QRISK3 improves detection of cardiovascular disease risk in patients with systemic lupus erythematosus

Personalizing cardiovascular risk prediction for patients with systemic lupus erythematosus

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.

Accumulation of Microvascular Target Organ Damage in Systemic Lupus Erythematosus Patients Is Associated with Increased Cardiovascular Risk

Background: Systemic lupus erythematosus (SLE) is a prototype autoimmune disease associated with increased cardiovascular (CV) burden. Besides increased arterial stiffness and subclinical atherosclerosis, microvascular dysfunction is considered an important component in the pathophysiology of CV disease. However, there is a lack of data regarding the effect of multiple target organ damage (TOD) on CV health. Objectives: This study aimed to evaluate (i) the presence of microvascular changes in SLE in various vascular beds, (ii) the possible associations between the accumulation of microvascular TOD and CV risk and (iii) whether Galectin-3 represents a predictor of combined microvascular TOD. Methods: Participants underwent (i) evaluation of skin microvascular perfusion (laser speckle contrast analysis), (ii) fundoscopy (non-mydriatic fundus camera), (iii) indirect assessment of myocardial perfusion (subendocardial viability ratio) and (iv) determination of urine albumin-to-creatinine ratio (UACR). CV risk was calculated using the QResearch Risk Estimator version 3 (QRISK3). Serum Galectin-3 levels were determined. Results: Forty-seven SLE patients and fifty controls were studied. SLE patients demonstrated impaired skin microvascular reactivity (160.2 ± 41.0 vs. 203.6 ± 40.1%), retinal arteriolar narrowing (88.1 ± 11.1 vs. 94.6 ± 13.5 μm) and higher UACR levels compared to controls. Furthermore, SLE individuals had significantly higher Galectin-3 levels [21.5(6.1) vs. 6.6(6.6) ng/dL], QRISK3 scores [7.0(8.6) vs. 1.3(3.6)%] and a greater chance for microvascular dysfunction. In the SLE group, patients with multiple TOD exhibited higher QRISK3. In the multivariate analysis, the accumulation of TOD correlated with disease activity and Galectin-3 (p < 0.05). Conclusions: Our study showed for the first time that SLE patients exhibit a greater number of cases of TOD. The accumulation of TOD was associated with increased CV risk. Clinicians dealing with SLE should be aware and seek microvascular alterations.

State of current management of the heightened risk for atherosclerotic cardiovascular events in an established cohort of patients with lupus erythematosus

OBJECTIVE

Patients with lupus erythematosus (LE) are at heightened risk for clinical events, chiefly heart attacks and strokes, from atherosclerotic cardiovascular disease (ASCVD). We recently proposed new guidelines to assess and manage ASCVD event risk specifically in LE. Here, we examined current cardiovascular management in light of these new recommendations.

METHODS

We studied our entire UPenn Longitudinal Lupus Cohort of patients with cutaneous LE, without (CLE-only) or with (CLE+SLE) concurrent systemic LE, for whom we had full access to medical records (n=370, LE-ASCVD Study Cohort).

RESULTS

Of our LE-ASCVD Study Cohort, 336 out of 370 (90.8%) had a designated primary-care physician. By the new guidelines, the most recent low-density lipoprotein (LDL) levels were above-goal for 249 out of 370 (67.3%). Two-hundred sixty-six (71.9%) had hypertension, which was undertreated or untreated in 198 out of 266 (74.4%). Of current smokers, 51 out of 63 (81.0%) had no documented smoking cessation counselling or referrals. Diabetes and triglyceridaemia were generally well managed. Of the cohort, 278 qualified for two widely used online estimators of ASCVD event risk in primary prevention: the ACC-ASCVD Risk Estimator Plus and QRisk3. We also stratified these 278 patients into our recently defined categories of ASCVD event risk in LE. These three methods for estimating ASCVD event risk showed clinically meaningful discordance for 169 out of 278 (60.8%). The documented rate of ASCVD events in the first 10 years after enrolment was 13.5% (95% CI 8.9%, 17.9%), similar between CLE-only and CLE+SLE, indicating an at-risk population despite the preponderance of women and an average age at enrolment of only 47 years.

CONCLUSION

Patients with CLE-only or CLE+SLE are undertreated compared with the new guidelines and, accordingly, they experience a significant burden of ASCVD events. Moreover, it is unclear how to accurately assess their future ASCVD event risk, except that it is substantial. Efforts are underway to improve ASCVD event risk estimation and guideline implementation in patients with lupus.

Subclinical Carotid Atherosclerosis in Patients with Rheumatoid Arthritis at Low Cardiovascular Risk

OBJECTIVE

To evaluate the rate of subclinical carotid atherosclerosis and clinical significance of immunoinflammatory markers in patients with rheumatoid arthritis (RA) at low cardiovascular risk.

MATERIALS AND METHODS

The study included 275 RA patients and a control group of 100 participants without autoimmune diseases. All study participants were at low cardiovascular risk, calculated by the QRISK3 scale (<20%), and free of cardiovascular disease. Ultrasound examination of carotid arteries was performed to measure cIMT and to detect atherosclerotic plaques (ASP) in carotid arteries. sIСАМ-1, sVСАМ, and sCD40L levels were determined by enzyme immunoassay.

RESULTS

Carotid ASP was observed more frequently in RA patients (27%) than in the control group (17%), p = 0.03. The frequency of ASP in RA patients did not depend on the disease's stage or activity. There was a significant correlation between cIMT and age, cardiovascular risk determined by QRISK3, level of total cholesterol, LDL, and blood pressure in RA patients, p < 0.05 in all cases. No correlation between cIMT and blood levels of sCD40L, sVCAM, and sICAM was found. In RA patients, a higher concentration of sVCAM was detected in the carotid ASP group compared to the non-atherosclerotic group. sCD40L was associated with cIMT and total cholesterol in the ASP group and with total cholesterol and blood pressure in non-atherosclerotic patients.

CONCLUSIONS

Subclinical atherosclerotic lesions of the carotid arteries were observed significantly more frequently in RA patients with low cardiovascular risk than in the control group. The results of the study demonstrate the association between cIMT, traditional cardiovascular risk factors, and immunoinflammatory markers in RA patients.

Generic and disease-adapted cardiovascular risk scores as predictors of atherosclerosis progression in SLE

OBJECTIVE

Studies show that generic cardiovascular risk (CVR) prediction tools may underestimate CVR in SLE. We examined, for the first time to our knowledge, whether generic and disease-adapted CVR scores may predict subclinical atherosclerosis progression in SLE.

METHODS

We included all eligible patients with SLE without a history of cardiovascular events or diabetes mellitus, who had a 3-year carotid and femoral ultrasound follow-up examination. Five generic (Systematic Coronary Risk Evaluation (SCORE), Framingham Risk Score (FRS), Pooled Cohort Risk Equation, Globorisk, Prospective Cardiovascular Münster) and three 'SLE-adapted' CVR scores (modified Systematic Coronary Risk Evaluation (mSCORE), modified Framingham Risk Score (mFRS), QRESEARCH Risk Estimator V.3 (QRISK3)) were calculated at baseline. The performance of CVR scores to predict atherosclerosis progression (defined as new atherosclerotic plaque development) was tested with Brier Score (BS), area under the receiver operating characteristic curve (AUROC) and Matthews correlation coefficient (MCC), while rank correlation was tested with Harrell's c-index. Binary logistic regression was also applied to examine determinants of subclinical atherosclerosis progression.

RESULTS

Twenty-six (21%) of 124 included patients (90% female, mean age 44.4±11.7 years) developed new atherosclerotic plaques after a mean of 39.7±3.8 months' follow-up period. Performance analysis showed that plaque progression was better predicted by the mFRS (BS 0.14, AUROC 0.80, MCC 0.22) and QRISK3 (BS 0.16, AUROC 0.75, MCC 0.25). c-Index showed no superiority for discrimination between mFRS and QRISK3. In the multivariate analysis, QRISK3 (OR 4.24, 95% CI 1.30 to 13.78, p=0.016) among the CVR prediction scores and age (OR 1.13, 95% CI 1.06 to 1.21, p<0.001), cumulative glucocorticoid dose (OR 1.04, 95% CI 1.01 to 1.07, p=0.010) and antiphospholipid antibodies (OR 3.66, 95% CI 1.24 to 10.80, p=0.019) among disease-related CVR factors were independently associated with plaque progression.

CONCLUSIONS

Application of SLE-adapted CVR scores such as QRISK3 or mFRS, as well as monitoring for glucocorticoid exposure and the presence of antiphospholipid antibodies, can help to improve CVR assessment and management in SLE.

Lupus nephropathy beyond immunosuppression: Searching for nephro and cardioprotection

Renal involvement in systemic lupus erythematosus (SLE) represents one of the most frequent organ manifestations, often leading to end-stage kidney disease (ESKD). Several therapies have been tested in patients with lupus nephritis (LN) to prevent further organ damage. The effectiveness of immunosuppressive therapy as a treatment for LN is abundant, supported by multiple clinical trials that have shown its efficacy in preventing the development of chronic kidney disease (CKD). In addition to immunosuppressive therapy, several traditional and recent therapies aimed at nephroprotection in patients with proteinuric chronic kidney disease are gaining importance in the setting of LN. Thus, immunosuppressive therapy should be accompanied by nephro- and cardioprotective measures to control cardiovascular risk factors and proteinuria to ensure a better renal prognosis. Despite this, the literature on these specific measures is relatively scarce, with recommendations focused on the blockade of the renin-angiotensin-aldosterone system (RAAS). This review explores the pharmacological options available for cardiovascular and renal protection outside the usual treatment schemes.

Mechanistic insight into premature atherosclerosis and cardiovascular complications in systemic lupus erythematosus

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.

QRISK3-based analysis of cardiovascular risk factors in patients with long-term but well-controlled systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is a multisystem inflammatory disease of unknown etiology. Corticosteroids and immunosuppressive agents are the principal forms of treatment for this condition. While cardiovascular disease (CVD) is known to be a major cause of death in patients with SLE, there has been no improvement over the last few decades with regard to diagnosis, treatment, or prognosis. The QRISK3 algorithm is a new algorithm that includes SLE-related risk factors; this tool can predict the risk of CVD over a ten-year period. In this study, involving 180 patients, we compared the performance of the Framingham risk score, the recalibrated risk prediction SCORE, and QRISK3 for the assessment of CVD in patients with a long course of disease and low disease activity. Then, we used a more efficient algorithm, QRISK3 to identify the risk factors for CVD. This was a prospective and cross-sectional study involving 116 patients. All patients fulfilled the ACR criteria. The systemic lupus erythematosus disease activity index 2000 (SLEDAI-2K) is widely used to assess disease activity in SLE patients; patients with a SLEDAI-2K less than or equal to 4 are considered to be stable. Thus, we defined well-controlled patients as those with a SLEDAI-2K score less than or equal to 4. The dose of glucocorticoid (GC) that patients received was less or equal to 10 mg per day. We recorded and assessed a range of traditional risk factors, current treatments, comorbidities, data at the time of onset, and SLE-related evaluations. The QRISK3 score, and the relative risk (RR) that this score defined, were used to estimate the risk of CVD in patients with SLE. According to these relative risks, the patients were divided into low- (n=28), intermediate- (n=46), and high-relative risk (n=31) groups for subgroup analysis. Of the 116 patients enrolled, 105 were eligible to be assessed for the risk of CVD. By univariate analyses, the RR was significantly related with age at the time of enrolment (p<0.001), age at onset (p<0.001), resting heart rate (RHR) (p<0.001), present dose of GCs (p<0.001), present SLEDAI-2K (p=0.015), aerobic exercise (p<0.001), initial SLEDAI-2K (p<0.001), and initial dose of GCs (p=0.048). In the multiple linear regression model, the RR of CVD was significantly correlated with the initial SLEDAI-2K score (β=2.112, p<0.001), initial dose of GCs (β=-0.009, p=0.041), resting heart rate (β=0.241, p=0.003) and age at onset (β=-0.208, p=0.004). Pearson's correlation showed that RHR was significantly associated with aerobic exercise (r=-0.322, p=0.001). Subgroup analysis further identified a positive correlation between the history of nephritis, metabolic syndrome (MetS), aerobic exercise, present dose of GCs, and the RR of CVD. Patients with long-term but well-controlled SLE had a high relative risk of CVD and that this was associated with resting heart rate (P=0.003), history of lupus nephritis (P<0.001), initial SLEDAI-2K score (P<0.001), and metabolic syndrome (P=0.017). However, age at onset (P<0.001), use of hydroxychloroquine (P=0.30) and Mycophenolate mofetil (P=0.01), and the initial dose of glucocorticoid (P=0.049), were protective factors. Younger SLE patients had a significantly higher relative risk of CVD than older patients (p<0.001). QRISK3 detected more SLE patients at high risk of CVD when compared to the Framingham and recalibrate SCORE. To reduce the risk of CVD in SLE patients, measures should be taken both during the initial stages of disease and for long-term management.

Challenges in Implementing Cardiovascular Risk Scores for Assessment of Young People With Childhood-Onset Autoimmune Rheumatic Conditions

Cardio-vascular risk (CVR) stratification tools have been implemented in clinical practice to guide management decision for primary prevention of cardiovascular disease. Less is known about how we can optimally estimate the CVR in children and adolescents or about the reliability of the risk stratification tools validated in adult populations. Chronic inflammation associated with autoimmune rheumatic disease (ARD) drives an increased risk for accelerated atherosclerosis in patients of all ages. Although the research is less advanced than in adult populations, it is recognized that young people with ARDs with childhood-onset have increased CVR compared to age-matched healthy controls, as supported by studies investigating lipid biomarker profile and markers of endothelial dysfunction. Further research is needed to address the unmet need for adequate CVR identification and management strategies in young people in general, and in those with underlying chronic inflammation in particular. This perspective paper explores various challenges in adequately identifying and managing CVR in younger populations and potential directions for future research.

Assessing the validity of QRISK3 in predicting cardiovascular events in systemic lupus erythematosus

Objectives

Traditional cardiovascular risk calculators such as the Framingham Risk Score (FRS) have been shown to underestimate risk in patients with SLE. The QRISK3 calculator is unique in including SLE and corticosteroid use as risk factors. This study aims to assess the validity of QRISK3 compared with other cardiovascular risk models in a cohort of patients with SLE in the USA.

Methods

We studied a prospective cohort of 366 adult patients with SLE without history of any cardiovascular event and followed them for 10 years. We compared the diagnostic performance of QRISK3 with FRS, modified FRS, Atherosclerotic Cardiovascular Disease (ASCVD), and Predictors of Risk for Elevated Flares, Damage Progression and Increased Cardiovascular Disease in Patients with SLE (PREDICTS).

Results

Sixty-four of the 366 patients (17.4%) experienced at least one cardiovascular event during the 10-year follow-up period. Of these patients 45% had a QRISK3 score >10%, whereas 20.5% of patients who did not have an event had a QRISK3 score >10% (p<0.001). The corresponding numbers for FRS, modified FRS, ASCVD and PREDICTS were 11.0% vs 7.2% (p=ns), 40.6% vs 28.0% (p=0.05), 12.2% vs 5.9% (p=ns), and 77% vs 32.1% (p<0.001), respectively. The areas under the receiver operating characteristic curve using QRISK3 >10% and high-risk PREDICTS were both larger than those using ASCVD >10%, FRS >10% and modified FRS >10%.

Conclusions

Both QRISK3 and PREDICTS demonstrated better performance in predicting risk of cardiovascular disease in this cohort of patients with SLE compared with FRS, modified FRS and ASCVD.

Cardiovascular Outcomes in Systemic Lupus Erythematosus

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.

