identify 70 patients with SLE who developed acute cerebral infarction or intracerebral hemorrhaging at four tertiary referral hospitals between 2008 and 2018. Intracerebral hemorrhaging was classified as lobar or deep, while cerebral infarction was classified according to the SSS-TOAST criteria. Physician notes were used to identify SLE activity, and their prevalences were compared among stroke subtypes. Outcomes were collected from the patients' medical records. Results The most common stroke subtype in patients with SLE was that of undetermined causes (31%), followed by small artery occlusion (16%), cardioaortic embolism (13%), other causes (11%), lobar hemorrhaging (10%), deep hemorrhaging (10%), and large artery atherosclerosis (9%). Stroke onset occurred during a period of high SLE activity in 21 patients (30%). The proportion of patients with high SLE activity varied according to stroke subtype (p=0.039) and was highest for cerebral infarction with undetermined causes. Stroke recurrence or death was observed in 40% of patients within 5 years after the initial stroke onset. Conclusion The contributions of SLE to stroke varied significantly according to the stroke subtype. Given the unfavorable prognosis, close stroke subtype-specific observation by rheumatologists and stroke specialists is recommended after stroke events.
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Affiliation(s)
- Takaya Kitano
- Department of Neurology, Osaka University Graduate School of Medicine, Japan
| | - Toru Hirano
- Department of Respiratory Medicine and Clinical Immunology, Osaka University Graduate School of Medicine, Japan
| | - Shuhei Okazaki
- Department of Neurology, Osaka University Graduate School of Medicine, Japan
| | - Eri Itotagawa
- Department of Respiratory Medicine and Clinical Immunology, Osaka University Graduate School of Medicine, Japan
| | - Yoshiki Yagita
- Department of Stroke Medicine, Kawasaki Medical School, Japan
| | | | | | | | | | - Hiroshi Fujiwara
- Division of Rheumatology and Allergy, Osaka General Medical Center, Japan
| | - Kenichi Todo
- Department of Neurology, Osaka University Graduate School of Medicine, Japan
| | - Tsutomu Sasaki
- Department of Neurology, Osaka University Graduate School of Medicine, Japan
| | - Atsushi Kumanogoh
- Department of Respiratory Medicine and Clinical Immunology, Osaka University Graduate School of Medicine, Japan
| | - Hideki Mochizuki
- Department of Neurology, Osaka University Graduate School of Medicine, Japan
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Comprehensive Analysis to Identify Key Genes Involved in Advanced Atherosclerosis. DISEASE MARKERS 2021; 2021:4026604. [PMID: 34925641 PMCID: PMC8683248 DOI: 10.1155/2021/4026604] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Accepted: 11/13/2021] [Indexed: 02/06/2023]
Abstract
Background The study was aimed at finding accurate and effective therapeutic targets and deepening our understanding of the mechanisms of advanced atherosclerosis (AA). Methods We downloaded the gene expression datasets GSE28829, GSE120521, and GSE43292 from Gene Expression Omnibus. Weighted gene coexpression network analysis (WGCNA) was performed for GSE28829, and functional enrichment analysis and protein–protein interaction network analysis were conducted on the key module. Significant genes in the key module were analyzed by molecular complex detection, and genes in the most important subnetwork were defined as hub genes. Multiple dataset analyses for hub genes were conducted. Genes that overlapped between hub genes and differentially expressed genes (DEGs) of GSE28829 and GSE120521 were defined as key genes. Further validation for key genes was performed using GSE28829 and GSE43292. Gene set enrichment analysis (GSEA) was applied to key genes. Results A total of 77 significant genes in the key module of GSE28829 were screened out that were mainly associated with inflammation and immunity. The subnetwork was obtained from significant genes, and 18 genes in this module were defined as hub genes, which were related to immunity and expressed in multiple diseases, particularly systemic lupus erythematosus. Some hub genes were regulated by SPI1 and associated with the blood, spleen, and lung. After overlapping with DEGs of GSE28829 and GSE120521, a total of 10 genes (HCK, ITGAM, CTSS, TYROBP, LAPTM5, FCER1G, ITGB2, NCF2, AIF1, and CD86) were identified as key genes. All key genes were validated and evaluated successfully and were related to immune response pathways. Conclusion Our study suggests that the key genes related to immune and inflammatory responses are involved in the development of AA. This may deepen our understanding of the mechanisms of and provide valuable therapeutic targets for AA.
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The Complex Role of C-Reactive Protein in Systemic Lupus Erythematosus. J Clin Med 2021; 10:jcm10245837. [PMID: 34945133 PMCID: PMC8708507 DOI: 10.3390/jcm10245837] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 11/29/2021] [Accepted: 12/09/2021] [Indexed: 12/12/2022] Open
Abstract
C-reactive protein (CRP) is well-known as a sensitive albeit unspecific biomarker of inflammation. In most rheumatic conditions, the level of this evolutionarily highly conserved pattern recognition molecule conveys reliable information regarding the degree of ongoing inflammation, driven mainly by interleukin-6. However, the underlying causes of increased CRP levels are numerous, including both infections and malignancies. In addition, low to moderate increases in CRP predict subsequent cardiovascular events, often occurring years later, in patients with angina and in healthy individuals. However, autoimmune diseases characterized by the Type I interferon gene signature (e.g., systemic lupus erythematosus, primary Sjögren’s syndrome and inflammatory myopathies) represent exceptions to the general rule that the concentrations of CRP correlate with the extent and severity of inflammation. In fact, adequate levels of CRP can be beneficial in autoimmune conditions, in that they contribute to efficient clearance of cell remnants and immune complexes through complement activation/modulation, opsonization and phagocytosis. Furthermore, emerging data indicate that CRP constitutes an autoantigen in systemic lupus erythematosus. At the same time, the increased risks of cardiovascular and cerebrovascular diseases in patients diagnosed with systemic lupus erythematosus and rheumatoid arthritis are well-established, with significant impacts on quality of life, accrual of organ damage, and premature mortality. This review describes CRP-mediated biological effects and the regulation of CRP release in relation to aspects of cardiovascular disease and mechanisms of autoimmunity, with particular focus on systemic lupus erythematosus.
