How accelerated atherosclerosis in SLE has changed our management of the disorder

Rate, pattern and factors related to damage in Brazilian systemic lupus erythematosus patients

The Systemic Lupus InternationalCollaborating Clinics/American College of Rheumatology (ACR) Damage Index (SDI) is an accepted instrument to ascertain damage. It has been shown to vary among differentSLE populations.The aim of this study was to assess SDI score, pattern and factors related to damage in Brazilian SLE outpatients. The SDI was obtained in 105 patients with a median age of 41 (5-95%, 19-61.7) years and a median SLE duration of 127 (17.6-345.9) months. Patients had a median SDI of 2 (0-8) and 81.9% had some damage (SDI > 0). Damage was associatedwith a higher number of ACR criteria for SLE in multivariate analysis (OR 2.32, 95%CI 1.23-4.37, P 0.009). Antiphospholipid syndrome (APS) (OR 9.82, 95%CI 2.74-35.23, P < 0.001), methylprednisolone pulses (OR 3.91, 95%CI 1.19-12.81, P 0.024), age (OR 1.70, 95%CI 1.02-1.13, P 0.011) and prednisone use duration (OR 1.01, 95%CI 1.002-1.02, P 0.020) were related to severe damage (SDI ≥4). Hypertensionwas associated with renal, cardiac and atherosclerotic damage, as cyclophosphamide pulses were with premature menopause. In conclusion, damage was very frequent in Brazilian SLE patients, mainly due to skin involvement, compared to other SLE populations. The presence of APS was the major independent contributor to the development of severe damage. Arterial hypertension was identified as a common risk factor for renal, cardiac and atherosclerotic damage.

Osteoporosis and cardiovascular disease care in systemic lupus erythematosus according to new quality indicators

OBJECTIVES

Quality indicators (QIs) for the assessment of care of patients with systemic lupus erythematosus (SLE) have been proposed. We evaluated care according to these proposed QIs for osteoporosis and cardiovascular disease (CVD) in patients with SLE in our rheumatology practice.

METHODS

We selected 200 patients with SLE according to American College of Rheumatology Criteria and ≥2 visits to our practice in 2007 to 2008. We performed a structured medical record review and collected demographics, SLE and past medical history, medications, laboratories and data concerning osteoporosis, and CVD management. We employed univariable analyses and multivariable regression analyses to test for factors associated with care meeting the proposed QIs.

RESULTS

Ninety-four percent of patients were female and 64% were white. Mean age was 46.3 years and mean lupus duration was 15.3 years. Twenty-nine percent were taking ≥7.5 mg prednisone per day for ≥3 months. The proportions of patients for whom care met the proposed QIs were as follows: 59% for bone mineral density testing, 62% for calcium and vitamin D supplementation, and 86% for antiresorptive or anabolic osteoporosis medications. Only 3% had 5 cardiac risk factors assessed within the year and 26% had 4 cardiac risk factors assessed annually. Smoking, fasting lipid panels, and diabetes mellitus were rarely assessed annually. Having a primary care physician within our health care network increased care meeting QIs.

CONCLUSIONS

Care according to newly proposed QIs for osteoporosis and CVD was suboptimal in our academic center. To standardize and improve care of patients with SLE, we suggest specific changes to the proposed QIs.

High prevalence of subclinical cardiovascular abnormalities in patients with systemic lupus erythematosus in spite of a very low clinical damage index

BACKGROUND AND AIM

To evaluate the prevalence of subclinical cardiovascular (CV) abnormalities in systemic lupus erythematosus (SLE) stratified according to SLE-related organ damage using the Systemic Lupus International Collaborating Clinics (SLICC) damage index.

METHODS AND RESULTS

We selected SLE patients without clinically overt CV events (n=45, 56% with SLICC=0, 44% with SLICC=1-4). CV evaluation was performed using cardiac and vascular echo-Doppler techniques. Post-ischemic flow-mediated dilation (FMD) over nitroglycerine-mediated dilation (NMD) of the brachial artery <0.70 defined endothelial dysfunction. The prevalence of preclinical CV abnormalities (CVAbn, including at least one of the following-carotid atherosclerosis, left ventricular (LV) hypertrophy, low arterial compliance, LV wall motion abnormalities, aortic regurgitation, FMD/NMD<0.70)-was 64% (16/25) in patients with SLICC=0 and 80% (16/20) in those with SLICC>0 (p=not significant (NS)). In particular, the prevalence of carotid atherosclerosis (28% vs. 16%), of LV hypertrophy (12% vs. 6%) and of LV wall motion abnormalities (15% vs. 12%), of low global arterial compliance (18% vs. 10%), prevalence of aortic regurgitation (30% vs. 18%) and/or aortic valve fibrosclerosis (10% vs. 8%), FMD<10% (14+/-5% vs. 14%+/-6) and prevalence of FMD/NMD<0.70 (53% vs. 52%) were comparable in SLE patients with SLICC>0 and in those with SLICC=0 (all p=NS). Of the SLE patients without carotid atherosclerosis, LV hypertrophy, low arterial compliance, LV wall motion abnormalities and aortic regurgitation (n=17), endothelial dysfunction was detected in 50% of those with SLICC=0 (6/12) and in 40% of those with SLICC>0 (2/5, p=NS).

CONCLUSIONS

SLE patients with SLICC=0 often have an elevated CV risk profile due to subclinical manifestations of CV disease detectable by cardiac and vascular echo-Doppler evaluations.

Factors determining participation in prevention trials among systemic lupus erythematosus patients: a qualitative study

OBJECTIVE

A feasibility study for a trial of strategies for the prevention of atherosclerosis in patients with systemic lupus erythematosus (SLE) was stopped because of inadequate recruitment. There is little understanding of the factors influencing patients' decisions about participation in prevention trials. Our goal was to determine factors that patients with SLE consider in deciding about participating in prevention trials, to uncover concerns about SLE trials, and to investigate how study design and purpose affect participation decisions.

METHODS

We conducted focus groups with trial participants (n = 13), trial nonparticipants (n = 8), and a group of patients with diabetes (n = 9). We conducted telephone interviews with SLE patients who refused participation in the trial and the focus groups (n = 10). A trained facilitator elicited factors influencing participation decisions. Transcripts were coded and grouped into themes using grounded theory.

RESULTS

Demographic characteristics of the groups were similar. Seven factors emerged as important in decision making: current health status, study design, physician involvement, personal benefit, altruism, time, and incentives. These factors were considered by individuals who elected to participate and those who did not, but weighed differently. Among the trial participants, good health status, encouragement from one's physician, and desires to learn and to contribute stimulated participation. Reasons for nonparticipation included current health status, medication and randomization concerns, and personal factors.

CONCLUSION

We observed that similar factors were weighed differently by participants and nonparticipants. