Cardiovascular manifestations in systemic lupus erythematosus. Prospective study of 100 patients

Opportunities and challenges of lupus care in Latin America, the Middle East, and Asia-Pacific: A call to action

Lupus remains a disease with a low prioritisation in the national agendas of many countries in Latin America, the Middle East, and Asia-Pacific, where there is a dearth of rheumatologists and limited access to new or even standard lupus treatments. There is thus an important need for education, advocacy, and outreach to prioritise lupus in these regions to ensure that patients receive the care they need. This article reviews some of the specific challenges facing the care and management of people with lupus in these regions and suggests strategies for improving patient outcomes. Specifically, we review and discuss (with a focus on the aforementioned regions) the epidemiology of lupus; economic costs, disease burden, and effects on quality of life; barriers to care related to disease assessment; barriers to effective treatment, including limitations of standard treatments, high glucocorticoid use, inadequate access to new treatments, and low adherence to medications; and strategies to improve lupus management and patient outcomes. We hope that this represents a call to action to come together and act now for the lupus community, policymakers, health authorities, and healthcare professionals to improve lupus management and patient outcomes in Latin America, the Middle East, and Asia-Pacific.

Autoimmune Myocarditis, Old Dogs and New Tricks

Autoimmunity significantly contributes to the pathogenesis of myocarditis, underscored by its increased frequency in autoimmune diseases such as systemic lupus erythematosus and polymyositis. Even in cases of myocarditis caused by viral infections, dysregulated immune responses contribute to pathogenesis. However, whether triggered by existing autoimmune conditions or viral infections, the precise antigens and immunologic pathways driving myocarditis remain incompletely understood. The emergence of myocarditis associated with immune checkpoint inhibitor therapy, commonly used for treating cancer, has afforded an opportunity to understand autoimmune mechanisms in myocarditis, with autoreactive T cells specific for cardiac myosin playing a pivotal role. Despite their self-antigen recognition, cardiac myosin-specific T cells can be present in healthy individuals due to bypassing the thymic selection stage. In recent studies, novel modalities in suppressing the activity of pathogenic T cells including cardiac myosin-specific T cells have proven effective in treating autoimmune myocarditis. This review offers an overview of the current understanding of heart antigens, autoantibodies, and immune cells as the autoimmune mechanisms underlying various forms of myocarditis, along with the latest updates on clinical management and prospects for future research.

Autoimmune Responses and Therapeutic Interventions for Systemic Lupus Erythematosus: A Comprehensive Review

Systemic Lupus Erythematosus (SLE) or Lupus is a multifactorial autoimmune disease of multiorgan malfunctioning of extremely heterogeneous and unclear etiology that affects multiple organs and physiological systems. Some racial groups and women of childbearing age are more susceptible to SLE pathogenesis. Impressive progress has been made towards a better understanding of different immune components contributing to SLE pathogenesis. Recent investigations have uncovered the detailed mechanisms of inflammatory responses and organ damage. Various environmental factors, pathogens, and toxicants, including ultraviolet light, drugs, viral pathogens, gut microbiome metabolites, and sex hormones trigger the onset of SLE pathogenesis in genetically susceptible individuals and result in the disruption of immune homeostasis of cytokines, macrophages, T cells, and B cells. Diagnosis and clinical investigations of SLE remain challenging due to its clinical heterogeneity and hitherto only a few approved antimalarials, glucocorticoids, immunosuppressants, and some nonsteroidal anti-inflammatory drugs (NSAIDs) are available for treatment. However, the adverse effects of renal and neuropsychiatric lupus and late diagnosis make therapy challenging. Additionally, SLE is also linked to an increased risk of cardiovascular diseases due to inflammatory responses and the risk of infection from immunosuppressive treatment. Due to the diversity of symptoms and treatment-resistant diseases, SLE management remains a challenging issue. Nevertheless, the use of next-generation therapeutics with stem cell and gene therapy may bring better outcomes to SLE treatment in the future. This review highlights the autoimmune responses as well as potential therapeutic interventions for SLE particularly focusing on the recent therapeutic advancements and challenges.

Myocarditis in connective tissue diseases: an often-overlooked clinical manifestation

To discuss what is currently known about myocarditis in the context of major connective tissue diseases, including Systemic lupus erythematosus, Rheumatoid Arthritis, Sjogren, Dermato-myositis and Polymyositis, Systemic Sclerosis, and Mixed connective tissue disease. Variability exists between studies regarding the incidence of myocarditis in connective tissue diseases, which is hypothesized to be the result of its subclinical course in most cases. Extensive gaps of knowledge exist in the field of pathophysiology. Although endomyocardial biopsy remains to be the gold standard for diagnosis, the advancement in non-invasive modalities such as cardiac MRI, echocardiography, and nuclear medicine has allowed for earlier and more frequent detection of myocarditis. A lack of treatment guidelines was found across the different connective tissue diseases. Most of the literature available revolved around myocarditis in the context of Systemic lupus erythematosus. Numerous recent studies were published that contributed to advancements in diagnosis and treatment however, there remains a lack of diagnostic and treatment guidelines.

Cardiac involvement in a Spanish unicentric prospective cohort of patients with systemic lupus erythematosus

BACKGROUND

Cardiac involvement is one of the most frequent manifestations of Systemic Lupus Erythematosus (SLE). Transthoracic echocardiogram (TTE) may be valuable for the early detection of cardiac abnormalities in SLE. Few studies analyze both TTE findings in SLE and the risk factors that predispose to different cardiac manifestations in a long follow-up cohort. We aimed to investigate cardiac involvement's prevalence, risk factors, and outcomes in a Spanish Lupus Clinic.

METHODS

Spanish single-center prospective study of cardiac involvement in SLE. Two hundred and one patients met the 2019 EULAR/ACR classification criteria, performed TTE, and were eligible for the study.

RESULTS

Cardiac involvement was present in 43.8%. Patients with older age, hypertension, hyperlipidemia, higher body mass index, peripheral arterial disease, thrombosis, and major cardiovascular events had significantly more cardiac involvement. Neurological, hematological, and serosal involvement (pleuritis and/or pericarditis) were clinical risk factors for abnormal TTE. The combination of the four clinical variables (dyspnea, chest pain, cough, and/or syncope) was present in 40.9% of the patients with abnormal TTE in the follow-up and was superior to each of the manifestations separately. Troponin I (TnI) ≥ 0.2 ng/mL and NTproBNP ≥ 300 pg/mL were excellent biomarkers with a good correlation with cardiac abnormalities. Anti-B2GP1 was the only autoantibody associated with cardiac involvement in our cohort. Presenting cardiac involvement was correlated with higher SLICC Damage Index and increased mortality risk in the 2-year follow-up period.

CONCLUSIONS

Cardiac involvement in SLE is diverse, heterogeneous, and highly prevalent. Presenting a pathological TTE was associated with greater damage accrual and greater mortality. Based on our results, we consider that echocardiographic screening of patients with SLE is essential, especially those symptomatic and/or with risk factors, to diagnose and treat cardiac involvement earlier.

Exploring the Risk Factors for Poor Survival in Lupus Pericarditis Patients: A Retrospective Cohort Study

Patients with systemic lupus erythematosus (SLE) have a higher risk of pericarditis, which could be fatal. The goal of this study was to identify the prognostic factors for mortality in patients with lupus pericarditis. Patients with lupus pericarditis treated at Chang Gung Memorial Hospital were included in this observational cohort study. This study conducted univariate and multivariate COX regression, as well as Kaplan−Meier survival curve analysis, to investigate mortality risk in SLE patients. The average age at admission was 40.78 ± 15.92 years. A total of 113 (16.4%) of the 689 patients had lupus pericarditis. Patients with lupus pericarditis exhibited older age, shorter follow-up, higher disease activities, and higher incidence rates of comorbidities than patients without pericarditis. Cox regression adjusted analysis indicated that lupus pericarditis (hazard ratio = 1.963, 95% CI = 1.315, 2.963, p = 0.001), old age at admission (HR = 1.053, 95% CI = 1.040, 1.065, p < 0.001), high SLEDAI score (HR = 1.079, 95% CI = 1.043, 1.116, p < 0.001), and end-stage kidney disease (ESKD) (HR = 2.533, 95% CI = 1.620, 3.961, p < 0.001) were all linked to increased mortality. Moreover, the Kaplan−Meier survival curve analysis revealed that patients with pericarditis compared to those without pericarditis had a higher mortality rate (log-rank test, p < 0.001). A high proportion of SLE patients have manifestations of lupus pericarditis. Moreover, patients with lupus pericarditis have a greater risk of mortality even if they have no pericardial tamponade. Therefore, these patients need prompt diagnosis and treatment.

Epidemiological Impact of Myocarditis

Myocarditis is an inflammatory disease of the heart muscle with a wide range of potential etiological factors and consequently varying clinical patterns across the world. In this review, we address the epidemiology of myocarditis. Myocarditis was considered a rare disease until intensified research efforts in recent decades revealed its true epidemiological importance. While it remains a challenge to determine the true prevalence of myocarditis, studies are underway to obtain better approximations of the proportions of this disease. Nowadays, the prevalence of myocarditis has been reported from 10.2 to 105.6 per 100,000 worldwide, and its annual occurrence is estimated at about 1.8 million cases. This wide range of reported cases reflects the uncertainty surrounding the true prevalence and a potential underdiagnosis of this disease. Since myocarditis continues to be a significant public health issue, particularly in young adults in whom myocarditis is among the most common causes of sudden cardiac death, improved diagnostic and therapeutic procedures are necessary. This manuscript aims to summarize the current knowledge on the epidemiology of myocarditis, new diagnostic approaches and the current epidemiological impact of the COVID-19 pandemic.

Lupus myocarditis-A rare case

Myocarditis in patients of systemic lupus erythematosus is extremely rare and is potentially life threatening. This may be the first presentation of the disease. Here, we report a patient who presented with features of heart failure and was later diagnosed to have SLE.

Non-traditional risk factors and the risk of myocardial infarction in the young in the US population-based cohort

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Young patients with myocardial infarction (MI) have both traditional risk factors and non-traditional risk factors.

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HTN, smoking, obesity, HLD and a family history of CAD were risks of MI in the young.

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HIV, SLE, and OSA were all associated with an elevated risk of MI, independent of traditional atherosclerotic risk factors.

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Close attention should be paid to emerging risk factors such as SLE, HIV and OSA.

Although most prevalent in elderly, myocardial infarction (MI) also affects younger adults. We sought to investigate baseline characteristics in young patients (<55 years) with MI using the National Inpatient Sample (NIS) database between 2004 and 2015. Multivariable logistic regression models were used to assess factors associated with acute myocardial infarction (AMI) in young patients. After multivariable analyses adjusted for age, sex, race, family history of atherosclerosis, body mass index (BMI), diabetes, hypertension, hyperlipidemia, chronic kidney disease, and current cigarette smoking; novel risk factors such as human immunodeficiency virus (HIV), systemic lupus erythematosus (SLE), and obstructive sleep apnea (OSA) were associated with a higher risk of developing an AMI in the young (adjusted OR for HIV 4.06; 95 CI 3.48–4.71, p < 0.001), (adjusted OR for SLE 2.12; 95 CI 1.89–2.39, p 0.04), and (adjusted OR for OSA 1.16; 95 CI 1.12–1.20, p < 0.001), respectively. Rheumatoid arthritis was associated with a lower risk of AMI (adjusted OR 0.83; 95 CI 0.76–0.89, p < 0.001). After multivariable analyses, cigarette smoking (adjusted OR 1.98; 95 CI 1.95–2.02, p < 0.001), obesity (adjusted OR 1.37; 95 CI 1.33–1.41, p = 0.003), hyperlipidemia (adjusted OR 1.07; 95 CI 1.04–1.08, p < 0.001) and a family history of CAD (adjusted OR 1.35; 95 CI 1.3–1.4, p < 0.001) were also associated with a higher risk of developing an AMI in the young. In conclusion, young patients with AMI have both traditional risk factors and non-traditional risk factors. In addition to traditional risk factors, close attention should be paid to emerging risk factors such as SLE, HIV and OSA.

No association of complement mannose-binding lectin deficiency with cardiovascular disease in patients with Systemic Lupus Erythematosus

Cardiovascular (CV) morbidity is the major cause of death in patients with Systemic Lupus Erythematosus (SLE). Previous studies on mannose-binding lectin (MBL) gene polymorphisms in SLE patients suggest that low levels of complement MBL are associated with cardiovascular disease (CVD). However, as large studies on MBL deficiency based on resulting MBL plasma concentrations are lacking, the aim of our study was to analyze the association of MBL concentrations with CVD in SLE patients. Plasma MBL levels SLE patients included in the Swiss SLE Cohort Study were quantified by ELISA. Five different CV organ manifestations were documented. Of 373 included patients (85.5% female) 62 patients had at least one CV manifestation. Patients with MBL deficiency (levels below 500 ng/ml or 1000 ng/ml) had no significantly increased frequency of CVD (19.4% vs. 15.2%, P = 0.3 or 17.7% vs. 15.7%, P = 0.7). After adjustment for traditional CV risk factors, MBL levels and positive antiphospholipid serology (APL+) a significant association of CVD with age, hypertension, disease duration and APL+ was demonstrated. In our study of a large cohort of patients with SLE, we could not confirm previous studies suggesting MBL deficiency to be associated with an increased risk for CVD.

Non-coronary cardiac manifestations of systemic lupus erythematosus in adults: a comparative study

Cardiac manifestations develop in the majority of patients with systemic lupus erythematosus (SLE) at some time during the course of their disease. This study was designed to assess cardiac abnormalities in patients with SLE by echocardiography and to compare the 2 groups of patients with and without cardiac manifestations. It was a transversal, descriptive study, conducted in the Internal Medicine Department at the Military Hospital of Tunis from January 2016 to June 2018. Eighty lupus patients, diagnosed on the basis of ACR (American college of rheumatology) criteria, were enrolled in the study and were evaluated by standard echocardiography with color Doppler. Out of 80 patients 42 (52%) had abnormal echocardiographic findings. Pericardial effusion was found in 55%, valvular abnormalities in 52% and 38% had pulmonary hypertension. Patients with pleural effusion (45 vs 15%) were more vulnerable to cardiac involvement as well as renal impairment (57 vs 44%). The difference, however, were not statistically significant (p>0.05) in the renal involvement. Active disease with low complement (80%) was associated with higher frequency of cardiac involvement than disease in remission (64%) but the result was not statistically significant (p=0.11). Cardiac abnormalities are very common in lupus patients even when clinically asymptomatic form. Echocardiography is an excellent non-invasive tool for cardiac evaluation. Their research must be systematic with echocardiography in order to reduce subsequent cardiac morbidity and mortality among the lupus patients.

Heart failure risk in systemic lupus erythematosus compared to diabetes mellitus and general medicaid patients

BACKGROUND

Patients with systemic lupus erythematosus (SLE) have a similar risk of myocardial infarction as those with diabetes mellitus (DM). Whether the risk of heart failure (HF) in SLE is similar to the elevated risk in DM is unknown. We sought to estimate the rates and risks for HF hospitalization among US Medicaid patients with SLE and to compare them to those for DM and the general Medicaid population.

METHODS

Using U.S. Medicaid data from 2007-2010, we identified patients with SLE or DM, and a matched cohort from the general Medicaid population and calculated incidence rates (IR), incidence rate ratios (IRR) and adjusted hazard ratios (HR) of a first HF hospitalization.

RESULTS

We identified 37,902 SLE (93% female, mean age 40.1 ± 12.1), 76,657 DM (93% female, mean age 40.0 ± 12.1), and 158,695 general Medicaid patients (93% female, mean age 40.2 ± 12.1). The IR per 1000-person years was 6.9 (95% CI 6.3-7.5) for SLE, 6.6 (95% CI 6.2-7.0) for DM, and 1.6 (95% CI 1.5-1.8) for general Medicaid patients. The highest IRR compared to general Medicaid was seen among SLE patients in age group 18-39 (14.7, 95% CI 13.9-15.5). Multivariable-adjusted HRs for HF compared to general Medicaid population were similar for SLE (2.7, 95% CI 2.3-3.1) and DM (3.0, 95% CI 2.6-3.4).

CONCLUSION

The incidence of HF among SLE patients was 2.7-fold higher than general Medicaid patients, and similar to DM. Further investigation into the biologic mechanism of HF among SLE compared to non-SLE and DM patients may shed light on the findings of this study.

Echocardiographic Assessment of Diastolic Function in Children with Incident Systemic Lupus Erythematosus

The timing and etiology of diastolic impairment in pediatric-onset systemic lupus erythematosus (SLE) are poorly understood. We compared echocardiographic metrics of left ventricular diastolic function in children at SLE diagnosis to controls and identified factors associated with diastolic indices. Echocardiograms of children aged 5-18 years within 1 year of SLE diagnosis and age-/sex-matched controls were retrospectively read by blinded cardiologists. Clinical characteristics were abstracted separately. Z-scores for diastolic indices (E/A, e', E/e', and isovolumetric relaxation time (IVRT)) were calculated using published normative data and study controls, and compared using linear mixed-effects models adjusted for blood pressure. Pericardial effusions and valvular disease were also evaluated. Linear regression was used to identify factors associated with diastolic measures. 85 children with incident SLE had echocardiograms performed a median of 6 days after diagnosis (interquartile range (IQR) 1-70). Prior cumulative prednisone exposure was minimal (median 60 mg, IQR 0-1652). SLE cases had lower E/A, lower e', higher E/e', and longer IVRT compared to controls. Though none met criteria for Grade I diastolic dysfunction, Z-scores for e', E/e', and IVRT were abnormal in 30%, 25%, and 6% of SLE cases, respectively. Greater disease activity was associated with lower septal e' (p < 0.01), higher E/e' (p = 0.02), and longer IVRT (p < 0.01). Children with incident SLE have worse diastolic indices at diagnosis compared to peers without SLE, independent of blood pressure and prior to significant prednisone exposure. Longitudinal studies will determine whether diastolic dysfunction develops in this population over time.

Cardiovascular Comorbidity in Inflammatory Rheumatological Conditions

BACKGROUND

Approximately 1.5 million adults in Germany suffer from an inflammatory rheumatological condition. The most common among these are rheumatoid arthritis and spondyloarthritis-above all axial spondyloarthritis, including ankylosing spondylitis (Bekhterev's disease) and psoriatic arthritis. These systemic inflammatory diseases often affect the heart as well.

METHODS

This review is based on pertinent articles retrieved by a selective literature search, on current European guidelines, and on the authors' clinical experience.

RESULTS

Rheumatic inflammation of cardiac structures can manifest itself as pericarditis, myocarditis, or endocarditis. The heart valves and the intracardiac conduction system can be affected as well, leading to AV block. Functional sequelae, e.g., congestive heart failure, can arise as a consequence of any inflammatory rheumatic disease. The long-term mortality of rheumatic diseases is elevated predominantly because of the increased risk for cardiovascular comorbidities. The cardiovascular risk profile should therefore be re-evaluated regularly (e.g., at 5-year intervals) in cooperation with the patient's primary care physician. The cardiovascular manifestations of rheumatic disease, such as pericarditis, myocarditis, and vasculitis, are treated initially with high-dose glucocorticoids and then over the long term with maintenance drugs such as methotrexate and azathioprine. Biological agents are sometimes used as well.

CONCLUSION

In patients with inflammatory rheumatic diseases, the elevated cardiovascular risk should be kept in mind and preventive measures should be initiated early. This subject should be further studied in controlled trials so that the treatment options for patients with cardiac involvement can be evaluated.

Child-onset systemic lupus erythematosus is associated with a higher incidence of myopericardial manifestations compared to adult-onset disease

OBJECTIVES

There are no population-based estimates of the incidence or risk factors for acute cardiac manifestations in children with systemic lupus erythematosus (SLE) to guide screening and diagnostic imaging practices. We estimated the incidence and prevalence of acute cardiac manifestations of child-onset SLE compared to adult-onset SLE and identified factors associated with cardiac diagnoses.

METHODS

We identified children (5-17 years) and adults (18-64 years) with incident SLE (≥3 International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9 CM) code 710.0, > 30 days apart) using Clinformatics® DataMart (OptumInsight, Eden Prairie, MN) deidentified United States administrative claims (2000-2013). We calculated incidence and prevalence of three outcomes: ≥ 1 diagnosis code for (1) pericarditis and/or myocarditis, (2) endocarditis, or (3) valvular insufficiency. Negative binomial regression was used to identify characteristics associated with cardiac diagnoses in children and determine whether SLE onset in childhood vs adulthood was independently associated with cardiac involvement.

RESULTS

There were 297 children and 6927 adults with new-onset SLE. A total of 17.8% of children had ICD-9 CM codes for acute cardiac diagnoses, the incidence of which were highest in the first year after SLE diagnosis (12.2 per 100 person-years). African American race (incidence rate ratio (IRR) 6.6, 95% confidence interval (CI) (2.9, 15.0), p < 0.01) and nephritis (IRR 7.0, 95% CI (2.6, 18.6), p < 0.01) were associated with acute cardiac diagnoses in children. Child-onset disease was independently associated with a 4.4-fold higher rate of pericarditis or myocarditis compared to adult-onset SLE after adjustment for other disease and demographic characteristics (95% CI (2.4, 8.0), p < 0.01).

CONCLUSION

This study establishes baseline estimates of the incidence and prevalence of pericarditis and myocarditis in child-onset SLE, which is substantially higher than that of adult-onset SLE. Prospective echocardiographic evaluations are needed to validate incidence measures and characterize the natural history of acute cardiac manifestations in child-onset SLE, as well as identify risk factors for poor cardiac outcomes to inform screening and management.

Prevalence of pulmonary hypertension in systemic lupus erythematosus: a meta-analysis

BACKGROUND AND AIMS

Pulmonary hypertension (PH) has been suggested to be associated with systemic lupus erythematosus (SLE). However, the results of prevalence studies on PH in SLE vary substantially. To derive a more precise estimation on the prevalence of PH in SLE, a meta-analysis was performed.

METHODS

Relevant literatures were searched in PubMed and EMBASE until November 2017. A total of 1366 articles were obtained after searching databases, and 23 studies were finally included in the meta-analysis. Heterogeneity test was performed, and publication bias was evaluated.

RESULTS

The result of analysis in random effect model showed that the pooled prevalence was 8% (95%CI 5-12%). There was no evidence of publication bias (p = 0.51). To evaluate the stability of our results, sensitivity analyses were performed, and the results showed no significant change when any one study was excluded. Subgroup analyses demonstrated that there were significant differences in PH prevalence in SLE patients of different gender, age, regions, year of publication, and diagnostic methods.

CONCLUSIONS

PH is prevalent in SLE patients, but it was significantly different between different gender, age, regions, year of publication, and diagnostic methods.

Increased Pulse Wave Velocity in Systemic Lupus Erythematosus: A Meta-Analysis

Systemic lupus erythematosus (SLE) is associated with increased cardiovascular risk. This study aims to derive a more precise estimation on pulse wave velocity (PWV) level in patients with SLE and related factors. A literature search was performed using PubMed, EMBASE, and The Cochrane Library databases, studies published up to February 28, 2017, in English. Pooled standardized mean difference (SMD) with 95% confidence interval (CI) was calculated by fixed-effect or random-effect model analysis. Heterogeneity test was performed by the Q statistic and quantified using I²; publication bias was evaluated using a funnel plot and Egger's linear regression test. Of 156 studies found, 27 met eligibility criteria, and 14 studies were finally included in the meta-analysis. Meta-analysis revealed that the SLE group had significantly higher PWV levels than the control group; SMD = 0.56 and 95% CI (0.30-0.82). Subgroup analyses showed that body mass index (BMI), sample size, and disease duration were associated with PWV in patients with SLE. Overall, our study suggests that patients with SLE have a higher PWV level, and it is associated with BMI, sample size, and disease duration.

Acute Myocardial Infarction in Young Systemic Lupus Erythematosus Patient with Normal Coronary Arteries

A 34-year-old female with a past medical history of systemic lupus erythematosus (SLE) and a deep venous thrombosis experienced substernal chest pain for 24 hours. Her physical exam was remarkable for brown macular rash over the face. Her initial electrocardiogram showed ST depression in lead V3–V6 along with an elevated troponin I level of 1.23 ng/dl (normal 0.0–0.4) that increased to 2.33 ng/dl in a four-hour duration. Cardiac catheterization revealed mild 10–20% focal plaque in the mid left anterior descending artery and otherwise normal coronary arteries. Laboratory data revealed an erythrocyte sedimentation rate of 98 mm/hour (normal 1–20), C-reactive protein of 25 mg/L (normal 0.0–2.9), and positive antinuclear antibody. In the absence of a significant coronary atherosclerosis along with elevated inflammatory markers, inflammation of coronary microcirculation was considered as an underlying pathophysiology of myocardial infarction. The patient was started on immunosuppression therapy with hydroxychloroquine and prednisone. Her chest pain improved and she was discharged in a stable condition. The patient remained stable and symptom-free over a follow-up period of nine months.

Cardiovascular disease in systemic lupus erythematosus: A comprehensive update

Heightened rates of both cardiovascular (CV) events and subclinical atherosclerosis, documented by imaging and vascular function techniques are well established in systemic lupus erythematosus (SLE). While traditional CV factors such as smoking, dyslipidemia, diabetes mellitus (DM), hypertension, central obesity and hyperhomocysteinemia have been reported to be prevalent in lupus patients, they do not fully explain the high rates of ischemic events so far reported, implying that other factors inherent to disease itself could account for the enhanced risk, including disease duration, activity and chronicity, psychosocial factors, medications, genetic variants and altered immunological mechanisms. Though the exact pathogenesis of atherosclerosis in the setting of lupus remains ill defined, an imbalance between endothelial damage and atheroprotection seems to be a central event. Insults leading to endothelial damage in the setting of lupus include oxidized low density lipoprotein (oxLDL), autoantibodies against endothelial cells and phospholipids, type I interferons (IFN) and neutrophil extracellular traps (NETs) directly or through activation of type I IFN pathway. Increased oxidative stress, reduced levels of the normally antioxidant high density lipoprotein (HDL), increased levels of proinflammatory HDL (piHDL) and reduced paraoxonase activity have been related to increased oxLDL levels. On the other hand, impaired atheroprotective mechanisms in lupus include decreased capacity of endothelial repair-partly mediated by type I IFN- and dampened production of atheroprotective autoantibodies. In the present review, traditional and disease related risk factors for CV disease (CVD) in the setting of chronic autoimmune disorders with special focus on SLE will be discussed.

Cardiac involvement in adult and juvenile idiopathic inflammatory myopathies

Idiopathic inflammatory myopathies (IIM) include the main subgroups polymyositis (PM), dermatomyositis (DM), inclusion body myositis (IBM) and juvenile DM (JDM). The mentioned subgroups are characterised by inflammation of skeletal muscles leading to muscle weakness and other organs can also be affected as well. Even though clinically significant heart involvement is uncommon, heart disease is one of the major causes of death in IIM. Recent studies show an increased prevalence of traditional cardiovascular risk factors in JDM and DM/PM, which need attention. The risk of developing atherosclerotic coronary artery disease is increased twofold to fourfold in DM/PM. New and improved diagnostic methods have in recent studies in PM/DM and JDM demonstrated a high prevalence of subclinical cardiac involvement, especially diastolic dysfunction. Interactions between proinflammatory cytokines and traditional risk factors might contribute to the pathogenesis of cardiac dysfunction. Heart involvement could also be related to myocarditis and/or myocardial fibrosis, leading to arrhythmias and congestive heart failure, demonstrated both in adult and juvenile IIM. Also, reduced heart rate variability (a known risk factor for cardiac morbidity and mortality) has been shown in long-standing JDM. Until more information is available, patients with IIM should follow the same recommendations for cardiovascular risk stratification and prevention as for the corresponding general population, but be aware that statins might worsen muscle symptoms mimicking myositis relapse. On the basis of recent studies, we recommend a low threshold for cardiac workup and follow-up in patients with IIM.

Systemic lupus erythematosus in Pakistan

Clinical features of systemic lupus erythematosus (SLE) have been described from different geographical regions in the world, with some clinical differences among different racial groups. Although data on the characteristics of SLE in Pakistan is scarce, it is not uncommon in the South East Asian region. The purpose of this study was, therefore, to delineate the clinical pattern and disease course in Pakistani patients with SLE and to compare it with international data on lupus patients. A total of 196 patients with SLE fulfilling the clinical and laboratory criteria of the American Rheumatism Association admitted to the hospital between 1986 and 2001 were studied by means of a retrospective review of their records. Demographically, it was seen that SLE is a disease predominantly of females in their third decade, which is consistent with worldwide data. The mean age of presentation was 31 years (range 14-76) and the mean duration of follow up was 34 (4-179) months. Generally, there was less cutaneous (46%), arthritic (38%), serositis (22%) and renal involvement (33%) but more neuropsychiatric symptoms (26%) in our population. Eighty-six percent of patients were ANA positive, whereas anti dsDNA was positive in 74% of patients. Infections, renal involvement, seizures and thrombocytopenia were associated with poor prognosis (P, 0.05). This study is the first of its kind in Pakistan. The clinical and laboratory characteristics of SLE patients in our study place our population in the middle of a spectrum between the Caucasians and other Asian populations. It has shown that the clinical characteristics of SLE patients in this country may be different to those of its neighbors.

Systemic lupus erythematosus coronary vasculitis demonstrated on cardiac computed tomography

Coronary artery aneurysms are an uncommon manifestation of systemic lupus erythematosus (SLE), with only 14 cases reported previously in the literature. Herein, we report a 29-year-old woman with SLE who developed clinical and serologic evidence of an SLE flare and presented with chest pain and elevated serum troponin-T level. Cardiac computed tomography was performed and demonstrated fusiform aneurysmal enlargement of the proximal and middle portions of the coronary arteries and a beaded appearance of the distal coronary arteries. Extensive intercostal artery aneurysms were also noted. Several areas of abnormal myocardial perfusion were also noted. The patient improved after treatment with steroid pulses and cyclophosphamide. This case report is the first description of the appearance of lupus coronary vasculitis on cardiac computed tomography.

Chance, genetics, and the heterogeneity of disease and pathogenesis in systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is a remarkably complex and heterogeneous systemic autoimmune disease. Disease complexity within individuals and heterogeneity among individuals, even genetically identical individuals, is driven by stochastic execution of a complex inherited program. Genome-wide association studies (GWAS) have progressively improved understanding of which genes are most critical to the potential for SLE and provided illuminating insight about the immune mechanisms that are engaged in SLE. What initiates expression of the genetic program to cause SLE within an individual and how that program is initiated remains poorly understood. If we extrapolate from all of the different experimental mouse models for SLE, we can begin to appreciate why SLE is so heterogeneous and consequently why prediction of disease outcome is so difficult. In this review, we critically evaluate extrinsic versus intrinsic cellular functions in the clearance and elimination of cellular debris and how dysfunction in that system may promote autoimmunity to nuclear antigens. We also examine several mouse models genetically prone to SLE either because of natural inheritance or inheritance of induced mutations to illustrate how different immune mechanisms may initiate autoimmunity and affect disease pathogenesis. Finally, we describe the heterogeneity of disease manifestations in SLE and discuss the mechanisms of disease pathogenesis with emphasis on glomerulonephritis. Particular attention is given to discussion of how anti-DNA autoantibody initiates experimental lupus nephritis (LN) in mice.

Cardiovascular involvement in autoimmune diseases

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

Cardiovascular disease in latin american patients with systemic lupus erythematosus: a cross-sectional study and a systematic review

Objective. This study was performed to determine the prevalence of and associated risk factors for cardiovascular disease (CVD) in Latin American (LA) patients with systemic lupus erythematosus (SLE). Methods. First, a cross-sectional analytical study was conducted in 310 Colombian patients with SLE in whom CVD was assessed. Associated factors were examined by multivariate regression analyses. Second, a systematic review of the literature on CVD in SLE in LA was performed. Results. There were 133 (36.5%) Colombian SLE patients with CVD. Dyslipidemia, smoking, coffee consumption, and pleural effusion were positively associated with CVD. An independent effect of coffee consumption and cigarette on CVD was found regardless of gender and duration of disease. In the systematic review, 60 articles fulfilling the eligibility criteria were included. A wide range of CVD prevalence was found (4%-79.5%). Several studies reported ancestry, genetic factors, and polyautoimmunity as novel risk factors for such a condition. Conclusions. A high rate of CVD is observed in LA patients with SLE. Awareness of the observed risk factors should encourage preventive population strategies for CVD in patients with SLE aimed at facilitating the suppression of cigarette smoking and coffee consumption as well as at the tight control of dyslipidemia and other modifiable risk factors.

Risk factors in cardiovascular disease in systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is a chronic and multisystemic autoimmune disorder which predominantly affecting women. The most common cause of death in SLE patients affected by disease for more than 5 years is cardiovascular disease (CVD). Epidemiological observations suggest that, together with classical conventional risk factors, other mechanisms (non-conventional/disease-specific factors) promote accelerated atherosclerosis in inflammatory diseases like SLE. Traditional CVD risk factors included age, hypertension, diabetes mellitus, dyslipidemia, previous vascular event defined as previous history of cerebrovascular accidents or ischemic heart disease, menopause and smoking. The non-traditional factors presents in SLE are disease-specific like renal disease manifestation as Lupus nephritis (LN), presence of pro-inflammatory cytokines, some of inflammatory mediators, antiphospholipid antibodies, anti-oxLDL antibodies, corticosteroid uses and cumulative dose of glucocorticoids. We will review traditional and non-traditional risk factors associated with CVD in SLE patients.

Short-term perioperative all-cause mortality and cardiovascular events in women with systemic lupus erythematosus

OBJECTIVE

Persons with systemic lupus erythematosus (SLE) are at an increased risk of cardiovascular disease (CVD) events, but this excess CVD burden in the perioperative setting is yet to be determined. We aimed to determine the risk of perioperative short-term all-cause mortality and CVD events among women with SLE compared to those without SLE.

METHODS

We conducted a cross-sectional analysis of pooled hospital discharge data of the Nationwide Inpatient Sample from 1998-2002. We abstracted diseases and procedures using International Classification of Diseases, Ninth Revision, Clinical Modification codes. The principal procedure was categorized into either a low, intermediate, or high risk level. Survey logistic regression adjusting for potential confounders provided estimates for stratum-specific odds of adverse events in women with SLE relative to those without SLE for each procedure risk level.

RESULTS

All-cause mortality was significantly greater among women with SLE having a low- (odds ratio [OR] 1.54, 95% confidence interval [95% CI] 1.00-2.37) or a high-risk principal procedure (OR 2.52, 95% CI 1.34-4.75) relative to women without SLE, but did not differ significantly among persons with intermediate-risk procedures. Women with SLE with a low-risk procedure were also more likely to experience a composite CVD event relative to women without SLE (OR 1.40, 95% CI 1.04-1.87).

CONCLUSION

Women with SLE are at an increased risk for short-term perioperative adverse events. These results highlight a need for greater scrutiny during perioperative evaluation and management of women with SLE.

Long-term cardiac changes in patients with systemic lupus erythematosus

Background

The aim of this study was evaluate the late-onset repercussions of heart alterations of patients with systemic lupus erythematosus (SLE) after a 13-year follow up.

Methods

A historical prospective study was carried out involving the analysis of data from the charts of patients with a confirmed diagnosis of lupus in follow up since 1998. The 13-year evolution was systematically reviewed and tabulated to facilitate the interpretation of the data.

Results

Forty-eight patient charts were analyzed. Mean patient age was 34.5 ± 10.8 years at the time of diagnosis and 41.0 ± 10.3 years at the time of the study (45 women and 3 men). Eight deaths occurred in the follow-up period (two due to heart problems). Among the alterations found on the complementary exams, 46.2% of cases demonstrated worsening at reevaluation and four patients required a heart catheterization. In these cases, coronary angioplasty was performed due to the severity of the obstructions and one case required a further catheterization, culminating in the need for surgical myocardial revascularization.

Conclusion

The analysis demonstrated progressive heart impairment, with high rates of alterations on conventional complementary exams, including the need for angioplasty or revascularization surgery in four patients. These findings indicate the need for rigorous cardiac follow up in patients with systemic lupus erythematosus.

Pulmonary hypertension in systemic lupus erythematosus: prevalence, predictors and diagnostic strategy

OBJECTIVES

To investigate the prevalence and predictors of pulmonary hypertension (PH) in patients with systemic lupus erythematosus (SLE) and to validate a diagnostic strategy.

METHODS

245 patients with SLE entered a screening program. Possible PH was defined as two consecutive systolic pulmonary arterial pressure (PAP) values ≥ 40mmHg by echocardiography. The subsequent diagnostic procedure, including right heart catheterization if needed, confirmed or excluded the diagnosis of PH secondary to cardiopulmonary disease or SLE-related pulmonary arterial hypertension (PAH). Independent predictors of PH were identified by multivariant multiple linear or logistic regression models. The sensitivity (S), specificity (SP), positive (PPV) and negative predictive values (NPV) were calculated for different screening cutoff values.