Assessment and management of the heightened risk for atherosclerotic cardiovascular events in patients with lupus erythematosus or dermatomyositis

For patients with lupus erythematosus (LE) or dermatomyositis (DM), there is an urgent need to address a heightened risk of clinical events, chiefly heart attacks and strokes, caused by atherosclerotic cardiovascular disease (ASCVD). Patients with LE or DM frequently exhibit high levels of conventional risk factors for ASCVD events, particularly dyslipoproteinemia and hypertension; an amplified burden of atherosclerotic plaques; and increased age- and sex-adjusted rates of ASCVD events compared with the general population. The rate of ASCVD events exceeds what would be expected from conventional risk factors, suggesting that disease-specific autoimmune processes exacerbate specific, known pathogenic steps in atherosclerosis. Importantly, despite their heightened risk, patients with LE or DM are often undertreated for known causative agents and exacerbators of ASCVD. Herein, we propose an approach to assess and manage the heightened risk of ASCVD events in patients with LE or DM. Our approach is modeled in large part on established approaches to patients with diabetes mellitus or stage 3 or 4 chronic kidney disease, which are well-studied conditions that also show heightened risk for ASCVD events and have been explicitly incorporated into standard clinical guidelines for ASCVD. Based on the available evidence, we conclude that patients with LE or DM require earlier and more aggressive screening and management of ASCVD. We suggest that physicians consider implementing multipliers of conventional risk calculators to trigger earlier initiation of lifestyle modifications and medical therapies in primary prevention of ASCVD events, employ vascular imaging to quantify the burden of subclinical plaques, and treat to lower lipid targets using statins and newer therapies, such as PCSK9 inhibitors, that decrease ASCVD events in nonautoimmune cohorts. More clinical vigilance is needed regarding surveillance, prevention, risk modification, and treatment of dyslipidemias, hypertension, and smoking in patients with LE or DM. All of these goals are achievable.

Accelerated Atherosclerosis in Systemic Lupus Erythematosus: Role of Fibroblast Growth Factor 23- Phosphate Axis

PURPOSE

Despite management advances, accelerated atherosclerotic cardiovascular disease (ACVD) remains a major cause of morbimortality in systemic lupus erythematosus (SLE) patients; that is not fully explained by traditional risk factors. Fibroblast growth factor-23 (FGF23) is a bone-derived phosphaturic hormone with multiple klotho-dependent and independent effects, including promotion of atherosclerosis and vascular calcification, particularly in the context of chronic kidney disease. Increased circulating FGF23 was reported in SLE patients, particularly with lupus nephritis (LN); but its atherogenic role in these disorders was not explored.

SUBJECTS AND METHODS

Three study groups of predominantly middle-aged females were categorized by the 2012 SLE International Collaborating Clinics (SLICC) criteria as SLE (without LN), LN, or controls matching for traditional CVD risk profile. Measures of SLE activity, damage, steroid therapy, and glomerular filtration rate were calculated. Fasting blood samples were checked for serum lipid profile, anti-DNA, urea, creatinine, uric acid, proteins, albumin, calcium, phosphorus, C3, C4, CRP, vitamin-D3, intact parathyroid hormone and FGF23 (iFGF23). By carotid ultrasonography, mean common carotid artery intima-media thickness (CC-IMT), plaque score (PS) and internal carotid resistive index (ICRI) were recorded.

RESULTS

CC-IMT, ICRI and serum iFGF23 differed along the study groups (LN>SLE>controls). In both SLE and LN patients, serum iFGF23 had a significant positive correlation with serum phosphorus, CC-IMT and PS. On multivariate analysis, the strongest predictor of increased CC-IMT was cumulative steroid dose in SLE and serum iFGF23 in LN patients. Most significant independent predictors of increased serum iFGF23 were hyperphosphatemia in SLE and proteinuria in LN patients.