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Qayyum W, Khan S, Iqbal MS, Khan MF, Yousafzai ZA, Afaq S. Massive haemorrhage: an unusual presentation of systemic lupus erythematosus. JRSM Open 2021; 12:20542704211062041. [PMID: 34868607 PMCID: PMC8638069 DOI: 10.1177/20542704211062041] [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] [Indexed: 11/30/2022] Open
Abstract
Systemic lupus erythematosus (SLE) usually affects young females and its presentation
with haemorrhage is unusual. Intracerebral bleed (ICB) has been described in a few case
reports, but massive haematuria has not been reported in the literature so far. Here, we
present a case of a 56 year-old-lady who presented with expanding lobar bleed and massive
haematuria as the first presentation of SLE secondary to vasculitis. Lupus vasculitis
usually presents with thrombosis-related complications and although bleeding in this
context is rare, it can lead to catastrophic consequences. Hence, vasculitis-related
bleeding should be taken under consideration in a challenging situation like ours.
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Affiliation(s)
- Wajeeha Qayyum
- Rehman Medical Institute, Peshawar, Khyber Pakhtunkhwa, Pakistan
| | - Sohail Khan
- Rehman Medical Institute, Peshawar, Khyber Pakhtunkhwa, Pakistan
| | | | | | | | - Saima Afaq
- Imperial College London, London, United Kingdom of Great Britain and Northern Ireland
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31
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Park DJ, Yoon CS, Choi SE, Xu H, Kang JH, Lee SS. Risk factors for thrombotic events in Korean patients with systemic lupus erythematosus. Sci Rep 2021; 11:23529. [PMID: 34876633 PMCID: PMC8651713 DOI: 10.1038/s41598-021-03074-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 11/29/2021] [Indexed: 11/28/2022] Open
Abstract
Thrombotic events (TE), including deep vein thrombosis, stroke, and myocardial infarction, occur in 30-40% of patients with systemic lupus erythematosus (SLE) resulting in substantial morbidity and mortality. We explored the risk factors for TE in SLE patients. We analyzed data obtained during a prospective cohort based on the KORean lupus NETwork (KORNET) registry, and enrolled 259 SLE patients with clinical data available at the onset of SLE. TE was defined as the presence of arterial or venous thrombosis. Multivariate Cox-proportional hazards analysis was performed to investigate risk factors for TE. During a mean follow-up of 103.3 months (SD 53.4), 27 patients (10.4%) had a TE. In multivariate analysis, hypertension (hazard ratio [HR] 7.805, 95% confidence interval [CI]: 1.929-31.581; P = 0.004), anti-phospholipid syndrome (APS) (HR 12.600, 95% CI: 4.305-36.292; P < 0.001), mean daily prednisolone > 5 mg/day (HR 3.666, 95% CI: 1.318-10.197; P = 0.013), and SLICC/ACR Damage Index (SDI) score (HR 1.992, 95% CI: 1.465-2.709; P < 0.001) were significantly associated with the development of TE in SLE patients. Instead, use of an ACEi or ARB (HR 0.159, 95% CI: 0.043-0.594; P = 0.006) was a protective factor against TE development in these patients. In conclusion, hypertension, higher mean daily dose of prednisolone, diagnosis of APS, and higher SDI were risk factors for TE in patients with SLE. On the other hand, the use of an ACEi or ARB was associated with a reduced risk of TE.
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Affiliation(s)
- Dong-Jin Park
- grid.411597.f0000 0004 0647 2471Division of Rheumatology, Department of Internal Medicine, Chonnam National University Medical School & Hospital, 42 Jebong-ro, Dong-gu, Gwangju, 61469 Republic of Korea
| | - Chang-Seok Yoon
- grid.411597.f0000 0004 0647 2471Division of Rheumatology, Department of Internal Medicine, Chonnam National University Medical School & Hospital, 42 Jebong-ro, Dong-gu, Gwangju, 61469 Republic of Korea
| | - Sung-Eun Choi
- grid.411597.f0000 0004 0647 2471Division of Rheumatology, Department of Internal Medicine, Chonnam National University Medical School & Hospital, 42 Jebong-ro, Dong-gu, Gwangju, 61469 Republic of Korea
| | - Haimuzi Xu
- grid.411597.f0000 0004 0647 2471Division of Rheumatology, Department of Internal Medicine, Chonnam National University Medical School & Hospital, 42 Jebong-ro, Dong-gu, Gwangju, 61469 Republic of Korea
| | - Ji-Hyoun Kang
- grid.411597.f0000 0004 0647 2471Division of Rheumatology, Department of Internal Medicine, Chonnam National University Medical School & Hospital, 42 Jebong-ro, Dong-gu, Gwangju, 61469 Republic of Korea
| | - Shin-Seok Lee
- Division of Rheumatology, Department of Internal Medicine, Chonnam National University Medical School & Hospital, 42 Jebong-ro, Dong-gu, Gwangju, 61469, Republic of Korea.
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Engel S, Boedecker S, Marczynski P, Bittner S, Steffen F, Weinmann A, Schwarting A, Zipp F, Weinmann-Menke J, Luessi F. Association of serum neurofilament light chain levels and neuropsychiatric manifestations in systemic lupus erythematosus. Ther Adv Neurol Disord 2021; 14:17562864211051497. [PMID: 34707690 PMCID: PMC8543555 DOI: 10.1177/17562864211051497] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Accepted: 09/17/2021] [Indexed: 02/03/2023] Open
Abstract
Background: The aim was to evaluate the diagnostic potential of serum neurofilament light chain (sNfL) measurements in patients with neuropsychiatric systemic lupus erythematosus (NPSLE). Methods: sNfL levels were determined by single molecule array assay in a retrospective cross-sectional cohort of 144 patients with systemic lupus erythematosus (SLE). After log-transformation of sNfL levels, mean sNfL levels were compared between NPSLE patients and SLE patients without neuropsychiatric disease using Student’s t test. Furthermore, the association of different neuropsychiatric manifestations with sNfL levels was assessed using a one-way analysis of variance (ANOVA) with post hoc analysis. Associations of sNfL with clinical and laboratory parameters were assessed by correlation and multiple linear regression analysis. Results: NPSLE patients (n = 69) had significantly higher sNfL levels than SLE patients without neuropsychiatric disease manifestations (n = 75; mean difference: 0.13, 95% CI: 0.04–0.22, p = 0.006). With regard to the category of NPSLE manifestation, mean sNfL levels were only increased in NPSLE patients with focal central nervous system (CNS) involvement (n = 45; mean difference: 0.16, 95% CI: 0.02–0.30, p = 0.019), whereas mean sNfL levels of NPSLE patients with diffuse CNS and peripheral nervous system involvement did not differ from those of SLE patients without neuropsychiatric manifestations. Age and serum creatinine concentrations were identified as relevant contributors to sNfL levels. Conclusion: sNfL is a promising, easily accessible biomarker for neuropsychiatric involvement in SLE patients and might therefore complement the diagnostic workup of SLE patients with suspected involvement of the nervous system.
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Affiliation(s)
- Sinah Engel
- Department of Neurology, Focus Program Translational Neuroscience (FTN), and Immunotherapy (FZI), Rhine-Main Neuroscience Network (rmn), University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Simone Boedecker
- Division of Nephrology, Rheumatology and Clinical Immunology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Paul Marczynski
- Division of Nephrology, Rheumatology and Clinical Immunology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Stefan Bittner
- Department of Neurology, Focus Program Translational Neuroscience (FTN), and Immunotherapy (FZI), Rhine-Main Neuroscience Network (rmn), University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Falk Steffen
- Department of Neurology, Focus Program Translational Neuroscience (FTN), and Immunotherapy (FZI), Rhine-Main Neuroscience Network (rmn), University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Arndt Weinmann
- Division of Nephrology, Rheumatology and Clinical Immunology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Andreas Schwarting
- Division of Nephrology, Rheumatology and Clinical Immunology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Frauke Zipp
- Department of Neurology, Focus Program Translational Neuroscience (FTN), and Immunotherapy (FZI), Rhine-Main Neuroscience Network (rmn), University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Julia Weinmann-Menke
- Division of Nephrology, Rheumatology and Clinical Immunology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Felix Luessi
- Department of Neurology, Focus Program Translational Neuroscience (FTN), Rhine Main Neuroscience Network (rmn²), University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany
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Galetta K, Bhattacharyya S. Acute Neurologic Manifestations of Systemic Immune-Mediated Diseases. Semin Neurol 2021; 41:541-553. [PMID: 34619780 DOI: 10.1055/s-0041-1733790] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Systemic autoimmune diseases can affect the peripheral and central nervous system. In this review, we outline the common inpatient consultations for patients with neurological symptoms from rheumatoid arthritis, Sjogren's syndrome, systemic lupus erythematosus, sarcoidosis, immunoglobulin G4-related disease, Behçet's disease, giant cell arteritis, granulomatosis with polyangiitis, microscopic polyangiitis, eosinophilic granulomatosis, polyarteritis nodosa, and ankylosing spondylitis. We discuss the symptoms, diagnostic strategies, and treatment options.
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Affiliation(s)
- Kristin Galetta
- Division of Hospital Neurology, Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Shamik Bhattacharyya
- Division of Hospital Neurology, Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts
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Restivo V, Candiloro S, Daidone M, Norrito R, Cataldi M, Minutolo G, Caracci F, Fasano S, Ciccia F, Casuccio A, Tuttolomondo A. Systematic review and meta-analysis of cardiovascular risk in rheumatological disease: Symptomatic and non-symptomatic events in rheumatoid arthritis and systemic lupus erythematosus. Autoimmun Rev 2021; 21:102925. [PMID: 34454117 DOI: 10.1016/j.autrev.2021.102925] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 08/22/2021] [Indexed: 12/14/2022]
Abstract
Although each autoimmune disease is associated with specific tissue or organ damage, rheumatic diseases share a pro-inflammatory pattern that might increase cardiovascular risk. Retrospective and prospective studies on patients affected by systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA) highlighted the concept of "accelerated atherosclerosis". Therefore, the purpose of this systematic review and meta-analysis is the assessment of symptomatic or asymptomatic cardiovascular events among patients with rheumatic diseases as RA and SLE. The literature research obtained all manuscripts published in the English language between 2015 and 2019 for a total of 2355 manuscripts. After selection through inclusion and exclusion criteria, four articles examined cardiovascular risk in RA patients, 8 in SLE patients, and 2 in RA and SLE patients. Patients with SLE had a RR of 1.98 (95% CI: 1.18-3.31) of symptomatic cardiovascular events compared to the unexposed cohort. The meta-regression analysis showed that younger patient (age per year increase β = -0.12 95%CI: -0.20, -0.4), belonging to studies conducted in continent different from America (β = -0.89; -95% CI: 1.67, -0.10), after 2000 (β = 0.87; 95% CI: 0.09, 1.65) and with a higher quality score 0.80 (95% CI: 0.31, 1.29) had a higher risk of cardiovascular events. In patients with RA, the RR of cardiovascular events was 1.55 (95% CI: 1.18-2.02). These data are helpful to implement cardiovascular preventive strategies among people suffering from rheumatologic diseases to decrease the incidence of cardiovascular events. However, these implementation needs to build a higher network between rheumatologists and primary care healthcare workers to furnish the same information to patients and monitor their preventive practice compliance.
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Affiliation(s)
- Vincenzo Restivo
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, 90127 Palermo, Italy.
| | - Stefania Candiloro
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, 90127 Palermo, Italy
| | - Mario Daidone
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, 90127 Palermo, Italy
| | - Rosario Norrito
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, 90127 Palermo, Italy
| | - Marco Cataldi
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, 90127 Palermo, Italy
| | - Giuseppa Minutolo
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, 90127 Palermo, Italy
| | - Francesca Caracci
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, 90127 Palermo, Italy
| | - Serena Fasano
- Division of Rheumatology, Department of Precision Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Francesco Ciccia
- Division of Rheumatology, Department of Precision Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Alessandra Casuccio
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, 90127 Palermo, Italy
| | - Antonino Tuttolomondo
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, 90127 Palermo, Italy
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35
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Ministrini S, Carbone F. PCSK9 and inflammation. Maybe a role in autoimmune diseases? Focus on rheumatoid arthritis and systemic lupus erythematosus. Curr Med Chem 2021; 29:970-979. [PMID: 34375179 DOI: 10.2174/0929867328666210810150940] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 06/17/2021] [Accepted: 06/28/2021] [Indexed: 11/22/2022]
Abstract
Despite a clear epidemiological link between autoimmune disease and cardiovascular (CV) risk exists, pathophysiological explanations are extremely complex and far from being elucidated. Dysregulation of metabolic pathways and chronic low-grade inflammation represent common pathways, but CV risk still remains underestimated in patients with autoimmune diseas. Among different candidate mediators, pro-protein convertase subtilisin/kexin type 9 (PCSK9) is attracting a growing attention, due to a combined effect on lipid metabolism and inflammatory response. Study on PCSK9 inhibitors have established a clear benefit on CV outcome without an established effect on inflammation. Conversely, evidence from sepsis and HIV infection strongly support a pro-inflammatory role of PCSK9. Still uncertain is instead the role of PCSK9 in autoimmune disease. So far reported clinical findings are controversial and likely reflect the poor knowledge of PCSK9 activity on monocyte/macrophage migration and activation. The complex signaling network around PCSK9 synthesis and metabolism may also have a role, especially concerning the involvement of scavenger receptors such as CD36. Such complexity in PCSK9 signaling seems particularly evident in autoimmune disease model. This would also potentially explain the observed independency between lipid profile and PCSK9 levels, the so-called "lipid paradox". In this narrative review we will summarize the current knowledge about the complex network of PCSK9 signaling. We will focus of upstream and downstream pathways with potential implication in autoimmune disease and potential effects of PCSK9 inhibiting strategies.
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Affiliation(s)
- Stefano Ministrini
- Internal Medicine, Angiology and Atherosclerosis; Department of Medicine and Surgery, University of Perugia, p.le Gambuli 1, 06132 Perugia, Italy
| | - Federico Carbone
- First Clinic of internal Medicine, Department of Internal Medicine, University of Genoa, 6 viale Benedetto XV, 16132 Genoa, Italy
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36
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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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37
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Pego-Reigosa JM, Restrepo Vélez J, Baldini C, Rúa-Figueroa Fernández de Larrinoa Í. Comorbidities (excluding lymphoma) in Sjögren's syndrome. Rheumatology (Oxford) 2021; 60:2075-2084. [PMID: 30770715 DOI: 10.1093/rheumatology/key329] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 09/04/2018] [Indexed: 12/21/2022] Open
Abstract
The information about comorbidities (excluding lymphoma) in primary Sjögren's syndrome (pSS) is relatively scarce. Cardiovascular disease, infections, musculoskeletal conditions or malignancy are likely the most relevant comorbid conditions in pSS. Different infections (particularly oral candidal infections) and fibromyalgia are extremely frequent in the daily clinical practice. On the other hand, the incidence of cardiovascular events and cancer in pSS is low, so information about them comes from large epidemiological studies or meta-analysis. For this reason, preclinical vascular disease is investigated by different techniques, demonstrating the presence of early atherosclerosis in pSS patients. Coronary events could be slightly more frequent in pSS than in the general population. The overall risk of malignancy in pSS patients seems to be slightly increased, likely due to excess occurrence of lymphoma. An association between pSS and thyroid cancer might exist, although it should be confirmed by further investigations.
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Svenungsson E, Gunnarsson I, Illescas-Bäckelin V, Trysberg E, Jönsen A, Leonard D, Sjöwall C, Pettersson S. Quick Systemic Lupus Activity Questionnaire (Q-SLAQ): a simplified version of SLAQ for patient-reported disease activity. Lupus Sci Med 2021; 8:8/1/e000471. [PMID: 33972457 PMCID: PMC8112425 DOI: 10.1136/lupus-2020-000471] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 04/02/2021] [Accepted: 04/12/2021] [Indexed: 11/11/2022]
Abstract
Objectives Most indices of disease activity in SLE combine physicians’ assessments and laboratory tests. However, there is also a need to capture patients’ perspectives of disease activity. Consequently, we need new, preferably quick and easy instruments to collect this information, which can be very useful for online consultations and registry purposes. We compared patients’ assessments of SLE disease impact/activity, as reported by a shorter version of the Quick Systemic Lupus Activity Questionnaire (Q-SLAQ), with physicians’ assessments using SLE Activity Measure (SLAM) and SLE Disease Activity Index (SLEDAI-2K) and with the original Systemic Lupus Activity Questionnaire (SLAQ). Methods Patients with SLE (n=115), with a disease duration of 15 years (IQR 17), completed the Q-SLAQ prior to physicians’ assessments by SLAM and SLEDAI-2K. A second set of patients (n=85) with similar characteristics filled out Q-SLAQ and SLAQ. Spearman’s ρ correlations were explored between patients’ total Q-SLAQ and subscales (Symptom Score, Patient’s Global Disease Activity) and physicians’ SLAM and SLEDAI-2K, with and without laboratory items (SLAM-nolab and SLEDAI-2K-nolab) and SLAQ. Corresponding items in Q-SLAQ and SLAM were compared. Results Correlations between patients’ and physicians’ assessments were higher for SLAM-nolab (total Q-SLAQ, ρ=0.71; Symptom Score, ρ=0.67; and Patient’s Global Disease Activity, ρ=0.68) than for the original SLAM (total Q-SLAQ, ρ=0.53; Symptom Score, ρ=0.50; and Patient’s Global Disease Activity, ρ=0.53). Regarding specific symptoms, fatigue (ρ=0.72) and alopecia (ρ=0.71) correlated best, while pulmonary/respiratory symptoms correlated least (ρ=0.19, p=0.039). Physicians assessment with SLEDAI-2K-nolab correlated weakly with patients’ assessments (total Q-SLAQ, ρ=0.30; Symptom Score, ρ=0.30; and Patient’s Global Disease Activity, ρ=0.36). Bivariate correlations between Q-SLAQ and SLAQ were good (ρ=0.82–0.96). Conclusions Q-SLAQ and the original SLAQ performed equally well, demonstrating that the shorter Q-SLAQ can safely be used to monitor patients’ perception of disease impact/activity. We also noted an intriguing discrepancy between physicians’ and patients’ evaluations of pulmonary/respiratory symptoms, which requires further investigations.
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Affiliation(s)
- Elisabet Svenungsson
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden .,Rheumatology, Karolinska University Hospital, Stockholm, Sweden
| | - Iva Gunnarsson
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.,Rheumatology, Karolinska University Hospital, Stockholm, Sweden
| | - Vera Illescas-Bäckelin
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Estelle Trysberg
- Department of Rheumatology and Inflammation Research, University of Gothenburg, Goteborg, Sweden
| | - Andreas Jönsen
- Department of Clinical Sciences Lund, Rheumatology, Lund University, Lund, Sweden
| | - Dag Leonard
- Department of Medical Sciences, Science for Life Laboratory, Rheumatology, Uppsala University, Uppsala, Sweden
| | - Christopher Sjöwall
- Department of Biomedical and Clinical Sciences, Division of Inflammation and Infection/Rheumatology, Linköping University, Linköping, Sweden
| | - Susanne Pettersson
- Rheumatology, Karolinska University Hospital, Stockholm, Sweden.,Department of Neurobiology, Care Sciences and Society, Division of Physiotherapy, Karolinska Institutet, Stockholm, Sweden
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Nived O, Ingvarsson RF, Jöud A, Linge P, Tydén H, Jönsen A, Bengtsson AA. Disease duration, age at diagnosis and organ damage are important factors for cardiovascular disease in SLE. Lupus Sci Med 2021; 7:7/1/e000398. [PMID: 32587062 PMCID: PMC7319716 DOI: 10.1136/lupus-2020-000398] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Revised: 05/07/2020] [Accepted: 05/24/2020] [Indexed: 12/19/2022]
Abstract
Objective To report the incidence rate ratios (IRR) of acute myocardial infarctions (AMI) and cerebrovascular events (CVE) in incident SLE cases from a defined population. To study the risk factors for cardiovascular events in all patients with SLE at our unit. Methods Patients with SLE diagnosed from 1981 to 2006 were followed through to 2016. IRRs of AMI and CVE were calculated. The AMI and CVE incidence patterns for patients with SLE were studied in relation to hypertension, smoking, renal dysfunction, anticardiolipin (aCL) antibodies at diagnosis, disease duration and organ damage before an event. Results 262 patients with SLE were included in the study; of these 175 were from the defined population. Overall, 37 AMI and 44 CVE were recorded. An increased IRR of 3 for AMI was found (p<0.001). Smoking, hypertension and reduced renal function were risk factors for AMI. An increased IRR of 3.3 for ischaemic CVE was found for women (p<0.001). Hypertension and aCL were risk factors for CVE. Organ damage before events was increased. Conclusions Cardiovascular events are increased in SLE and are associated with hypertension, smoking and increased damage rate.
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Affiliation(s)
- Ola Nived
- Department of Rheumatology, Institution for Clinical Sciences, Lund, Sweden
| | - Ragnar Freyr Ingvarsson
- Department of Rheumatology, Institution for Clinical Sciences, Lund, Sweden.,Landspitali University Hospital, Reykjavik, Iceland
| | - Anna Jöud
- Division of Occupational and Environmental Medicine, Department of Laboratory Medicine, Lund University, Lund, Sweden
| | - Petrus Linge
- Department of Rheumatology, Institution for Clinical Sciences, Lund, Sweden
| | - Helena Tydén
- Department of Rheumatology, Institution for Clinical Sciences, Lund, Sweden
| | - Andreas Jönsen
- Department of Rheumatology, Institution for Clinical Sciences, Lund, Sweden
| | - Anders A Bengtsson
- Department of Rheumatology, Institution for Clinical Sciences, Lund, Sweden
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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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Mishima K, Ayano M, Nishida T, Tatsutani T, Inokuchi S, Kimoto Y, Mitoma H, Akahoshi M, Arinobu Y, Akashi K, Horiuchi T, Niiro H. Use of 18F-Fluorodeoxyglucose-Positron Emission Tomography/Computed Tomography to successfully diagnose central nervous system vasculitis in systemic lupus erythematosus and antiphospholipid syndrome: a case report. Mod Rheumatol Case Rep 2021; 5:278-284. [PMID: 33783324 DOI: 10.1080/24725625.2021.1905220] [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: 10/21/2022]
Abstract
A 53-year-old woman was admitted to our hospital for headache secondary to an acute subdural haematoma in the right cerebellar tentorium. She had been diagnosed with systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APS) two years before presentation and was initiated on prednisolone (PSL) 40 mg/day as induction therapy, which was subsequently tapered to 5 mg/day. Her thrombocytopenia and renal impairment were managed by warfarin with a target prothrombin time-international normalised ratio of 2-3. Her history also included 5 instances of triggerless acute subdural haematoma in the right cerebellar tentorium in the preceding 8 months. Warfarin therapy was suspected as the cause of her bleeding; however, dose adjustment was ineffective. During the current admission, neither magnetic resonance imaging nor cerebral angiography could reveal the cause of the bleeding. However, spinal fluid IL-6 was 25.7 pg/mL, and 18F-Fluorodeoxyglucose-Positron Emission Tomography/Computed Tomography showed fluorodeoxyglucose accumulation in the right medial occipital lobe cortex in the proximity of the haemorrhage site. Based on these two findings, we suspected vasculitis as the cause of recurrent bleeding. After ruling out malignancy, re-induction therapy with intravenous cyclophosphamide 500 mg/m2/month and PSL 30 mg/day was initiated. PSL was tapered to 2 mg/day and no signs of relapse have developed at 2 years after discharge. Her clinical course also supported vasculitis as the cause of recurrent central nervous system (CNS) bleeding and we discuss the usefulness of 18F-Fluorodeoxyglucose-Positron Emission Tomography in the diagnosis and treatment of CNS vasculitis in SLE and/or APS.
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Affiliation(s)
- Koji Mishima
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Masahiro Ayano
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan.,Department of Cancer Stem Cell Research, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Tomoya Nishida
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Tomofumi Tatsutani
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Shoichiro Inokuchi
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Yasutaka Kimoto
- Department of Internal Medicine, Kyushu University Beppu Hospital, Beppu, Japan
| | - Hiroki Mitoma
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Mitsuteru Akahoshi
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Yojiro Arinobu
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Koichi Akashi
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Takahiko Horiuchi
- Department of Internal Medicine, Kyushu University Beppu Hospital, Beppu, Japan
| | - Hiroaki Niiro
- Department of Medical Education, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
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42
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Type I Interferon as cardiovascular risk factor in systemic and cutaneous lupus erythematosus: A systematic review. Autoimmun Rev 2021; 20:102794. [PMID: 33722754 DOI: 10.1016/j.autrev.2021.102794] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 01/14/2021] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Patients with systemic lupus erythematosus (SLE) have a high burden of cardiovascular disease (CVD) of multifactorial origin. The aim of this systematic review is to analyze the role of the interferon I (IFN-I) signature and fibroblast growth factor-23 (FGF-23) in patients with SLE or cutaneous lupus erythematosus (CLE) herein. MATERIALS AND METHODS We conducted a systematic literature search in PubMed and Scopus using keywords for major adverse cardiovascular events (MACE) and intermediate outcomes (endothelial dysfunction, subclinical atherosclerosis, platelet activation) associated with IFN-I or FGF-23 in patients with SLE and CLE. RESULTS 4745 citations were screened, of which 12 studies were included. IFN-I was associated with MACE in two third of the studies and the association was strongest for cardiac events. An association of IFN-I was found in all studies investigating impaired vascular function, but only in 50% (respectively 40%) of reports examining the relation of IFN-I and platelet activation (respectively subclinical atherosclerosis). Altogether the reports were of variable bias and quality due to high variability of examined IFN-I biomarkers and inconsistent results for different outcome measures. No studies investigating the cardiovascular risk of circulating IFN-I in CLE, nor FGF-23 in SLE or CLE were found. CONCLUSION Clinical studies measuring the association between IFN-I and direct / intermediate measures of CVD are rare and ambiguous in SLE and nonexistent in CLE, hampering a definite conclusion.