RESULTS

88% patients were women. The mean (SD) age at the time of enrolment was 45 (16) years. 12 cases of PH were detected, all secondary, with a resulting prevalence of 5%. Two consecutive echocardiographic PAP measurements ≥ 40mmHg performed best as the cutoff point for screening (S 100%, SP 97%, PPV 70, NPV 100), as compared with single PAP measurements ≥ 30mmHg or ≥ 40mmHg The age at the time of enrolment was the only variable independently associated with PAP values (p=0.0001), with the SLICC damage index score showing a borderline association (p=0.08). Only the age at the time of enrolment showed an independent association with PH (OR 1.10, 95% CI 1.06-1.17).

CONCLUSION

We found a low prevalence of PH. Screening echocardiograms in asymptomatic lupus patients are thus not recommended. Two consecutive PAP values ≥ 40mmHg by echocardiogram is the best screening cutoff for starting investigations in SLE patients with suspected PH.

Prognostic factors for survival in systemic lupus erythematosus associated pulmonary hypertension

Objective: Pulmonary hypertension (PH) is a rare but severe manifestation of systemic lupus erythematosus (SLE) that can ultimately result in death. The identification of factors that prognosticate survival in SLE-PH is necessary for appropriate monitoring, timing of therapeutics and lung transplantation. The primary objective of this study was to identify prognostic factors for survival in SLE-PH through review of the literature. The methodological quality of the prognostic studies was also evaluated .Methods: A systematic review of the literature was performed to identify studies evaluating prognostic factors for survival in SLE-PH. Medline, EMBASE, CINAHL, and Cochrane Central Registry of Controlled Trials (inception – week 2 2010) were searched. A standardized abstraction form was used by two independent reviewers to extract prognostic factors. Methodological quality was evaluated using a validated quality index. Results: Twenty-three observational studies from 375 citations were evaluated. Elevated mean pulmonary artery pressure, Raynaud’s phenomenon, thrombocytopenia, plexiform lesion, infection, thrombosis, pregnancy, pulmonary vasculitis and anticardiolipin antibodies were associated with decreased survival. Lupus disease activity, nephritis and central nervous system disease were not associated with survival. The sample sizes were small and methodological quality of the studies was variable. Conclusion: This study summarizes factors that may be associated with decreased survival in SLE-PH. The small sample sizes and variable methodological quality preclude definitive conclusions. This study provides the groundwork for further research using large cohorts.

Prediction of cardiovascular events by using non-vascular findings on routine chest CT

Background

Routine computed tomography (CT) examinations contain an abundance of findings unrelated to the diagnostic question. Those with prognostic significance may contribute to early detection and treatment of disease, irrelevant findings can be ignored. We aimed to assess the association between unrequested chest CT findings in lungs, mediastinum and pleura and future cardiovascular events.

Methods

Multi-center case-cohort study in 5 tertiary and 3 secondary care hospitals involving 10410 subjects who underwent routine chest CT for non-cardiovascular reasons. 493 cardiovascular hospitalizations or deaths were recorded during an average follow-up time of 17.8 months. 1191 patients were randomly sampled to serve as a control subcohort. Hazard ratios and annualized event rates were calculated.

Results

Abnormalities in the lung (26–44%), pleura (14–15%) and mediastinum (20%) were common. Hazard ratios after adjustment for age and sex were for airway wall thickening 2.26 (1.59–3.22), ground glass opacities 2.50 (1.72–3.62), consolidations 1.97 (1.12–3.47), pleural effusions 2.77 (1.81–4.25) and lymph-nodes 2.04 (1.40–2.96). Corresponding annual event rates were 5.5%, 6.0%, 3.8%, 10.2% and 4.4%.

Conclusions

We have identified several common chest CT findings that are predictive for future risk of cardiovascular events and found that other findings have little utility for this. The added value of the non-vascular predictors to established vascular calcifications on CT remains to be determined.

Cardiovascular disease in systemic lupus erythematosus: the role of traditional and lupus related risk factors

Atherosclerosis is a chronic inflammatory disorder characterized by immune cell activation, inflammation driven plaque formation and subsequent destabilization. In other disorders of an inflammatory nature, the chronic inflammatory state per se has been linked to acceleration of the atherosclerotic process which is underlined by an increased incidence of cardiovascular disease (CVD) in disorders such as systemic lupus erythematosus (SLE), rheumatoid arthritis (RA) and antiphopholipid (Hughes) syndrome (APS). SLE is an autoimmune disease that may affect any organ. Premature coronary heart disease has emerged as a major cause of morbidity and mortality in SLE. In addition to mortality, cardiovascular morbidity is also markedly increased in these patients, compared with the general population. The increased cardiovascular risk can be explained only partially by an increased prevalence of classical risk factors for cardiovascular disease; it also appears to be related to inflammation. Inflammation is increasingly being considered central to the pathogenesis of atherosclerosis and an important risk factor for vascular disease. Recent epidemiologic and pathogenesis studies have suggested a great deal in common between the pathogenesis of prototypic autoimmune disease such as SLE and that of atherosclerosis.

We will review traditional risk factors for CVD in SLE. We will also discuss the role of inflammation in atherosclerosis, as well as possible treatment strategies in these patients.

[Pulmonary arterial hypertension in systemic lupus erythematosus]

Pulmonary hypertension (PH) is a serious complication of connective tissue diseases. The prevalence of PH in systemic lupus erythematosus (SLE) ranges from 0.5 to 17.5%, depending on whether echocardiography or right heart catheterization is used as the gold standard for diagnosis. The recent guidelines for the diagnosis and treatment of pulmonary hypertension include several potential causes of PH in SLE, including: a primary vasculopathy similar to idiopathic pulmonary arterial hypertension (PAH); left heart diseases; post-thromboembolic disease; hypoxia and fibrosis resulting from interstitial lung disease; and the infrequent SLE-associated pulmonary veno-occlusive disease. The pathogenesis of PAH associated with lupus is yet unclear, but likely includes a role for the genetic background, the presence of antiphospholipid antibodies, and some level of endothelial dysfunction. The evolution of SLE-associated PH is highly variable and difficult to elicit because the published series have used heterogeneous inclusion criteria. Optimal therapeutic management of PAH associated with lupus is unclear because no dedicated randomized controlled trial is yet available. Treatment usually includes arterial pulmonary vasodilators and immunosuppressive agents when the patients have NYHA functional class II, III or IV dyspnea.