CONCLUSION

FGF23-phosphate axis has a key role in accelerated ACVD in SLE patients. Serum phosphorus and iFGF23 should be included in ACVD risk profile assessment of these patients. Prospective studies shall define the role of dietary and/or pharmacologic control of hyperphosphatemia and proteinuria in reducing circulating iFGF23 and ACVD in them.

QRISK3 Relation to Carotid Plaque is Higher than that of SCORE In Patients with Systemic Lupus Erythematosus

INTRODUCTION

Systemic lupus erythematosus (SLE) has been described as an independent risk factor for the development of cardiovascular (CV) disease. Recently, the QRESEARCH risk estimator version 3 (QRISK3) calculator has been launched for CV risk assessment in the general population. QRISK3 now includes the presence of SLE as one of its variables for calculating CV risk. Our objective was to compare the predictive capacity between QRISK3 and the Systematic Coronary Risk Assessment (SCORE) for the presence of subclinical carotid atherosclerosis in patients with SLE.

METHODS

296 patients with SLE were recruited. The presence of subclinical atherosclerosis was evaluated by carotid ultrasound to identify carotid plaque and the thickness of the carotid intima media (cIMT). QRISK3 and SCORE were calculated. The relationship of QRISK3 and SCORE with each other and with the presence of subclinical carotid atherosclerosis (both carotid plaque and cIMT) was studied.

RESULTS

There was no correlation between SCORE and QRISK3 in patients with SLE (Rho Spearman r= -0.008, p= 0.90). Although QRISK3 showed a statistically significant correlation with cIMT (Rho Spearman r = 0.420, p= 0.000), this relationship was not found between SCORE and cIMT (Rho Spearman r= -0.005, p= 0.93). The discrimination capacity of QRISK3 for the presence of carotid plaque was statistically significant and superior to that of SCORE (AUC 0.765 [95% CI 0.711-0.820] vs 0.561 [95% CI 0.494-0.629], p= 0.000).

CONCLUSION

QRISK3 discrimination for subclinical atherosclerosis is higher than that of SCORE. QRISK3, and not SCORE, should be used for the calculation of CV risk in patients with SLE.

Reviewing the use and quality of machine learning in developing clinical prediction models for cardiovascular disease

Cardiovascular disease (CVD) is one of the leading causes of death across the world. CVD can lead to angina, heart attacks, heart failure, strokes, and eventually, death; among many other serious conditions. The early intervention with those at a higher risk of developing CVD, typically with statin treatment, leads to better health outcomes. For this reason, clinical prediction models (CPMs) have been developed to identify those at a high risk of developing CVD so that treatment can begin at an earlier stage. Currently, CPMs are built around statistical analysis of factors linked to developing CVD, such as body mass index and family history. The emerging field of machine learning (ML) in healthcare, using computer algorithms that learn from a dataset without explicit programming, has the potential to outperform the CPMs available today. ML has already shown exciting progress in the detection of skin malignancies, bone fractures and many other medical conditions. In this review, we will analyse and explain the CPMs currently in use with comparisons to their developing ML counterparts. We have found that although the newest non-ML CPMs are effective, ML-based approaches consistently outperform them. However, improvements to the literature need to be made before ML should be implemented over current CPMs.

Primary Sjögren's Syndrome and Cardiovascular Disease

Sjögren's syndrome is a rheumatic autoimmune disease that primarily affects middle-aged women and runs a slowly progressing course with sicca symptoms being the prevalent manifestation. Premature atherosclerosis and increased cardiovascular (CV) morbidity and mortality are frequently encountered in rheumatic diseases characterized by significant systemic inflammation, such as the inflammatory arthritides, systemic vasculitides and systemic lupus erythematosus. In the same context, chronic inflammation and immune aberrations underlying Sjögren's syndrome are also reported to be associated with augmented risk of atherosclerosis. Increased CV disease (CVD) frequency has been found in recent meta-analyses. The involvement of the CV system is not a common feature of Sjögren's syndrome; however, specific manifestations, such as autoantibody-mediated heart block, pericarditis, pulmonary arterial hypertension and dysautonomia, have been described. This review focuses on studies addressing CV morbidity in Sjögren's syndrome and presents current data regarding distinct CV features of the disease.

