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Porsch F, Binder CJ. Autoimmune diseases and atherosclerotic cardiovascular disease. Nat Rev Cardiol 2024:10.1038/s41569-024-01045-7. [PMID: 38937626 DOI: 10.1038/s41569-024-01045-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/28/2024] [Indexed: 06/29/2024]
Abstract
Autoimmune diseases are associated with a dramatically increased risk of atherosclerotic cardiovascular disease and its clinical manifestations. The increased risk is consistent with the notion that atherogenesis is modulated by both protective and disease-promoting immune mechanisms. Notably, traditional cardiovascular risk factors such as dyslipidaemia and hypertension alone do not explain the increased risk of cardiovascular disease associated with autoimmune diseases. Several mechanisms have been implicated in mediating the autoimmunity-associated cardiovascular risk, either directly or by modulating the effect of other risk factors in a complex interplay. Aberrant leukocyte function and pro-inflammatory cytokines are central to both disease entities, resulting in vascular dysfunction, impaired resolution of inflammation and promotion of chronic inflammation. Similarly, loss of tolerance to self-antigens and the generation of autoantibodies are key features of autoimmunity but are also implicated in the maladaptive inflammatory response during atherosclerotic cardiovascular disease. Therefore, immunomodulatory therapies are potential efficacious interventions to directly reduce the risk of cardiovascular disease, and biomarkers of autoimmune disease activity could be relevant tools to stratify patients with autoimmunity according to their cardiovascular risk. In this Review, we discuss the pathophysiological aspects of the increased cardiovascular risk associated with autoimmunity and highlight the many open questions that need to be answered to develop novel therapies that specifically address this unmet clinical need.
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Affiliation(s)
- Florentina Porsch
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Christoph J Binder
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria.
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Inflammatory, Serological and Vascular Determinants of Cardiovascular Disease in Systemic Lupus Erythematosus Patients. Int J Mol Sci 2019; 20:ijms20092154. [PMID: 31052336 PMCID: PMC6540240 DOI: 10.3390/ijms20092154] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 04/16/2019] [Accepted: 04/24/2019] [Indexed: 12/20/2022] Open
Abstract
Background and aim: Systemic lupus erythematosus (SLE) is associated with increased risk of cardiovascular disease (CVD). Among many mechanisms, accelerated atherosclerosis, endothelial dysfunction, and hypercoagulability play a main role. Here, we investigate whether inflammatory, serological and clinical markers of SLE determine and correlate with arterial stiffness in SLE patients. Materials and methods: Routine blood samples, inflammatory mediators, specific antibodies, and 24 h proteinuria were measured in 43 SLE patients and 43 age and sex-matched controls using routine laboratory assays. We also assessed arterial stiffness by measuring radial artery applanation tonometry-derived augmentation index (AI), normalized AI (AIx@75), aortic pulse pressure, central systolic, diastolic and peripheral blood pressure. Results: SLE patients showed a significantly greater arterial stiffness vs. controls, as demonstrated by the significantly higher AIx@75 and aortic pulse pressure. Interestingly, regression analysis showed that age, systolic pulse pressure, inflammatory markers (erythrocyte sedimentation rate and C-reactive protein), daily dose of glucocorticoids, and cumulative organ damage positively correlated with arterial stiffness. Conclusions: SLE patients show increased arterial stiffness which correlates with markers of inflammation, that is involved in early alterations in arterial walls. Applanation tonometry can be used to screen SLE patients for subclinical vascular damage to implement prevention strategies for CVD.
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Kurmann RD, Mankad R. Atherosclerotic vascular disease in the autoimmune rheumatologic woman. Clin Cardiol 2018; 41:258-263. [PMID: 29480591 DOI: 10.1002/clc.22916] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 01/30/2018] [Accepted: 02/01/2018] [Indexed: 01/03/2023] Open
Abstract
Autoimmune rheumatologic conditions have increased cardiovascular morbidity and mortality compared to the general population. Many of these diseases occur more commonly in women, such as rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), systemic sclerosis, and Sjogren's. Most of the literature that has identified the link between autoimmune diseases and atherosclerotic cardiovascular disease (ASCVD) has been regarding patients with RA and SLE. The reason for the increased ASCVD is related to both traditional risk factors for atherosclerosis and nontraditional risk factors such as the burden of inflammation. Presently, our ability to adequately determinecardiovascular risk in the autoimmune patient is subpar, as scoring systems fail to take into account the role of inflammation. No present guidelines exist that take into account the increased burden of cardiovascular disease in this complex patient cohort.
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Affiliation(s)
| | - Rekha Mankad
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
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Tselios K, Gladman DD, Su J, Ace O, Urowitz MB. Evolution of Risk Factors for Atherosclerotic Cardiovascular Events in Systemic Lupus Erythematosus: A Longterm Prospective Study. J Rheumatol 2017; 44:1841-1849. [DOI: 10.3899/jrheum.161121] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/28/2017] [Indexed: 01/13/2023]
Abstract
Objective.We previously reported the effect of certain factors on cardiovascular disease (CVD) in 250 women with systemic lupus erythematosus (SLE) followed for 8 years. The aim of this study was to delineate their evolution after 15 years of followup.Methods.There were 210 women with SLE and 138 age-matched healthy women available for analysis after 15 years. Cardiovascular events (CVE) included angina pectoris, myocardial infarction (fatal and nonfatal), transient ischemic attack, and stroke (fatal and nonfatal). Analysis was performed with SAS 9.3 software; p < 0.05 was considered significant.Results.CVE occurred in 41/210 patients (19.5%) and 9/138 controls (6.5%), most of them in the second part (2008–2015) of the study (24/210, 11.4% vs 17/241, 7.1% in SLE group). Coronary artery disease was more common in patients (32/210, 15.2% vs 5/138, 3.6%, p = 0.0041). There was no significant difference for cerebrovascular disease (10/210, 4.8% vs 3/138, 2.2%, p = 0.213). SLE was the most prominent CVE predictor in the first 8 years (HR 2.8, 95% CI 1.3–6.3). Hypertension and diabetes were more frequent in patients who developed CVE during the second half of the study. Thirty-one deaths occurred in patients with SLE (10 because of CVD) and 6 in controls (none because of CVD).Conclusion.The relative importance of atherosclerotic risk factors is significantly differentiated over time in SLE. Disease-related factors seem to dominate CV risk during the early stages while traditional factors, partially related to corticosteroid treatment, play a significant role later in the disease course.
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Soh MC, Nelson-Piercy C, Westgren M, McCowan L, Pasupathy D. Do adverse pregnancy outcomes contribute to accelerated cardiovascular events seen in young women with systemic lupus erythematosus? Lupus 2017; 26:1351-1367. [PMID: 28728509 DOI: 10.1177/0961203317719146] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Cardiovascular events (CVEs) are prevalent in patients with systemic lupus erythematosus (SLE), and it is the young women who are disproportionately at risk. The risk factors for accelerated cardiovascular disease remain unclear, with multiple studies producing conflicting results. In this paper, we aim to address both traditional and SLE-specific risk factors postulated to drive the accelerated vascular disease in this cohort. We also discuss the more recent hypothesis that adverse pregnancy outcomes in the form of maternal-placental syndrome and resultant preterm delivery could potentially contribute to the CVEs seen in young women with SLE who have fewer traditional cardiovascular risk factors. The pathophysiology of how placental-mediated vascular insufficiency and hypoxia (with the secretion of placenta-like growth factor (PlGF) and soluble fms-tyrosine-like kinase-1 (sFlt-1), soluble endoglin (sEng) and other placental factors) work synergistically to damage the vascular endothelium is discussed. Adverse pregnancy outcomes ultimately are a small contributing factor to the complex pathophysiological process of cardiovascular disease in patients with SLE. Future collaborative studies between cardiologists, obstetricians, obstetric physicians and rheumatologists may pave the way for a better understanding of a likely multifactorial aetiological process.
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Affiliation(s)
- M C Soh
- 1 Women's Health Academic Centre, King's College London, United Kingdom.,3 Faculty of Medical and Health Science, University of Auckland, New Zealand
| | - C Nelson-Piercy
- 1 Women's Health Academic Centre, King's College London, United Kingdom
| | - M Westgren
- 2 Department of Clinical Science, Karolinska Institutet, Sweden
| | - L McCowan
- 3 Faculty of Medical and Health Science, University of Auckland, New Zealand.,4 National Women's Health, South Auckland Clinical School of Medicine and Counties Manukau Health, Auckland, New Zealand
| | - D Pasupathy
- 1 Women's Health Academic Centre, King's College London, United Kingdom.,5 Biomedical Research Centre at Guy's & St Thomas's NHS Foundation Trust and King's College London, United Kingdom
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Nakagawa P, Masjoan-Juncos JX, Basha H, Janic B, Worou ME, Liao TD, Romero CA, Peterson EL, Carretero OA. Effects of N-acetyl-seryl-asparyl-lysyl-proline on blood pressure, renal damage, and mortality in systemic lupus erythematosus. Physiol Rep 2017; 5:5/2/e13084. [PMID: 28126732 PMCID: PMC5269407 DOI: 10.14814/phy2.13084] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Revised: 08/15/2016] [Accepted: 09/12/2016] [Indexed: 11/24/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is an autoimmune disease with a high prevalence of hypertension. NZBWF1 (SLE‐Hyp) mice develop hypertension that can be prevented by modulating T cells. The peptide N‐acetyl‐seryl‐aspartyl‐lysyl‐proline (Ac‐SDKP) decreases renal damage and improves renal function in a model of SLE without hypertension (MRL/lpr). However, it is not known whether Ac‐SDKP prevents hypertension in NZBWF1 mice. We hypothesized that in SLE‐Hyp, Ac‐SDKP prevents hypertension and renal damage by modulating T cells. Animals were divided into four groups: (1) control + vehicle, (2) control + Ac‐SDKP, (3) SLE + vehicle, and (4) SLE + Ac‐SDKP. Systolic blood pressure (SBP), albuminuria, renal fibrosis, and T‐cell phenotype were analyzed. SBP was higher in SLE compared to control mice and was not decreased by Ac‐SDKP treatment. Half of SLE mice developed an acute and severe form of hypertension accompanied by albuminuria followed by death. Ac‐SDKP delayed development of severe hypertension, albuminuria, and early mortality, but this delay did not reach statistical significance. Ac‐SDKP prevented glomerulosclerosis, but not interstitial fibrosis in SLE‐Hyp mice. SLE‐Hyp mice showed a decrease in helper and cytotoxic T cells as well as an increase in double negative lymphocytes and T helper 17 cells, but these cells were unaffected by Ac‐SDKP. In conclusion, Ac‐SDKP prevents kidney damage, without affecting blood pressure in an SLE animal model. However, during the acute relapse of SLE, Ac‐SDKP might also delay the manifestation of an acute and severe form of hypertension leading to early mortality. Ac‐SDKP is a potential tool to treat renal damage in SLE‐Hyp mice.
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Affiliation(s)
- Pablo Nakagawa
- Hypertension and Vascular Research Division, Department of Internal Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Juan X Masjoan-Juncos
- Hypertension and Vascular Research Division, Department of Internal Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Heba Basha
- Hypertension and Vascular Research Division, Department of Internal Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Branislava Janic
- Hypertension and Vascular Research Division, Department of Internal Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Morel E Worou
- Hypertension and Vascular Research Division, Department of Internal Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Tang-Dong Liao
- Hypertension and Vascular Research Division, Department of Internal Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Cesar A Romero
- Hypertension and Vascular Research Division, Department of Internal Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Edward L Peterson
- Department of Public Health Sciences, Henry Ford Hospital, Detroit, Michigan
| | - Oscar A Carretero
- Hypertension and Vascular Research Division, Department of Internal Medicine, Henry Ford Hospital, Detroit, Michigan
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Bhatt SP, Handa R, Gulati GS, Sharma S, Pandey RM, Aggarwal P, Ramakrishnan L, Shankar S. Peripheral vascular disease in systemic lupus erythematosus. Lupus 2016; 16:720-3. [PMID: 17728365 DOI: 10.1177/0961203307081123] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
With increasing longevity of lupus patients, peripheral vascular disease (PVD) has become an important cause of morbidity. With no systematic study of PVD in systemic lupus erythematosus (SLE), this study was undertaken to define the frequency and spectrum of PVD in SLE and factors affecting such an occurrence. All medium-sized peripheral arteries of bilateral upper and lower extremities were studied in 50 SLE patients using Doppler ultrasonography. PVD was defined clinically as one or more of intermittent claudication, absent/unequal pulses, gangrene or ischemic ulcers and sub-clinically as asymptomatic patients with Doppler abnormalities, with ≥50% reduction in diameter considered hemodynamically significant. Mean (SD) age of the patients was 31.6 (10.1) years. Forty-one percent were hypertensive. Dyslipidemia was found in 62%. Fifteen (30%) had Raynaud's phenomenon. Fourteen (28%) patients had PVD, of whom three had positive markers for antiphospholipid antibody (aPL) and six were asymptomatic. Ischemic ulcers were seen in eight (16%), gangrene in three (6%), femoral artery plaques in two (4%), stenosis in four (8%) and intermittent claudication in none. Dyslipidemia was found to independently affect occurrence of PVD (OR = 5.37, [95% CI 1.05—27.5], P = 0.05). The causes of PVD overlap significantly and further studies are needed to ascertain the relative contribution of each. Lupus (2007) 16, 720—723.
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Affiliation(s)
- S P Bhatt
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
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Hayata ALS, Borba EF, Bonfá E, Kochen JAL, Goldenstein-Schainberg C. The frequency of high/moderate lipoprotein risk factor for coronary artery disease is significant in juvenile-onset systemic lupus erythematosus. Lupus 2016; 14:613-7. [PMID: 16175933 DOI: 10.1191/0961203305lu2177oa] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
To determine the prevalence of dyslipoproteinemia on a large juvenile systemic lupus erythematosus (jSLE) cohort, we selected 40 patients after rigorous exclusion criteria. Lipoprotein levels were determinated after 12 hours fast and risk levels for CAD were defined by standards of the Brazilian Guidelines for dyslipoproteinemia according to US-NCEP. All individuals were under steroid therapy and chloroquine and 43% had active disease. Thirty patients (75%) had high-risk levels for CAD (23 isolated low HDL, while in seven subjects low HDL was associated to high TG in four, high LDL in one, high TG/LDL in one and high TC/LDL in one). Remarkably, overall analysis revealed that 85% patients were included in high/medium risk levels group (29% for TC, 29% for LDL, 88% for HDL, and 18% for TG) and these disturbances occured mainly in the first four years of disease. Unexpectedly, one-third of the patients presented two or more high/medium lipoprotein risk factors. Independently, active jSLE was associated to TG (OR = 3.2; P < 0.001) and had a tendency towards reduction on HDL (OR = 8.5; P = 0.056). Considering improvements on jSLE outcome, the increased frequency of high/medium lipoprotein risk levels for CAD reinforces the need of prevention measures in order to minimize deleterious effects of this disturbance.
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Affiliation(s)
- A L S Hayata
- Division of Rheumatology, University of São Paulo, Brazil.
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Muangchan C, van Vollenhoven RF, Bernatsky SR, Smith CD, Hudson M, Inanç M, Rothfield NF, Nash PT, Furie RA, Senécal JL, Chandran V, Burgos-Vargas R, Ramsey-Goldman R, Pope JE. Treatment Algorithms in Systemic Lupus Erythematosus. Arthritis Care Res (Hoboken) 2016; 67:1237-1245. [PMID: 25777803 DOI: 10.1002/acr.22589] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2014] [Revised: 02/01/2015] [Accepted: 03/10/2015] [Indexed: 01/14/2023]
Abstract
OBJECTIVE To establish agreement on systemic lupus erythematosus (SLE) treatment. METHODS SLE experts (n = 69) were e-mailed scenarios and indicated preferred treatments. Algorithms were constructed and agreement determined (≥50% respondents indicating ≥70% agreement). RESULTS Initially, 54% (n = 37) responded suggesting treatment for scenarios; 13 experts rated agreement with scenarios. Fourteen of 16 scenarios had agreement as follows: discoid lupus: first-line therapy was topical agents and hydroxychloroquine and/or glucocorticoids then azathioprine and subsequently mycophenolate (mofetil); uncomplicated cutaneous vasculitis: initial treatment was glucocorticoids ± hydroxychloroquine ± methotrexate, followed by azathioprine or mycophenolate and then cyclophosphamide; arthritis: initial therapy was hydroxychloroquine and/or glucocorticoids, then methotrexate and subsequently rituximab; pericarditis: first-line therapy was nonsteroidal antiinflammatory drugs, then glucocorticoids with/without hydroxychloroquine, then azathioprine, mycophenolate, or methotrexate and finally belimumab or rituximab, and/or a pericardial window; interstitial lung disease/alveolitis: induction was glucocorticoids and mycophenolate or cyclophosphamide, then rituximab or intravenous gamma globulin (IVIG), and maintenance followed with azathioprine or mycophenolate; pulmonary hypertension: glucocorticoids and mycophenolate or cyclophosphamide and an endothelin receptor antagonist were initial therapies, subsequent treatments were phosphodiesterase-5 inhibitors and then prostanoids and rituximab; antiphospholipid antibody syndrome: standard anticoagulation with/without hydroxychloroquine, then a thrombin inhibitor for venous thrombosis, versus adding aspirin or platelet inhibition drugs for arterial events; mononeuritis multiplex and central nervous system vasculitis: first-line therapy was glucocorticoids and cyclophosphamide followed by maintenance with azathioprine or mycophenolate, and then rituximab, IVIG, or plasmapheresis; and serious lupus nephritis: first-line therapy was glucocorticoids and mycophenolate, then cyclophosphamide then rituximab. CONCLUSION We established variable agreement on treatment approaches. For some treatment decisions there was good agreement between experts even if no randomized controlled trial data were available.
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Affiliation(s)
- Chayawee Muangchan
- Siriraj Hospital, Mahidol University, Bangkok, Thailand, and University of Western Ontario, London, Ontario, Canada
| | | | - Sasha R Bernatsky
- Montreal General Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | | | - Marie Hudson
- Jewish General Hospital and McGill University, Montreal, Quebec, Canada
| | | | | | - Peter T Nash
- University of Queensland, Brisbane, Queensland, Australia
| | | | - Jean-Luc Senécal
- Centre Hospitalier and School of Medicine of the University of Montreal, Montreal, Quebec, Canada
| | - Vinod Chandran
- University of Toronto and University Health Network, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Ruben Burgos-Vargas
- Hospital General de México and Universidad Nacional Autónoma de México, Mexico City, Mexico
| | | | - Janet E Pope
- University of Western Ontario, London, Ontario, Canada
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Mankad R. Atherosclerotic vascular disease in the autoimmune rheumatologic patient. Curr Atheroscler Rep 2015; 17:497. [PMID: 25721102 DOI: 10.1007/s11883-015-0497-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Autoimmune diseases, such as rheumatoid arthritis and systemic lupus erythematosus, have a strong association with an increased risk of atherosclerotic cardiovascular diseases (ASCVD), particularly ischemic heart disease (IHD). A majority of the autoimmune conditions occur predominantly in women, and as women continue to experience a higher cardiovascular mortality compared to men, this potential added risk factor must be recognized. Inflammation and immune mechanisms have been shown to be an underlying mechanism for the development of atherosclerosis, thus sharing a common mechanism with rheumatologic conditions. There is an under recognition, in both patient and physician, of the increased cardiovascular (CV) risk within the autoimmune population, with present CV risk profile algorithms performing poorly in these patients. Traditional risk factors play a role in the development of IHD in the autoimmune patient, but their overall significance is unclear and does not fully explain the elevated CV risk. The role of inflammation and risk factors in autoimmune conditions, and their link to the elevated CV risk will be explored within this article.
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Affiliation(s)
- Rekha Mankad
- Division of Cardiovascular Diseases, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA,
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Tselios K, Sheane BJ, Gladman DD, Urowitz MB. Optimal Monitoring For Coronary Heart Disease Risk in Patients with Systemic Lupus Erythematosus: A Systematic Review. J Rheumatol 2015; 43:54-65. [DOI: 10.3899/jrheum.150460] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/28/2015] [Indexed: 01/11/2023]
Abstract
Objective.Premature coronary heart disease (CHD) significantly affects morbidity and mortality in systemic lupus erythematosus (SLE). Several studies have detected factors influencing the atherosclerotic process, as well as methods to quantify the atherosclerotic burden in subclinical stages. The aim of this systematic review was to identify the minimum investigations to optimally monitor CHD risk in SLE.Methods.English-restricted literature review was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines through Ovid Medline, Embase, and Cochrane Central databases, from inception until May 2014 (Medline until October 2014). Specific search terms included, among others, “SLE,” “atherosclerosis,” “CHD,” “myocardial ischemia,” “acute coronary syndrome,” “myocardial infarction,” and “angina pectoris.” We identified 101 eligible articles, 23 with cardiovascular events (CVE) as endpoints and 78 with measures of subclinical atherosclerosis. The Newcastle-Ottawa scale was used for quality assessment.Results.Certain traditional and disease-specific factors were identified as independent predictors for CHD. Among the former were age (particularly postmenopausal state), male sex, arterial hypertension, dyslipidemia, and smoking. Disease activity and duration, cumulative damage, antiphospholipid antibodies, high sensitivity C-reactive protein, and renal disease were the most consistent disease-related factors. Corticosteroids were linked to increased CHD risk whereas antimalarials were protective. Concerning imaging techniques, carotid ultrasonography (intima-media thickness and plaque) was shown to independently predict CVE.Conclusion.Premature CHD in SLE is multifactorial; modifiable variables should be monitored at frequent intervals to ensure prompt management. Disease-specific factors also affect the atherogenic process and should be evaluated regularly. Carotid ultrasonography may hold promise in predicting CVE in selected high-risk patients.
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Tselios K, Koumaras C, Gladman DD, Urowitz MB. Dyslipidemia in systemic lupus erythematosus: just another comorbidity? Semin Arthritis Rheum 2015; 45:604-10. [PMID: 26711309 DOI: 10.1016/j.semarthrit.2015.10.010] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 10/13/2015] [Accepted: 10/23/2015] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Among traditional atherosclerotic risk factors, dyslipidemia is believed to decisively affect the long-term prognosis of lupus patients, not only with regard to cardiovascular events but also by influencing other manifestations, such as lupus nephritis. The aim of this study was to review the epidemiology, pathogenesis, evidence for its impact on atherosclerosis manifestations and management of dyslipidemia in lupus patients. METHODS English-restricted MEDLINE database search (Medical Subject Headings: lupus or systemic lupus erythematosus and dyslipidemia or hyperlipidemia). RESULTS The prevalence of dyslipidemia in systemic lupus erythematosus (SLE) ranges from 36% at diagnosis to 60% or even higher after 3 years, depending on definition. Multiple pathogenetic mechanisms are implicated, including antibodies against lipoprotein lipase and cytokines affecting the balance between pro- and anti-atherogenic lipoproteins. Dyslipidemia has a clear impact on clinical cardiovascular disease and surrogate markers for subclinical atherosclerosis. Moreover, it negatively affects end-organ damage (kidneys and brain). Treatment with statins yielded contradictory results as per minimizing cardiovascular risk. CONCLUSIONS Dyslipidemia is a significant comorbidity of lupus patients with multiple negative effects in the long term. Its treatment represents a modifiable risk factor; prompt and adequate treatment can minimize unnecessary burden in lupus patients, thus reducing hospitalizations and their overall morbidity and mortality.
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Affiliation(s)
- Konstantinos Tselios
- Centre for Prognosis Studies in Rheumatic Diseases, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Charalambos Koumaras
- 1st Department of Internal Medicine, 424 General Military Hospital of Thessaloniki, Thessaloniki, Greece
| | - Dafna D Gladman
- Centre for Prognosis Studies in Rheumatic Diseases, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Murray B Urowitz
- Centre for Prognosis Studies in Rheumatic Diseases, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada.
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13
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Abdulla MC, Alungal J, Hashim S, Ali MM, Musambil M. SLE presenting as multiple hemorrhagic complications. Lupus 2015; 24:1103-6. [DOI: 10.1177/0961203315573853] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Accepted: 01/28/2015] [Indexed: 11/15/2022]
Abstract
A 24 year old female with hereditary spastic paraplegia presented with intermittent headache for one year. She also had lower abdominal pain and vomiting for two months. She was pale, had icterus and mild splenomegaly. On diagnostic evaluation she was found to have hemolytic anemia, thrombocytopenia and bilateral adrenal, subdural, soft tissue (scalp and orbit) hemorrhages due to systemic lupus erythematosus (SLE). However, antiphospholipid syndrome (APS) antibodies were negative. Bilateral adrenal hemorrhage without associated APS is a rare phenomenon in SLE. We describe a case of SLE presenting with sequence of rare hemorrhagic complications in concert.
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Affiliation(s)
- M C Abdulla
- Department of Internal Medicine, M.E.S. Medical College, Perinthalmanna, India
| | - J Alungal
- Department of Internal Medicine, M.E.S. Medical College, Perinthalmanna, India
| | - S Hashim
- Department of Internal Medicine, M.E.S. Medical College, Perinthalmanna, India
| | - M M Ali
- Department of Internal Medicine, M.E.S. Medical College, Perinthalmanna, India
| | - M Musambil
- Medical biotechnology Central Research Laboratory, M.E.S. Medical College, Perinthalmanna, India
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Nikpour M, Gladman DD, Urowitz MB. Premature coronary heart disease in systemic lupus erythematosus: what risk factors do we understand? Lupus 2014; 22:1243-50. [PMID: 24097996 DOI: 10.1177/0961203313493031] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Coronary heart disease (CHD) is a major cause of mortality in systemic lupus erythematosus (SLE). This 'accelerated atherosclerosis' is due to a combination of traditional risk factors such as hypertension and hyperlipidemia, and also disease-related factors such as chronic inflammation. Recent work has provided valuable insights into the relative contribution of various risk factors and also identified novel risk factors. An understanding of risk factors is fundamental to the prevention of CHD in SLE. In this review, we will discuss the role of risk factors for CHD in SLE and offer some strategies for their assessment and management.
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Affiliation(s)
- M Nikpour
- 1University of Toronto Lupus Clinic and the Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital, Canada
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Sacre K, Escoubet B, Pasquet B, Chauveheid MP, Zennaro MC, Tubach F, Papo T. Increased arterial stiffness in systemic lupus erythematosus (SLE) patients at low risk for cardiovascular disease: a cross-sectional controlled study. PLoS One 2014; 9:e94511. [PMID: 24722263 PMCID: PMC3983200 DOI: 10.1371/journal.pone.0094511] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Accepted: 03/17/2014] [Indexed: 11/19/2022] Open
Abstract
Cardiovascular disease (CVD) is a major cause of death in systemic lupus erythematosus (SLE) patients. Although the risk for cardiovascular events in patients with SLE is significant, the absolute number of events per year in any given cohort remains small. Thus, CVD risks stratification in patients with SLE focuses on surrogate markers for atherosclerosis at an early stage, such as reduced elasticity of arteries. Our study was designed to determine whether arterial stiffness is increased in SLE patients at low risk for CVD and analyze the role for traditional and non-traditional CVD risk factors on arterial stiffness in SLE. Carotid-femoral pulse wave velocity (PWV) was prospectively assessed as a measure of arterial stiffness in 41 SLE patients and 35 controls (CTL). Adjustment on age or Framingham score was performed using a logistic regression model. Factors associated with PWV were identified separately in SLE patients and in controls using Pearson's correlation coefficient for univariate analysis and multiple linear regression for multivariate analysis. SLE patients and controls displayed a low 10-year risk for CVD according to Framingham score (1.8±3.6% in SLE vs 1.6±2.8% in CTL, p = 0.46). Pulse wave velocity was, however, higher in SLE patients (7.1±1.6 m/s) as compared to controls (6.3±0.8 m/s; p = 0.01, after Framingham score adjustment) and correlated with internal carotid wall thickness (p = 0.0017). In multivariable analysis, only systolic blood pressure (p = 0.0005) and cumulative dose of glucocorticoids (p = 0.01) were associated with PWV in SLE patients. Interestingly, the link between systolic blood pressure (SBP) and arterial stiffness was also confirmed in SLE patients with normal systolic blood pressure. In conclusion, arterial stiffness is increased in SLE patients despite a low risk for CVD according to Framingham score and is associated with systolic blood pressure and glucocorticoid therapy.
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Affiliation(s)
- Karim Sacre
- Département de Médecine Interne, Hôpital Bichat, Université Paris Diderot, PRES Sorbonne Paris Cité, Assistance Publique Hôpitaux de Paris, Paris, France
- INSERM U1149, Paris, France
- Département Hospitalo-Universitaire FIRE (Fibrosis, Inflammation and Remodelling in Renal and Respiratory Diseases), Paris, France
- * E-mail:
| | - Brigitte Escoubet
- Département de Physiologie, Hôpital Bichat, Université Paris Diderot, PRES Sorbonne Paris Cité, Assistance Publique Hôpitaux de Paris, INSERM U1138, Paris, France
| | - Blandine Pasquet
- Département d'Epidémiologie et Recherche Clinique, Hôpital Bichat, Université Paris Diderot, PRES Sorbonne Paris Cité, Assistance Publique Hôpitaux de Paris, INSERM CIE 801, Paris, France
| | - Marie-Paule Chauveheid
- Département de Médecine Interne, Hôpital Bichat, Université Paris Diderot, PRES Sorbonne Paris Cité, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Maria-Christina Zennaro
- Département de Cardiologie, Hôpital Européen Georges Pompidou, Université Paris Descartes, PRES Sorbonne Paris Cité, Assistance Publique-Hôpitaux de Paris, INSERM, UMRS 970, Paris, France
| | - Florence Tubach
- Département d'Epidémiologie et Recherche Clinique, Hôpital Bichat, Université Paris Diderot, PRES Sorbonne Paris Cité, Assistance Publique Hôpitaux de Paris, INSERM CIE 801, Paris, France
| | - Thomas Papo
- Département de Médecine Interne, Hôpital Bichat, Université Paris Diderot, PRES Sorbonne Paris Cité, Assistance Publique Hôpitaux de Paris, Paris, France
- INSERM U1149, Paris, France
- Département Hospitalo-Universitaire FIRE (Fibrosis, Inflammation and Remodelling in Renal and Respiratory Diseases), Paris, France
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Chen YM, Lin CH, Chen HH, Chang SN, Hsieh TY, Hung WT, Hsieh CW, Lai KL, Lan JL, Chen DY, Lan TH. Onset age affects mortality and renal outcome of female systemic lupus erythematosus patients: a nationwide population-based study in Taiwan. Rheumatology (Oxford) 2014; 53:180-185. [DOI: 10.1093/rheumatology/ket330] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Abstract
Ischemic stroke is increased in systemic lupus erythematosus (SLE) patients. The differential diagnosis of stroke in SLE is complex. Transient ischemic attack and ischemic stroke share pathophysiologic mechanisms, but prognosis may vary depending on severity and cause, and definitions are dependent on the timing and extent of the diagnostic evaluation. In SLE patients with a history of transient ischemic attacks, stroke occurred in 57%. Cerebrovascular events account for 20% to 30% of deaths in patients with SLE. In SLE, both disease-specific and traditional stroke risk factors are important.
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Affiliation(s)
- H Timlin
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - M Petri
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
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18
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Venegas-Pont M, Mathis KW, Iliescu R, Ray WH, Glover PH, Ryan MJ. Blood pressure and renal hemodynamic responses to acute angiotensin II infusion are enhanced in a female mouse model of systemic lupus erythematosus. Am J Physiol Regul Integr Comp Physiol 2011; 301:R1286-92. [PMID: 21900645 DOI: 10.1152/ajpregu.00079.2011] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Inflammation and immune system dysfunction contributes to the development of cardiovascular and renal disease. Systemic lupus erythematosus (SLE) is a chronic autoimmune inflammatory disorder that carries a high risk for both renal and cardiovascular disease. While hemodynamic changes that may contribute to increased cardiovascular risk have been reported in humans and animal models of SLE, renal hemodynamics have not been widely studied. The renin-angiotensin system (RAS) plays a central role in renal hemodynamic control, and although RAS blockade is a common therapeutic strategy, the role of RAS in hemodynamic function during SLE is not clear. This study tested whether mean arterial pressure (MAP) and renal hemodynamic responses to acute infusions of ANG II in anesthetized animals were enhanced in an established female mouse model of SLE (NZBWF1). Baseline MAP was not different between anesthetized SLE and control (NZWLacJ) mice, while renal blood flow (RBF) was significantly lower in mice with SLE. SLE mice exhibited an enhanced pressor response and greater reduction in RBF after ANG II infusion. An acute infusion of the ANG II receptor blocker losartan increased RBF in control mice but not in mice with SLE. Renin and ANG II type 1 receptor expression was significantly lower, and ANG II type 2 receptor expression was increased in the renal cortex from SLE mice compared with controls. These data suggest that there are fewer ANG II receptors in the kidneys from mice with SLE but that the existing receptors exhibit an enhanced sensitivity to ANG II.