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Rossides M. Stroke Is Different in Systemic Lupus Erythematosus: Implications for Survival and Functionality. J Rheumatol 2021; 48:476-478. [PMID: 33649062 DOI: 10.3899/jrheum.201209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Marios Rossides
- M. Rossides, MD, MSc, PhD Candidate in Clinical Epidemiology, Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.
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44
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Lu X, Wang Y, Zhang J, Pu D, Hu N, Luo J, An Q, He L. Patients with systemic lupus erythematosus face a high risk of cardiovascular disease: A systematic review and Meta-analysis. Int Immunopharmacol 2021; 94:107466. [PMID: 33636561 DOI: 10.1016/j.intimp.2021.107466] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 01/24/2021] [Accepted: 02/01/2021] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Patients with systemic lupus erythematosus (SLE) have increased mortality related to cardiovascular disease (CVD). This systematic review and meta-analysis identified the risk of CVD in SLE patients, CVD risk factors in SLE patients, and the risk of CVD in lupus nephritis (LN) patients. METHODS On-line databases were used to search the eligible studies from January 2013 to August 2020. The relevant characteristics and the data of disease extracted from included publications. RESULTS A total of 20 studies were included in this meta-analysis. Compared with the general or healthy population, the risk of CVD in SLE patients increased by 2 times (RR = 2.35, 95% CI: 1.95-2.84, P < 0.05). SLE patients had a significantly increased risk of atherosclerosis (RR = 2.31, 95% CI: 1.16-4.60), stroke (RR = 2.30, 95% CI: 1.52-3.50), myocardial infarction (RR = 2.66, 95% CI: 1.97-3.59), peripheral vascular disease (RR = 2.56, 95% CI: 1.07-6.09) and heart failure (RR = 2.89, 95% CI: 1.63-5.13), but no significant increased risk of coronary artery disease (RR = 1.93, 95% CI: 0.67-5.59). SLE patients were more susceptible to lead hypertension than general or healthy population (RR = 2.31, 95% CI: 1.62-3.29). Compared with the SLE patients, the risk of CVD in LN patients was increased by 2 times (RR = 1.75, 95% CI: 1.13-2.70). CONCLUSION The results of this meta-analysis suggest that SLE patients have a higher risk of developing CVD compared with the general or healthy population, and the risk of CVD in LN patients is significantly higher than that in SLE patients.
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Affiliation(s)
- Xiaohong Lu
- Department of Rheumatology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China.
| | - YanHua Wang
- Department of Rheumatology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Jing Zhang
- Department of Rheumatology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Dan Pu
- Department of Rheumatology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Nan Hu
- Department of Rheumatology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Jing Luo
- Department of Rheumatology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Qi An
- Department of Rheumatology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Lan He
- Department of Rheumatology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China.
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45
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Tummala R, Abreu G, Pineda L, Michaels MA, Kalyani RN, Furie RA, Morand EF. Safety profile of anifrolumab in patients with active SLE: an integrated analysis of phase II and III trials. Lupus Sci Med 2021; 8:e000464. [PMID: 33597205 PMCID: PMC7893670 DOI: 10.1136/lupus-2020-000464] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/11/2021] [Accepted: 01/11/2021] [Indexed: 12/18/2022]
Abstract
OBJECTIVE In phase II and III trials, anifrolumab, a human monoclonal antibody that binds type I interferon receptor subunit 1, has shown efficacy in adults with moderate to severe SLE. We evaluated the safety and tolerability of anifrolumab using data pooled from these trials to more precisely estimate the rate and severity of adverse events (AEs). METHODS Data were pooled from patients receiving monthly intravenous anifrolumab 300 mg or placebo in MUSE, TULIP-1 and TULIP-2. Key safety endpoints included percentages and exposure-adjusted incidence rates (EAIRs) of patients who experienced AEs, serious AEs (SAEs), AEs leading to discontinuation and AEs of special interest. RESULTS During treatment, 86.9% of patients receiving anifrolumab 300 mg (n=459) experienced AEs (≥1) versus 79.4% receiving placebo (n=466), and 4.1% versus 5.2% experienced an AE leading to discontinuation of investigational product. SAEs (≥1) were experienced by 11.8% and 16.7% of patients receiving anifrolumab and placebo, respectively (EAIR risk difference (95% CI) -7.2 (-12.5 to -1.9)), including lupus exacerbations classified as SAEs (1.5% and 3%, respectively). Infections occurred in 69.7% and 55.4% of patients receiving anifrolumab and placebo, respectively; difference in reported rates was driven by herpes zoster (HZ) and mild and moderate respiratory (excluding pneumonia) infections. The risk of HZ was increased with anifrolumab versus placebo (6.1% vs 1.3%, respectively; EAIR risk difference (95% CI) 5.4 (2.8 to 8.4)); most HZ events were mild or moderate, cutaneous and resolved without treatment discontinuation. Serious infections occurred in 4.8% and 5.6% of patients receiving anifrolumab and placebo, respectively. CONCLUSIONS In this pooled analysis of 925 patients with moderate to severe SLE, monthly intravenous anifrolumab 300 mg was generally well tolerated over 52 weeks with an acceptable safety profile. Anifrolumab was associated with an increased incidence of HZ and respiratory tract infections and lower reported rate of SLE worsening as SAEs.