Systemic Lupus Erythematosus, Its Impact on Selected Cardiovascular Risk Factors, and Correlation with Duration of Illness: A Pilot Study

Systemic lupus erythematosus is a rare autoimmune disease. It leads to an increased production of proinflammatory molecules that accelerates atherogenesis and could cause an endothelium dysfunction. The aim of the study was to assess cardiovascular risk factors such as BMI and lipid profile as well as left ventricular ejection fraction among patients with SLE, and a correlation of these factors with duration of the disease. Materials and Methods. The researched group consisted of patients with SLE, being under control of the outpatient clinic of cardiology. This group included 38 patients among whom 34 were women (56.17 ± 11.05 years) and 4 were men (65.50 ± 9.22 years). The control group consisted of 19 healthy women (53.31 ± 11.94 years) and 2 healthy men (38.51 ± 7.53 years). Measurements were taken in the same conditions by trained medical staff. Results. Excessive body weight (BMI >25 kg/m²) was more frequent in the SLE group, but it was not statistically significant (55.26% vs. 52.38%, p = 0.6159). LVEF values were lower in their searched group, and this factor showed statistical significance (53.92% ± 6.46 vs. 58.67% ± 4.69, p = 0.0044). Thickness of the IMT was higher and statistically important among patients with SLE, both in left (1.22 ± 0.27 mm vs. 0.7 ± 0.21 mm, p = 0.0001) and right common carotid artery (1.16 ± 0.26 mm vs. 0.59 ± 0.15 mm, p = 0.0001), compared to the controls. Conclusions. Patients with SLE are at greater risk of developing cardiovascular diseases as the illness progresses. The activity of the disease according to the SLEDAI-2K scale may have an impact on the LVEF values which was significantly decreased in the group with active disease, but further thorough investigation is required to fully evaluate the impact of individual components of the disease and its treatment on the CVD development and mortality.

Underperformance of clinical risk scores in identifying vascular ultrasound-based high cardiovascular risk in systemic lupus erythematosus

AIMS

The aim of this study was to assess the performance of eight clinical risk prediction scores to identify individuals with systemic lupus erythematosus (SLE) at high cardiovascular disease (CVD) risk, as defined by the presence of atherosclerotic plaques.

METHODS

CVD risk was estimated in 210 eligible SLE patients without prior CVD or diabetes mellitus (female: 93.3%, mean age: 44.8 ± 12 years) using five generic (Systematic Coronary Risk Evaluation (SCORE), Framingham Risk Score (FRS), Pooled Cohort Risk Equations (ASCVD), Globorisk, Prospective Cardiovascular Münster Study risk calculator (PROCAM)) and three 'SLE-adapted' (modified-SCORE, modified-FRS, QRESEARCH risk estimator, version 3 (QRISK3)) CVD risk scores, as well as ultrasound examination of the carotid and femoral arteries. Calibration, discrimination and classification measures to identify high CVD risk based on the presence of atherosclerotic plaques were assessed for all risk models. CVD risk reclassification was applied for all scores by incorporating ultrasound results.

RESULTS

Moderate calibration (p-value range from 0.38 to 0.63) and discrimination (area under the curve 0.73-0.84), and low-to-moderate sensitivity (8.3-71.4%) and classification ability (Matthews correlation coefficient (MCC) 0.25-0.47) were observed for all risk models to identify patients with plaques at any arterial site as high-risk. MCC was improved for modified-FRS versus FRS (0.43 vs 0.36), but not for modified-SCORE versus SCORE (0.25 vs 0.25). Based on plaque presence, CVD risk was upgraded to high-risk in 10%, 16.1%, 20.5%, 21.5%, 24%, 28.2% and 28.6% of cases classified as non-high-risk by QRISK3, modified-FRS, Globorisk, FRS/PROCAM, ASCVD, modified-SCORE and SCORE, respectively.

CONCLUSIONS

Most of the five generic and three 'SLE-adapted' clinical risk scores underestimated high CVD risk defined by atherosclerotic plaque presence in patients with SLE.