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Affiliation(s)
- Marcia Venegas-Pont
- Department of Physiology and Biophysics and Center for Excellence in Cardiovascular Renal Research, University of Mississippi Medical Center, Jackson, Mississippi 39216-4505, USA
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Symmons DPM, Gabriel SE. Epidemiology of CVD in rheumatic disease, with a focus on RA and SLE. Nat Rev Rheumatol 2011; 7:399-408. [PMID: 21629241 DOI: 10.1038/nrrheum.2011.75] [Citation(s) in RCA: 269] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The excess risk of cardiovascular disease (CVD) associated with inflammatory rheumatic diseases has long been recognized. Patients with established rheumatoid arthritis (RA) or systemic lupus erythematosus (SLE) have higher mortality compared with the general population. Over 50% of premature deaths in RA are attributable to CVD. Excess mortality in SLE follows a bimodal pattern, with the early peak predominantly a consequence of active lupus or its complications, and the later peak largely attributable to atherosclerosis. Patients with RA or SLE are also at increased risk of nonfatal ischemic heart disease. The management and outcome of myocardial infarction and congestive heart failure in patients with RA or SLE differs from that in the general population. Traditional CVD risk factors (TRF) include increasing age, male gender, smoking, hypertension, hypercholesterolemia and diabetes. Whereas some TRFs are elevated in patients with RA or SLE, several are not, and others exhibit paradoxical relationships. Risk scores developed for the general population based on TRFs are likely, therefore, to underestimate CVD risk in RA and SLE. Until additional research and disease-specific risk prediction tools are available, current evidence supports aggressive treatment of disease activity, and careful screening for and management of TRFs.
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Affiliation(s)
- Deborah P M Symmons
- Arthritis Research UK Epidemiology Unit, Manchester Academic Health Science Center, University of Manchester, Oxford Road, Manchester M13 0PT, UK. deborah.symmons@ manchester.ac.uk
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SABIO JOSÉMARIO, VARGAS-HITOS JOSÉANTONIO, NAVARRETE-NAVARRETE NURIA, MEDIAVILLA JUANDIEGO, JIMÉNEZ-JÁIMEZ JUAN, DÍAZ-CHAMORRO ANTONIO, JIMÉNEZ-ALONSO JUAN. Prevalence of and Factors Associated with Hypertension in Young and Old Women with Systemic Lupus Erythematosus. J Rheumatol 2011; 38:1026-32. [DOI: 10.3899/jrheum.101132] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Objective.Hypertension (HT) is more prevalent in patients with systemic lupus erythematosus (SLE) than among the general population and it has been associated with atherosclerotic cardiovascular diseases in these patients. We examined the proportion of HT and factors associated with it in young and old women with SLE.Methods.Participants (112 women with SLE and 223 healthy age-matched women) were categorized as young (age ≤ 40 years) or old (age > 40 years). We compared cardiovascular and specific SLE-related variables and inflammatory markers in hypertensive and normotensive women with SLE for each age range. We also assessed the factors independently associated with HT in the entire cohort and in each age range by means of a multivariate regression analysis.Results.The prevalence of HT was higher in women with SLE than in controls (56% vs 29%; p < 0.001), and was proportionally higher in younger women with SLE (40% vs 11%; p < 0.001) than in older women with SLE (74% vs 47%; p = 0.001). After adjustment for potential confounders, HT was associated with renal involvement and higher nonobesity-related insulin levels in younger women with SLE. In older patients, HT was associated with age, renal involvement, and obesity. Finally, in the entire cohort, HT was associated with age, insulin, renal involvement, and the Systemic Lupus Erythematosus Disease Activity Index score.Conclusion.An association between HT and insulin has been identified in women with SLE, particularly younger ones. Factors associated with HT in women with SLE differed depending on their age. HT was more prevalent in women with SLE than in control subjects, being proportionally higher in young women with SLE.
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21
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van Leuven SI, Mendez-Fernandez YV, Stroes ES, Tak PP, Major AS. Statin therapy in lupus-mediated atherogenesis: two birds with one stone? Ann Rheum Dis 2011; 70:245-8. [PMID: 21068103 PMCID: PMC3306212 DOI: 10.1136/ard.2010.133827] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
The atherosclerotic process is accelerated in patients with systemic lupus erythematosus (SLE). In addition to a robust lipid-lowering effect, various immunomodulatory functions have been ascribed to statins. By virtue of the latter they may be able to reduce atherosclerotic vascular disease in SLE by inhibiting immune activation within the arterial wall and by attenuating lupus activity. The effects of statins on SLE as well as on lupus-mediated atherogenesis in vivo are discussed in this viewpoint.
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Affiliation(s)
- Sander I van Leuven
- Department of Vascular Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA.
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Nikpour M, Gladman DD, Ibanez D, Harvey PJ, Urowitz MB. Variability over time and correlates of cholesterol and blood pressure in systemic lupus erythematosus: a longitudinal cohort study. Arthritis Res Ther 2010; 12:R125. [PMID: 20591138 PMCID: PMC2911919 DOI: 10.1186/ar3063] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2009] [Revised: 06/12/2010] [Accepted: 06/30/2010] [Indexed: 12/02/2022] Open
Abstract
Introduction Total cholesterol (TC) and blood pressure (BP) are likely to take a dynamic course over time in patients with systemic lupus erythematosus (SLE). This would have important implications in terms of using single-point-in-time measurements of these variables to assess coronary artery disease (CAD) risk. The objective of this study was to describe and quantify variability over time of TC and BP among patients with SLE and to determine their correlates. Methods Patients in the Toronto lupus cohort who had two or more serial measurements of TC and systolic and diastolic BP (SBP and DBP) were included in the analysis. Variability over time was described in terms of the proportion of patients whose TC and BP profile fluctuated between normal and elevated (TC > 5.2 mmol/L; SBP ≥ 140 mm Hg or DBP ≥ 90 mm Hg), and also in terms of within- and between-patient variance quantified by using analysis of variance modeling. Generalized estimating equations (GEEs) were used to determine independent correlates of each of TC, SBP, and DBP, treated as continuous outcome variables. Results In total, 1,260 patients, comprising 26,267 measurements of each of TC, SBP, and DBP, were included. Mean ± SD number of measurements per patient was 20.8 ± 20. Mean ± SD time interval between measurements was 5.4 ± 9.7 months. Mean ± SD time interval from the start to the end of the study was 9.3 ± 8.5 years. Over time, 64.7% of patients varied between having normal and elevated cholesterol levels, whereas the status of 46.4% of patients varied between normotensive and hypertensive. By using analysis of variance (ANOVA), the within-patient percentage of total variance for each of TC, SBP, and DBP was 48.2%, 51.2%, and 63.9%, respectively. By using GEE, independent correlates of TC and BP included age, disease activity, and corticosteroids; antimalarial use was negatively correlated with TC (all P values < 0.0001). Conclusions TC and BP vary markedly over time in patients with SLE. This variability is due not only to lipid-lowering and antihypertensive medications, but also to disease- and treatment-related factors such as disease activity, corticosteroids, and antimalarials. The dynamic nature of TC and BP in SLE makes a compelling case for deriving summary measures that better capture cumulative exposure to these risk factors.
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Affiliation(s)
- Mandana Nikpour
- University of Toronto Lupus Clinic and the Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada
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Lu LJ, Wallace DJ, Navarra SV, Weisman MH. Lupus Registries: Evolution and Challenges. Semin Arthritis Rheum 2010; 39:224-45. [DOI: 10.1016/j.semarthrit.2008.08.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2008] [Revised: 08/07/2008] [Accepted: 08/25/2008] [Indexed: 11/27/2022]
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Nikpour M, Gladman DD, Ibañez D, Urowitz MB. Variability and correlates of high sensitivity C-reactive protein in systemic lupus erythematosus. Lupus 2009; 18:966-73. [DOI: 10.1177/0961203309105130] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In the general population, high-sensitivity C-reactive protein (hsCRP), a marker of inflammation, is relatively stable over time and independently predicts cardiovascular events. Systemic lupus erythematosus (SLE), a chronic inflammatory disease, is strongly associated with coronary artery disease (CAD). The objective of this study was to determine the variability and correlates of hsCRP in patients with SLE. Two cohorts from the University of Toronto Lupus Clinic, one with newly diagnosed and the other with prevalent SLE for 4 or more years, were selected. HsCRP was measured on serially collected samples, and hsCRP levels were ranked according to quartiles of cardiovascular risk. Correlates of hsCRP were determined using multivariate regression modelling with analysis of repeated measures. Among 58 patients in the inception cohort, over time, 36 (62%) moved from one hsCRP risk quartile to another. Among 414 patients in the prevalent cohort, 294 (71.0%) moved from one risk quartile to another. In both cohorts, within-patient variance comprised the majority of total variance in hsCRP levels. In multivariate regression analysis, hsCRP increased with age ( P = 0.002), postmenopausal status ( P = 0.03), smoking ( P = 0.007) and presence of infection ( P = 0.0001) and decreased with use of immunosuppressives ( P = 0.02). There is marked variability of hsCRP level over time in SLE, regardless of disease duration. This variability is due to age and SLE treatment, menopausal status, smoking and the occurrence of infection. The variability of hsCRP in SLE casts doubt over its usefulness as an independent predictor of CAD risk in this disease and potentially in other chronic inflammatory diseases.
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Affiliation(s)
- M Nikpour
- University of Toronto Lupus Clinic and the Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital, Toronto, Ontario, Canada
| | - DD Gladman
- University of Toronto Lupus Clinic and the Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital, Toronto, Ontario, Canada
| | - D Ibañez
- University of Toronto Lupus Clinic and the Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital, Toronto, Ontario, Canada
| | - MB Urowitz
- University of Toronto Lupus Clinic and the Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital, Toronto, Ontario, Canada
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25
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Mok CC. Accelerated atherosclerosis, arterial thromboembolism, and preventive strategies in systemic lupus erythematosus. Scand J Rheumatol 2009; 35:85-95. [PMID: 16641040 DOI: 10.1080/03009740600601526] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
With improved disease survival, arterial thromboembolism has become an important cause of morbidity in patients with systemic lupus erythematosus (SLE). A number of conventional and non-conventional risk factors are associated with accelerated atherosclerosis. Regular surveillance and control of traditional risk factors is mandatory, and so is the appropriate use of the statins, anti-malarial agents, anti-platelet agents, and anti-coagulation for primary and secondary prevention of arterial thromboembolism in SLE patients. Judicious use of corticosteroids, calcineurin inhibitors, hormonal replacement therapy, and the cyclooxygenase 2 inhibitors is equally important.
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Affiliation(s)
- C C Mok
- Department of Medicine, Tuen Mun Hospital, Hong Kong, SAR China.
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NIKPOUR MANDANA, GLADMAN DAFNAD, IBAÑEZ DOMINIQUE, BRUCE IANN, BURNS ROBERTJ, UROWITZ MURRAYB. Myocardial Perfusion Imaging in Assessing Risk of Coronary Events in Patients with Systemic Lupus Erythematosus. J Rheumatol 2009; 36:288-94. [DOI: 10.3899/jrheum.080776] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Objective.Classic risk factors do not fully account for the increased risk of coronary artery disease (CAD) in systemic lupus erythematosus (SLE), making identification of the subset of patients at risk challenging. In this prospective cohort study we investigated whether myocardial perfusion defects in SLE are predictive of CAD events, independently of traditional Framingham risk factors.Methods.We performed myocardial perfusion imaging in 122 women with SLE who did not have a history of CAD. Patients had clinical and serologic evaluation, and an assessment of cardiac risk factors. They were then followed for the occurrence of CAD events. Cox regression models were used to determine independent predictors of CAD.Results.Forty-six (37.7%) patients had perfusion defects. Median followup was 8.7 years, during which 15 CAD events occurred (1 myocardial infarction, 14 angina). Cox modeling showed that myocardial perfusion defects are strongly predictive of CAD [hazard ratio (HR) 13.0, 95% CI 2.8 to 60.1, p = 0.001]. Although the 10-year Framingham risk score was significantly predictive of CAD (HR 1.8, 95% CI 1.1 to 2.9, p = 0.01), the risk scores in groups with normal and abnormal scans were similar to the “low-risk” general population.Conclusion.In women with SLE, myocardial perfusion defects are strongly and independently predictive of CAD. Our findings suggest that myocardial perfusion imaging to assess risk of future coronary events should be considered in women with SLE.
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Ryan MJ. The pathophysiology of hypertension in systemic lupus erythematosus. Am J Physiol Regul Integr Comp Physiol 2009; 296:R1258-67. [PMID: 19158408 DOI: 10.1152/ajpregu.90864.2008] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Systemic lupus erythematosus (SLE) is a chronic autoimmune inflammatory disorder that predominantly affects women during their reproductive years. Although SLE can affect any organ system, the kidneys are prominently involved in the form of immune complex glomerulonephritis. In addition, in women with SLE, risk for the development of cardiovascular disease is dramatically increased. Hypertension is a major risk factor for cardiovascular disease and is highly prevalent in women with SLE. Nevertheless, there has been little exploration of the pathophysiological mechanisms that promote SLE hypertension. This review discusses the role of several mechanisms, with an emphasis on the kidney, in SLE hypertension. These mechanisms include the renin-angiotensin system, endothelin, oxidative stress, sex steroids, metabolic changes, peroxisome proliferator-activated receptor-gamma, and, perhaps most importantly, chronic inflammation and cytokines. Growing evidence suggests a link between chronic inflammation and hypertension. Therefore, elucidation of mechanisms that promote SLE hypertension may be of significant value not only for patients with SLE, but also for a better understanding of the basis for essential hypertension.
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Affiliation(s)
- Michael J Ryan
- Physiology & Biophysics, University of Mississippi Medical Center, Jackson, MS 39216, USA.
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Telles RW, Lanna C, Ferreira GA, Souza AJ, Navarro TP, Ribeiro AL. Carotid atherosclerotic alterations in systemic lupus erythematosus patients treated at a Brazilian university setting. Lupus 2008; 17:105-13. [DOI: 10.1177/0961203307085312] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
To determine the frequency of carotid plaque and intima-media thickness (IMT) in patients with systemic lupus erythematosus (SLE) and their association with risk factors in a Brazilian university setting. Carotid plaque and IMT were identified and measured by ultrasonography. Traditional risk factors and lupus-related factors were analysed. One hundred and seventy-two patients (women = 96%, age = 38 ± 11 years) were evaluated. The frequency of carotid plaque was 9.3%. The median (IR) IMT was 0.60 mm (0.54—0.71 mm). Age, family history (FH) of premature coronary disease, low-density cholesterol (LDL-c) >100 mg/dL, hypertriglyceridemia, diabetes, hypertension, smoking, postmenopause, number of risk factors, Framingham risk score, age at diagnosis, duration of lupus, mucocutaneous manifestations and duration of prednisone use were associated with plaque ( P < 0.05), univariate analysis. Nephritis, immunosuppressive therapy, intravenous methylprednisolone and a higher average daily dose of prednisone were associated with the absence of plaque. Independent predictors of plaque were smoking ( P = 0.004), LDL-c >100 mg/dL ( P = 0.044), Framingham score ( P = 0.006) and absence of immunosuppressive therapy ( P = 0.032). There was an independent correlation between IMT and age ( P < 0.001) and duration of prednisone use ( P = 0.020). Subclinical atherosclerosis was associated with traditional risk and SLE-related factors, especially the absence of immunosuppressive therapy. The present study suggests that the levels of LDL-c should be kept under 100mg/dL in lupus. Lupus (2008) 17, 105—113.
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Affiliation(s)
- RW Telles
- Rheumatology Service of the Hospital das Clínicas, Locomotor System Department of the School of Medicine at the Federal University of Minas Gerais, Belo Horizonte, MG, Brazil, , , Member of the Pronuclear Project - Brazilian Society of Rheumatology, SP, Brazil
| | - Ccd Lanna
- Rheumatology Service of the Hospital das Clínicas, Locomotor System Department of the School of Medicine at the Federal University of Minas Gerais, Belo Horizonte, MG, Brazil
| | - GA Ferreira
- Rheumatology Service of the Hospital das Clínicas, Locomotor System Department of the School of Medicine at the Federal University of Minas Gerais, Belo Horizonte, MG, Brazil
| | - AJ Souza
- Laboratory of Vascular Ultrasonography - Hermes Pardini Laboratory, MG, Brazil
| | - TP Navarro
- Vascular Surgery Service of the Hospital das Clínicas, the Federal University of Minas Gerais, Belo Horizonte, MG, Brazil
| | - AL Ribeiro
- Cardiology Service of the Hospital das Clínicas, Internal Medicine Department of the School of Medicine at the Federal University of Minas Gerais, Belo Horizonte, MG, Brazil
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Kavey REW, Allada V, Daniels SR, Hayman LL, McCrindle BW, Newburger JW, Parekh RS, Steinberger J. Cardiovascular risk reduction in high-risk pediatric patients: a scientific statement from the American Heart Association Expert Panel on Population and Prevention Science; the Councils on Cardiovascular Disease in the Young, Epidemiology and Prevention, Nutrition, Physical Activity and Metabolism, High Blood Pressure Research, Cardiovascular Nursing, and the Kidney in Heart Disease; and the Interdisciplinary Working Group on Quality of Care and Outcomes Research. J Cardiovasc Nurs 2007; 22:218-53. [PMID: 17545824 DOI: 10.1097/01.jcn.0000267827.50320.85] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Although for most children the process of atherosclerosis is subclinical, dramatically accelerated atherosclerosis occurs in some pediatric disease states, with clinical coronary events occurring in childhood and very early adult life. As with most scientific statements about children and the future risk for cardiovascular disease, there are no randomized trials documenting the effects of risk reduction on hard clinical outcomes. A growing body of literature, however, identifies the importance of premature cardiovascular disease in the course of certain pediatric diagnoses and addresses the response to risk factor reduction. For this scientific statement, a panel of experts reviewed what is known about very premature cardiovascular disease in 8 high-risk pediatric diagnoses and, from the science base, developed practical recommendations for management of cardiovascular risk.
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Elliott JR, Manzi S, Edmundowicz D. The role of preventive cardiology in systemic lupus erythematosus. Curr Rheumatol Rep 2007; 9:125-30. [PMID: 17502042 DOI: 10.1007/s11926-007-0006-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
With improved therapeutic advances in the care of systemic lupus erythematosus patients, cardiovascular disease has emerged as a leading cause of death. Premature atherosclerosis in lupus patients is probably an interaction between traditional cardiovascular risk factors, inflammatory factors, and factors related to lupus itself. Despite knowledge of this accelerated cardiac risk, evaluation of traditional risk factors has been sub-par. We propose that lupus patients be evaluated by preventive cardiologists and have access to their expertise and resources. In addition to nephrologists and dermatologists, preventive cardiologists should be an integral part of the care of patients with lupus.
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Affiliation(s)
- Jennifer Rae Elliott
- University of Pittsburgh School of Medicine, S727 Biomedical Sciences Tower, 3500 Terrace Street, Pittsburgh, PA 15261, USA.
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Kavey REW, Allada V, Daniels SR, Hayman LL, McCrindle BW, Newburger JW, Parekh RS, Steinberger J. Cardiovascular Risk Reduction in High-Risk Pediatric Patients. Circulation 2006; 114:2710-38. [PMID: 17130340 DOI: 10.1161/circulationaha.106.179568] [Citation(s) in RCA: 485] [Impact Index Per Article: 26.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Although for most children the process of atherosclerosis is subclinical, dramatically accelerated atherosclerosis occurs in some pediatric disease states, with clinical coronary events occurring in childhood and very early adult life. As with most scientific statements about children and the future risk for cardiovascular disease, there are no randomized trials documenting the effects of risk reduction on hard clinical outcomes. A growing body of literature, however, identifies the importance of premature cardiovascular disease in the course of certain pediatric diagnoses and addresses the response to risk factor reduction. For this scientific statement, a panel of experts reviewed what is known about very premature cardiovascular disease in 8 high-risk pediatric diagnoses and, from the science base, developed practical recommendations for management of cardiovascular risk.
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Chaiamnuay S, Bertoli AM, Roseman JM, McGwin G, Apte M, Durán S, Vilá LM, Reveille JD, Alarcón GS. African-American and Hispanic ethnicities, renal involvement and obesity predispose to hypertension in systemic lupus erythematosus: results from LUMINA, a multiethnic cohort (LUMINAXLV). Ann Rheum Dis 2006; 66:618-22. [PMID: 17107981 PMCID: PMC1954629 DOI: 10.1136/ard.2006.059311] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To examine the predictors of the occurrence of hypertension in a large multiethnic US cohort. PATIENTS AND METHODS There were 614 patients with systemic lupus erythematoses (SLE; > or = 4 American College of Rheumatology revised criteria) with < or = 5 years of disease duration at entry into the cohort (T0) and of Hispanic (Texan or Puerto Rican), African-American or Caucasian ethnicity. T0 variables were compared between patients who did and did not develop hypertension (blood pressure > or = 140/90 mm Hg on at least two occasions and/or the use of antihypertensive drugs) after T0. Significant and clinically relevant variables were then examined by a stepwise logistic regression model. RESULTS A total of 379 patients without hypertension at T0 were included (patients who developed hypertension prior to SLE diagnosis (n = 126) or before T0 (n = 109) were excluded). Predictors of hypertension were African-American and Texan-Hispanic ethnicities, renal involvement and a higher body mass index. CONCLUSIONS Traditional cardiovascular risk factors, disease-related factors and ethnicity play a role in the occurrence of hypertension in patients with SLE. Controlling renal involvement and optimising body weight may prevent the occurrence of hypertension.
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Urowitz MB, Gladman DD, Ibanez D, Berliner Y. Modification of hypertension and hypercholesterolaemia in patients with systemic lupus erythematosus: a quality improvement study. Ann Rheum Dis 2006; 65:115-7. [PMID: 16344496 PMCID: PMC1798000 DOI: 10.1136/ard.2005.038802] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Hypercholesterolaemia and hypertension are risk factors for coronary artery disease in patients with systemic lupus erythematosus (SLE). OBJECTIVE To examine the recognition and management of hypercholesterolaemia and hypertension in patients with SLE before and after a quality improvement study. METHOD Patients with SLE have been followed up prospectively at the University of Toronto Lupus Clinic since 1970. The charts of all patients who entered the clinic since 1990 were reviewed to ensure completeness of data on anti-hypertensive treatment (AHT) and lipid lowering agents (LLA). Recognition and management of hypercholesterolaemia and hypertension were evaluated for the periods 1990-1995 and 1996-2001. RESULTS Comparison of treatment between time periods showed that during 1990-1995 204/559 (36%) patients seen were hypertensive, of whom 180 (88%) were receiving AHT, and during 1996-2001 241/576 (42%) patients seen were hypertensive, of whom 232 (96%) were receiving AHT (p = 0.0013). A comparison of treatment for hypercholesterolaemia showed that 21/236 (9%) hypercholesterolaemic patients were being treated with LLA in the earlier period compared with 74/261 (28%) in the later period (p<0.0001). CONCLUSIONS Treatment for hypertension and hyperlipidaemia has increased in the past 6 years compared with the previous 6 years, but a number of patients eligible for these treatments remain untreated.
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Affiliation(s)
- M B Urowitz
- Rheumatology Department, University Health Network, Toronto Western Hospital, Canada.
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Mok CC, Tang SSK, To CH, Petri M. Incidence and risk factors of thromboembolism in systemic lupus erythematosus: A comparison of three ethnic groups. ACTA ACUST UNITED AC 2005; 52:2774-82. [PMID: 16142761 DOI: 10.1002/art.21224] [Citation(s) in RCA: 151] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVE To compare the incidence and risk factors for thromboembolic events in systemic lupus erythematosus (SLE) patients of different ethnic backgrounds. METHODS SLE patients who were newly diagnosed or were referred within 6 months of diagnosis between 1996 and 2002 were prospectively followed up for the occurrence of thromboembolic events. Cumulative hazard and risk factors for thromboembolism were evaluated and compared among patients of different ethnic origins. RESULTS We studied 625 patients who fulfilled the American College of Rheumatology criteria for SLE (89% women): 258 Chinese, 140 African Americans, and 227 Caucasians. The mean +/- SD age at SLE diagnosis was 35.7 +/- 14 years. After a followup of 3,094 patient-years, 48 arterial events and 40 venous events occurred in 83 patients. The overall incidence of arterial and venous thromboembolism was 16/1,000 patient-years and 13/1,000 patient-years, respectively. The cumulative hazard of arterial events at 60 months after the diagnosis of SLE was 8.5%, 8.1%, and 5.1% for the Chinese, African Americans, and Caucasians, respectively. The corresponding cumulative risk of venous events was 3.7%, 6.6%, and 10.3%, respectively (P = 0.008 for Chinese versus Caucasians, by log rank test). Smoking, obesity, antiphospholipid antibodies, and use of antimalarial agents and exogenous estrogens were less frequent in the Chinese patients. In Cox regression models, low levels of high-density lipoprotein (HDL) cholesterol, Chinese ethnicity, oral ulcers, and serositis predicted arterial events, whereas male sex, low levels of HDL cholesterol, antiphospholipid antibodies, non-Chinese ethnicity, obesity, renal disease, and hemolytic anemia predicted venous events. CONCLUSION There are ethnic differences in the incidence of arterial and venous thromboembolism in patients with SLE that cannot be fully explained by the clinical factors studied. Further evaluation of other genetic and immunologic factors is warranted.