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Affiliation(s)
- Raj Tummala
- Biopharmaceuticals R&D, AstraZeneca, Gaithersburg, Maryland, USA
| | - Gabriel Abreu
- BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Lilia Pineda
- Biopharmaceuticals R&D, AstraZeneca, Gaithersburg, Maryland, USA
| | - M Alex Michaels
- Biopharmaceuticals R&D, AstraZeneca, Gaithersburg, Maryland, USA
| | - Rubana N Kalyani
- Biopharmaceuticals R&D, AstraZeneca, Gaithersburg, Maryland, USA
| | - Richard A Furie
- Division of Rheumatology, Zucker School of Medicine at Hofstra/Northwell, Great Neck, New York, USA
| | - Eric F Morand
- Centre for Inflammatory Disease, Monash University, Melbourne, Victoria, Australia
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Increased short-term risk of cardiovascular events in inflammatory rheumatic diseases: results from a population-based cohort. Rheumatol Int 2021; 41:311-318. [PMID: 33388968 DOI: 10.1007/s00296-020-04754-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 11/13/2020] [Indexed: 10/22/2022]
Abstract
Cardiovascular diseases represent the first cause of death globally. Inflammatory rheumatic disease (IRMD) patients, due to their lifelong inflammatory status, are at increased risk of developing premature cardiovascular disease. We aimed to assess the risk for cardiovascular events (CVE) in a population-based study. We followed 10,153 adults from the EpiDoC Cohort, a large Portuguese population-based prospective study (2011-2016). IRMD patients were identified at baseline and followed during 5 years. CVE were defined as a composite of self-reported myocardial infarction or angina pectoris, arrhythmias, valvular disease, stroke or transient ischemic attack and peripheral artery disease. Statistical analysis was performed by utilizing multivariate logistic regression and goodness-of-fit and area under ROC curve. At baseline, IRMD patients had similar age as the non-IRMD participants (mean age 55 vs 53 years-old; 72.1% female); dyslipidaemia and sedentary lifestyle were more common (40.7% vs 31.4%, p = 0.033; 87.3% vs 67%, p = 0.016, respectively). During an average follow-up of 2.6 years, 26 CVE were reported among IRMD patients. IRMD patients had higher odd of CVE (OR 1.64, 95% CI 1.04-2.58; p = 0.03), despite comparable mortality rates (1.7% vs 0.7%, p = 0.806). A stepwise approach attained that gender, age, history of hypertension, body mass index, IRMD and follow-up time are the most important predictive variables of CVE (AUC 0.80). IRMD patients, at community level, have an increased short-term risk of major CVE when compared to non-IRMD, and that highlights the potential benefit of a systematic screening and more aggressive cardiovascular risk assessment and management of these patients.
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47
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Arnaud L, Tektonidou MG. Long-term outcomes in systemic lupus erythematosus: trends over time and major contributors. Rheumatology (Oxford) 2020; 59:v29-v38. [PMID: 33280012 PMCID: PMC7719040 DOI: 10.1093/rheumatology/keaa382] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 06/03/2020] [Indexed: 12/20/2022] Open
Abstract
SLE is a chronic autoimmune rheumatic disorder of high heterogeneity in clinical presentation, treatment response and prognosis. Long-term outcomes in SLE have been dramatically improved over the past decades, however, increased morbidity and mortality, especially among young individuals, still exists. Unmet needs include residual disease activity and frequent flares, glucocorticoid treatment dependency and toxicity, comorbidity burden, reduced health-related quality of life, health disparities and damage. The main determinants of long-term outcomes in SLE are age, sex, race/ethnicity, genetic profile, environmental factors including smoking, disease activity, major organ involvement such as lupus nephritis and CNS involvement, comorbidities including cardiovascular disease and serious infections, coexistence with APS, treatment adherence, socio-economic factors and access to care. In this review we discuss trends in long-term outcomes in SLE over the years and major contributors such as genetic, disease-related, treatment, comorbidity, socio-economic and other factors.
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Affiliation(s)
- Laurent Arnaud
- Department of Rheumatology, Hôpitaux Universitaires de Strasbourg, INSERM UMR-S 1109, Centre National de Référence des Maladies Auto-immunes Systémiques Rares (RESO), Strasbourg, France
| | - Maria G Tektonidou
- Rheumatology Unit, First Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Joint Rheumatology Program, Laiko Hospital, Athens, Greece
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48
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Barbhaiya M, Feldman CH, Chen SK, Guan H, Fischer MA, Everett BM, Costenbader KH. Comparative Risks of Cardiovascular Disease in Patients With Systemic Lupus Erythematosus, Diabetes Mellitus, and in General Medicaid Recipients. Arthritis Care Res (Hoboken) 2020; 72:1431-1439. [PMID: 32475049 DOI: 10.1002/acr.24328] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 05/19/2020] [Indexed: 01/06/2023]
Abstract
OBJECTIVE Cardiovascular disease (CVD) risk is elevated in patients with systemic lupus erythematosus (SLE) and diabetes mellitus (DM), but whether risk of CVD in patients with SLE is as high as in those with DM is unknown. The present study was undertaken to compare CVD risks between patients with SLE and DM and general population US Medicaid recipients. METHODS In a cohort study, we identified age- and sex-matched adults (1:2:4) with SLE or DM and those from the general population using Medicaid Analytic eXtract, 2007-2010. We collected data on baseline sociodemographic factors, comorbidities, and medications. We used Cox regression models to calculate hazard ratios (HRs) of hospitalized nonfatal CVD events (combined myocardial infarction [MI] and stroke) and MI and stroke separately, accounting for competing risk of death and adjusting for covariates. We compared risks in age-stratified models. RESULTS We identified 40,212 SLE patients, 80,424 DM patients, and 160,848 general population patients; 92.5% were female, and the mean ± SD age was 40.3 ± 12.1 years. Nonfatal CVD incidence rate per 1,000 person-years was 8.99 for patients with SLE, 7.07 for those with DM, and 2.36 for the general population. Nonfatal CVD risk was higher in SLE compared to DM (HR 1.27 [95% confidence interval (95% CI) 1.15-1.40]), driven by excess risk at ages 18-39 years (HR 2.22 [95% CI 1.81-2.71]). Patients with SLE had higher risk of CVD compared to the general population (HR 2.67 [95% CI 2.38-2.99]). CONCLUSION SLE patients had a 27% higher risk of nonfatal CVD events compared to age- and sex-matched patients with DM and more than twice the risk of the Medicaid general population. The highest relative risk occurred at ages 18-39 years. These high risks merit aggressive evaluation for modifiable factors and research to identify prevention strategies.