Underperformance of clinical risk scores in identifying vascular ultrasound-based high cardiovascular risk in systemic lupus erythematosus

AIMS

The aim of this study was to assess the performance of eight clinical risk prediction scores to identify individuals with systemic lupus erythematosus (SLE) at high cardiovascular disease (CVD) risk, as defined by the presence of atherosclerotic plaques.

METHODS

CVD risk was estimated in 210 eligible SLE patients without prior CVD or diabetes mellitus (female: 93.3%, mean age: 44.8 ± 12 years) using five generic (Systematic Coronary Risk Evaluation (SCORE), Framingham Risk Score (FRS), Pooled Cohort Risk Equations (ASCVD), Globorisk, Prospective Cardiovascular Münster Study risk calculator (PROCAM)) and three 'SLE-adapted' (modified-SCORE, modified-FRS, QRESEARCH risk estimator, version 3 (QRISK3)) CVD risk scores, as well as ultrasound examination of the carotid and femoral arteries. Calibration, discrimination and classification measures to identify high CVD risk based on the presence of atherosclerotic plaques were assessed for all risk models. CVD risk reclassification was applied for all scores by incorporating ultrasound results.

RESULTS

Moderate calibration (p-value range from 0.38 to 0.63) and discrimination (area under the curve 0.73-0.84), and low-to-moderate sensitivity (8.3-71.4%) and classification ability (Matthews correlation coefficient (MCC) 0.25-0.47) were observed for all risk models to identify patients with plaques at any arterial site as high-risk. MCC was improved for modified-FRS versus FRS (0.43 vs 0.36), but not for modified-SCORE versus SCORE (0.25 vs 0.25). Based on plaque presence, CVD risk was upgraded to high-risk in 10%, 16.1%, 20.5%, 21.5%, 24%, 28.2% and 28.6% of cases classified as non-high-risk by QRISK3, modified-FRS, Globorisk, FRS/PROCAM, ASCVD, modified-SCORE and SCORE, respectively.

CONCLUSIONS

Most of the five generic and three 'SLE-adapted' clinical risk scores underestimated high CVD risk defined by atherosclerotic plaque presence in patients with SLE.

Cardiovascular risk stratification and appropriate use of statins in patients with systemic lupus erythematosus according to different strategies

INTRODUCTION/OBJECTIVES

Cardiovascular risk management of patients with systemic lupus erythematosus (SLE) is medically relevant. The objectives were to estimate the cardiovascular risk by different strategies in patients with SLE, analyzing which proportion of patients would be candidates to receive statin therapy, and identify how many patients with statin indication received such drugs.

METHOD

A cross-sectional study was performed from a secondary database. Following the recommendations of National Institute for Health and Care Excellence (NICE) guidelines and the Argentine Consensus, the QRISK-3 and the adjusted Framingham (multiplying factor × 2) scores were calculated in primary prevention subjects. The indications for statin therapy according to these recommendations were analyzed.

RESULTS

In total, 110 patients were included. Regarding patients without previous cardiovascular history, the median adjusted Framingham score was 12.8% (4.1-21.9), and 45.2%, 22.6%, and 32.2% of them were classified at low, moderate, or high risk. The median QRISK-3 score was 6.0% (2.1-14.1) and 42.1% of subjects were classified "at risk". Only 60% of subjects in secondary prevention received statins, although no patient received the recommended doses. Analyzing patients in primary prevention who did not receive statins (87%), 43.4% and 45.2% of the patients were eligible for statin therapy according to NICE guidelines and Argentine Consensus, respectively.

CONCLUSIONS

Our findings showed that a large proportion of patients with SLE have a considerable cardiovascular risk and many of them would be eligible for statin therapy. However, the statin use observed was low.Key Points• A large proportion of patients with lupus have a considerable cardiovascular risk, explained in part by dyslipidemia.• Many patients with SLE would be eligible for statin therapy according to risk stratification based on conventional risk factors.• The use of statins in this population is inadequate.