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Affiliation(s)
- Chi Chiu Mok
- Department of Medicine, Tuen Mun Hospital, New Territories, Hong Kong, China.
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Costenbader KH, Karlson EW, Gall V, de Pablo P, Finckh A, Lynch M, Bermas B, Schur PH, Liang MH. Barriers to a trial of atherosclerosis prevention in systemic lupus erythematosus. ACTA ACUST UNITED AC 2005; 53:718-23. [PMID: 16208639 DOI: 10.1002/art.21441] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE The effectiveness of aggressive management of traditional risk factors for accelerated atherosclerosis in systemic lupus erythematosus (SLE) has been advocated but not proven. We conducted a pilot, randomized, controlled trial of known prevention medications (pravastatin, ramipril, aspirin, and a combination B vitamin) plus individualized cardiovascular prevention education. We describe our experience in recruiting and retaining patients with SLE in this trial. METHODS Patients with SLE by American College of Rheumatology criteria who lived within 1 hour of the hospital and had visits within the past 3 years were screened. All eligible patients were contacted by the principal investigator who was not their physician. The reasons for nonparticipation were elicited in a nonjudgmental manner. RESULTS A total of 662 patients met the selection criteria for the study. Of these, 295 patients (45%) with contraindications to study medications were excluded. Ninety-seven (40%) of 244 eligible patients refused to participate. More than 40% of those phoned were unwilling to participate and, among those, 19% felt they were too sick, too well, or taking too many medications already. A total of 41 patients were enrolled in the trial, and 22 dropped out within 4 months. CONCLUSION SLE is a chronic disease, and the development and testing of interventions aimed at the prevention of long-term sequelae are of paramount importance. Prevention trials in SLE face serious challenges, including the recruitment and retention of participants. Our experience provides insights into the barriers to participation in randomized prevention trials in SLE.
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Toloza SMA, Uribe AG, McGwin G, Alarcón GS, Fessler BJ, Bastian HM, Vilá LM, Wu R, Shoenfeld Y, Roseman JM, Reveille JD. Systemic lupus erythematosus in a multiethnic US cohort (LUMINA): XXIII. Baseline predictors of vascular events. ACTA ACUST UNITED AC 2004; 50:3947-57. [PMID: 15593203 DOI: 10.1002/art.20622] [Citation(s) in RCA: 222] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To determine the baseline (time 0) risk factors associated with the subsequent occurrence of vascular events in a multiethnic US cohort (LUMINA [LUpus in MInorities: NAture versus nurture]) of patients with systemic lupus erythematosus (SLE). METHODS Five hundred forty-six LUMINA patients were assessed at time 0 for traditional and nontraditional (disease-related) risk factors for vascular events. These were defined as 1) cardiovascular (myocardial infarction and/or definite or classic angina and/or the undergoing of a vascular procedure for myocardial infarction [coronary artery bypass graft]), 2) cerebrovascular (stroke), and 3) peripheral vascular (arterial claudication and/or gangrene or significant tissue loss and/or arterial thrombosis in peripheral arteries). The observation time (followup time in the cohort) was the interval between time 0 and the last visit. The unit of analysis was the patient and not each vascular event. Variables at time 0 and vascular events were examined by univariable and multivariable (logistic and Cox proportional hazards regression) analyses. Age, sex, ethnicity, followup time, and all known risk factors for the occurrence of vascular events were included in the model. RESULTS Thirty-four patients (6.2%) developed one or more vascular event after time 0. The overall median duration of followup in the cohort was 73.8 months (range 10.8-111.3 months). Vascular events (13 cardiovascular, 18 cerebrovascular, 5 peripheral vascular) occurred in 7 Hispanics from Texas (6.5%), 1 Hispanic from Puerto Rico (1.2%), 15 African Americans (7.5%), and 11 Caucasians (7.1%). The mean total number of traditional risk factors was significantly higher in patients who developed vascular events than in those who did not (7.1 versus 5.6). Independent predictors of vascular events were older age, current smoking status, longer followup time, elevated serum levels of C-reactive protein (CRP), and the presence of any antiphospholipid antibody. The same variables were identified when time-dependent analyses were performed, although azathioprine use was also found to be a contributing factor. CONCLUSION Smoking, previously not reported in SLE, emerged as a predictor of vascular events and should be strongly discouraged. Antiphospholipid antibodies and CRP support the role of inflammation and autoimmunity in the development of accelerated atherosclerosis in SLE. Ethnicity was not associated with vascular events in our patients.
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Affiliation(s)
- Sergio M A Toloza
- School of Medicine, The University of Alabama at Birmingham, Birmingham, AL 35294, USA
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Bruce IN, Urowitz MB, Gladman DD, Ibañez D, Steiner G. Risk factors for coronary heart disease in women with systemic lupus erythematosus: The Toronto Risk Factor Study. ACTA ACUST UNITED AC 2003; 48:3159-67. [PMID: 14613278 DOI: 10.1002/art.11296] [Citation(s) in RCA: 260] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Because women with systemic lupus erythematosus (SLE) are 5-8 times more likely to develop coronary heart disease (CHD) than are women in the general population, we assessed the prevalence of classic risk factors for CHD in women with SLE. METHODS Consecutive female patients with SLE who were without evidence of CHD and were attending a large lupus clinic in Toronto were studied. The control population was recruited from among age-matched subjects attending a family practice unit for an annual physical examination. The prevalence of classic CHD risk factors and the 10-year risk of a CHD-related event were determined using the Framingham risk assessment formula. Lipid subfractions, other metabolic risk factors, lifestyle variables, and demographic characteristics were also compared between the 2 groups. RESULTS We studied 250 SLE patients and 250 controls whose mean +/- SD age was 44.8 +/- 12 years and 44.3 +/- 15 years, respectively. Hypertension and diabetes were significantly more common among the SLE patients. Although the SLE patients had a higher mean number of CHD risk factors per patient, the 10-year risk of a CHD-related event, using the Framingham multiple risk factor assessment, was the same in SLE patients and controls (3.2%). Compared with controls, SLE patients had higher levels of very low-density lipoprotein cholesterol and total triglycerides, and had higher levels of homocysteine despite having higher folate levels. Premature menopause, sedentary lifestyle, and an at-risk body habitus were also more prevalent in SLE patients. CONCLUSION Women with SLE have a range of detectable coronary risk factors that are not fully reflected in the Framingham risk factor formula. These factors are likely to contribute to the loss of protection from CHD that has been observed in SLE.
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Affiliation(s)
- Ian N Bruce
- University of Toronto Lupus Clinic, and Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital, Toronto, Ontario, Canada
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Sander GE, Giles TD. Cardiovascular Complications of Collagen Vascular Disease. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2002; 4:151-159. [PMID: 11858777 DOI: 10.1007/s11936-002-0035-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Collagen vascular diseases commonly affect the heart; cardiovascular events are the major cause of mortality in people with these diseases. A striking feature of the cardiac involvement in individuals with systemic lupus erythematosus (SLE) and rheumatoid arthritis is aggressive and accelerated atherosclerosis; women with SLE in the 35- to 44-year-old age group are more than 50 times more likely to suffer myocardial infarction than are matched controls. Traditional risk factors contribute to the accelerated atherosclerosis, but cannot explain the extent of risk. It is possible that the inflammatory process, which is similar to the inflammatory process in atherosclerosis, pays a critical pathophysiologic role. It is critically important to identify the presence of traditional cardiovascular risk factors (eg, tobacco usage, hypertension, hypercholesterolemia, diabetes, homocysteinemia), and to modify these to secondary prevention targets. Cardiac valvular disease is common in individuals with SLE and rheumatoid arthritis; its presence should be anticipated and subacute bacterial endocarditis prophylaxis precautions initiated. Cardiac autonomic neuropathy and conduction disturbances are common in people with heart disease related to systemic sclerosis and human leukocyte antigen B27; these patients should be monitored carefully for evidence of dysrhythmias.
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Affiliation(s)
- Gary E. Sander
- Section of Cardiology, Department of Medicine, Louisiana State University Health Sciences Center, 1542 Tulane Avenue, New Orleans, LA 70112, USA.
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Sabio JM, Mediavilla JD, Fernández-Torres C, Aliaga L, Jiménez-Alonso J. Risk factors related to hypertension in a Spanish systemic lupus erythematosus cohort. Lupus 2002; 10:451-2. [PMID: 11434583 DOI: 10.1191/096120301678646227] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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