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Affiliation(s)
- Medha Barbhaiya
- Barbara Volcker Center for Women and Rheumatic Diseases, Hospital for Special Surgery and Weill Cornell Medical College, New York, New York, United States
| | - Candace H Feldman
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, United States
| | - Sarah K Chen
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, United States
| | - Hongshu Guan
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, United States
| | | | | | - Karen H Costenbader
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, United States
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49
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Fanouriakis A, Tziolos N, Bertsias G, Boumpas DT. Update οn the diagnosis and management of systemic lupus erythematosus. Ann Rheum Dis 2020; 80:14-25. [PMID: 33051219 DOI: 10.1136/annrheumdis-2020-218272] [Citation(s) in RCA: 290] [Impact Index Per Article: 72.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 09/09/2020] [Accepted: 09/10/2020] [Indexed: 12/15/2022]
Abstract
Clinical heterogeneity, unpredictable course and flares are characteristics of systemic lupus erythematosus (SLE). Although SLE is-by and large-a systemic disease, occasionally it can be organ-dominant, posing diagnostic challenges. To date, diagnosis of SLE remains clinical with a few cases being negative for serologic tests. Diagnostic criteria are not available and classification criteria are often used for diagnosis, yet with significant caveats. Newer sets of criteria (European League Against Rheumatism (EULAR)/American College of Rheumatology (ACR) 2019) enable earlier and more accurate classification of SLE. Several disease endotypes have been recognised over the years. There is increased recognition of milder cases at presentation, but almost half of them progress overtime to more severe disease. Approximately 70% of patients follow a relapsing-remitting course, the remaining divided equally between a prolonged remission and a persistently active disease. Treatment goals include long-term patient survival, prevention of flares and organ damage, and optimisation of health-related quality of life. For organ-threatening or life-threatening SLE, treatment usually includes an initial period of high-intensity immunosuppressive therapy to control disease activity, followed by a longer period of less intensive therapy to consolidate response and prevent relapses. Management of disease-related and treatment-related comorbidities, especially infections and atherosclerosis, is of paramount importance. New disease-modifying conventional and biologic agents-used alone, in combination or sequentially-have improved rates of achieving both short-term and long-term treatment goals, including minimisation of glucocorticoid use.
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Affiliation(s)
| | - Nikolaos Tziolos
- 4th Department of Internal Medicine, "Attikon" University Hospital, Athens, Greece
| | - George Bertsias
- Rheumatology, Clinical Immunology and Allergy, University of Crete School of Medicine, Iraklio, Crete, Greece.,Laboratory of Autoimmunity-Inflammation, Institute of Molecular Biology and Biotechnology, Heraklion, Crete, Greece
| | - Dimitrios T Boumpas
- 4th Department of Internal Medicine, "Attikon" University Hospital, Athens, Greece .,Joint Rheumatology Program, Medical School, National and Kapodistrian University of Athens, Athens, Greece.,Medical School, University of Cyprus, Nicosia, Cyprus.,Laboratory of Autoimmunity and Inflammation, Biomedical Research Foundation of the Academy of Athens, Athens, Cyprus
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50
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Svensson C, Eriksson P, Zachrisson H, Sjöwall C. High-Frequency Ultrasound of Multiple Arterial Areas Reveals Increased Intima Media Thickness, Vessel Wall Appearance, and Atherosclerotic Plaques in Systemic Lupus Erythematosus. Front Med (Lausanne) 2020; 7:581336. [PMID: 33163501 PMCID: PMC7581856 DOI: 10.3389/fmed.2020.581336] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 09/04/2020] [Indexed: 02/06/2023] Open
Abstract
Introduction: Despite improved therapies and management, patients with systemic lupus erythematosus (SLE) still have increased risks of cerebrovascular and cardiovascular disease. High-frequency ultrasound (US) provides an opportunity to distinguish atherosclerosis from inflammation in the vessels. We hypothesized that an extended US protocol may add information regarding vascular affection in SLE. Methods: Sixty patients (52 women, 8 men; mean age 43.2 ± 11.3 years) with SLE characterized by either lupus nephritis (LN; n = 20), antiphospholipid syndrome (APS; n = 20), or skin and joint involvement (n = 20) as well as matched healthy controls (n = 60) were included. Intima-media thickness (IMT), assessment of vessel walls, and plaque occurrence were recorded using high-frequency US (GE Logic E9) in common carotid, internal carotid, brachiocephalic, subclavian, axillary, common femoral, and proximal superficial femoral arteries as well as in the aortic arch. Results: For the entire SLE group, IMT was increased in the internal carotid artery (0.52 ± 0.17 vs. 0.45 ± 0.09 mm, p = 0.004), the common femoral artery (0.57 ± 0.23 vs. 0.49 ± 0.11 mm, p < 0.01), the subclavian artery (0.58 ± 0.19 vs. 0.53 ± 0.13 mm, p = 0.02), and the aortic arch (1.21 ± 0.63 vs. 0.98 ± 0.25 mm, p = 0.002) compared to controls. These differences were primarily observed in the APS and LN groups compared to controls. Vessels with increased IMT ≥0.9 mm had a smooth, medium echogenic appearance in areas free of atherosclerotic plaques. Atherosclerotic plaques were detected in 15/60 patients (25%) as compared to 2/60 of the controls (3%). Plaques were predominantly (67%) located in the carotid bifurcation. Multivariate analysis revealed influence of age on IMT in all vessel areas. Furthermore, in the common femoral artery, sagittal abdominal diameter, diastolic blood pressure, and cholesterol all showed association with increased IMT. In the internal carotid artery, male sex and presence of Raynaud phenomenon influenced IMT. Conclusion: Among SLE patients without presence of plaques, an extended US protocol revealed increased wall thickness with predominantly medium echogenic appearance highlighting possibly inflammation or early atherosclerosis. The appearance of vessel walls has not previously been studied in detail. An increased number of plaques were found in SLE compared to age- and sex-matched healthy controls. We found similar risk factors for increased IMT and occurrence of plaques, possibly indicating atherosclerotic mechanisms rather than inflammation.
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Affiliation(s)
- Christina Svensson
- Department of Clinical Physiology, University Hospital, Linköping, Sweden.,Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Per Eriksson
- Division of Inflammation and Infection, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Helene Zachrisson
- Department of Clinical Physiology, University Hospital, Linköping, Sweden.,Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Christopher Sjöwall
- Division of Inflammation and Infection, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
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