[A wolf in sheep's clothing: atypical systemic lupus erythematosus (SLE) presenting as cardiovascular disease]

CASE REPORT

A 51-year-old woman diagnosed as having valvular cardiomyopathy since age 34 was admitted for an evaluation for a heart transplant because of progressive congestive heart failure. When antiphospholipid antibodies were detected, the diagnosis of a thus far undetected systemic lupus erythematosus (SLE) was confirmed, manifesting primarily by cardiac involvement and an antiphospholipid antibody syndrome. Despite an advanced stage of heart failure, the patient responded well to azathioprine. Nevertheless, the potential necessity of a heart transplant remained. Its atypical presentation impeded a timely diagnosis of SLE significantly, however, in retrospect the correct diagnosis would have been possible at an earlier time point.

CONCLUSION

Though rare, SLE represents an important differential diagnosis in cases of severe valvular disease and cardiomyopathy, particularly in young women.

Plasma from systemic lupus patients compromises cholesterol homeostasis: a potential mechanism linking autoimmunity to atherosclerotic cardiovascular disease

Atherosclerotic cardiovascular disease (ASCVD) contributes to morbidity and mortality in systemic lupus erythematosus (SLE). Immunologic derangements may disrupt cholesterol balance in vessel wall monocytes/macrophages and endothelium. We determined whether lupus plasma impacts expression of cholesterol 27-hydroxylase, an anti-atherogenic cholesterol-degrading enzyme that promotes cellular cholesterol efflux, in THP-1 human monocytes and primary human aortic endothelial cells (HAEC). THP-1 monocytes and HAEC were incubated in medium containing SLE patient plasma or apparently healthy control human plasma (CHP). SLE plasma decreased 27-hydroxylase message in THP-1 monocytes by 47 +/- 8% (p < 0.008) and in HAEC by 51 +/- 5.5% (n = 5, p < 0.001). THP-1 macrophages were incubated in 25% lupus plasma or CHP and cholesterol-loaded (50 microg ml(-1) acetylated low density lipoprotein). Lupus plasma more than doubled macrophage foam cell transformation (74 +/- 3% vs. 35 +/- 3% for CHP, n = 3, p < 0.001). Impaired cholesterol homeostasis in SLE provides further evidence of immune involvement in atherogenesis. Strategies to inhibit or reverse arterial cholesterol accumulation may benefit SLE patients.

Atherosclerosis in Asian Indians with systemic lupus erythematosus

OBJECTIVES

Atherosclerosis has emerged as an important late complication of systemic lupus erythematosus (SLE). Asian Indians, as an ethnic group, are known to be metabolically predisposed to development of early atherosclerosis. No data on this aspect of SLE are available from Asia. This study was undertaken to find the frequency of atherosclerosis in Indian lupus patients and the factors affecting such an occurrence.

METHODS

Carotid artery intimo-medial thickness (IMT) and plaque were used as markers of atherosclerosis. High-resolution B-mode ultrasonography was used to compare carotid IMT and plaque in 50 patients with SLE and 50 age- and sex-matched healthy controls.

RESULTS

Patients with lupus (age 31.6+/-10.05, median 30.5 years; disease duration 52.3+/-36.7, median 46 months) exhibited a significantly greater IMT than controls (0.417+/-0.07 vs. 0.362+/-00.07 mm; p = 0.003). Carotid plaques were seen in seven (14%) cases. None of the control population had plaques (p = 0.006). On bivariate analysis, the IMT was significantly affected by age, systolic blood pressure (SBP), disease duration and menopausal status. On multivariate analysis, the only factor significantly affecting IMT was SBP. The Systemic Lupus International Collaborating Clinics/American College of Rheumatology (SLICC/ACR) score was the sole factor found to significantly affect the occurrence of plaque.

CONCLUSIONS

Asian Indian lupus patients in our study, despite being relatively young and with shorter disease duration, exhibited premature atherosclerosis in the form of significantly thicker intimo-media and plaque. The factors found to affect accelerated atherosclerosis in our cohort were age, SBP, disease duration, postmenopausal status and the SLICC/ACR score.

Systemic lupus erythematosus in the Fars Province of Iran

Abstract

Clinical features of systemic lupus erythematosus (SLE) have been described from different geographical regions in the world. However, data from many Middle East countries, including Iran, are scarce. This study aims to demonstrate the demographic, clinical, and laboratory characteristics in Iranian patients with SLE. In this prospective study, all the patients referring to Shiraz educational hospitals (Nemazi–Hafez) with SLE (American College of Rheumatology criteria) during a 5-year period (2001 to 2006) were included. A complete history was taken; physical examination and routine hematological, serological, and immunological tests were done for each patient. There were 356 women and 54 men with an average age of 30.27 years at the onset of disease. Of the patients, 78% had hematological abnormalities, 65.5% had articular involvement, 54.5% had photosensitivity, and 60.5% had malar rash. Serositis occurred in 38% of patients of whom 12% had pericarditis and 26% had pleuritis. Nephritis was diagnosed in 48% of the cases and consisted always of glomerular nephritis. Biopsy-proven lupus nephritis was in most cases class IV(49.7% of all the biopsies). Oral ulcers were observed in 28% of patients. Neuropsychiatric manifestations, gastrointestinal involvement, and lymphadenopathy were observed in 31.5%, 8.3%, and 14.2% of patients, respectively. In all, 93% of patients were positive for antinuclear antibodies, whereas antidouble-stranded DNA was positive in 83% of patients. Coomb’s positive hemolytic anemia appeared in 12.4% of the cases. Rheumatoid factor was detected in 9.7% of patients, and lupus erythematosus cell was seen in 32.5% of them. In all, 196 (47.8%) patients represented hypocomplementemia. Regarding hematological manifestations, 74.5% had microcytic hypochromic anemia, 64.6% had leukopenia, and 44.6% had thrombocytopenia; 18 (4.4%) patients died during the study period of which eight (2%) died because of cardiopulmonary involvement. Generally, there was more cutaneous, serositis, and neuropsychiatric involvement in our population than other Middle East countries. Serositis was associated with poorer prognosis, and the pattern of disease in these patients was much more sever than patients without serositis ( P = 0.001). This is the first study of its kind in Iran. More multicenter studies should be undertaken in Iran to describe the pattern of SLE.

A Long-Term Follow-up after Cardiac Transplantation in a Lupus Patient: Case Report and Review of the Literature

Heart or heart-lung transplantations have only rarely been performed in patients with systemic lupus erythematosus (SLE), who like other patients with multi-system autoimmune diseases are traditionally excluded from consideration for such transplantations. In view of the limited experience with heart transplantation in these patients, we report the successful transplantation outcome in a lupus patient and review the literature in relation to graft and recipient conditions.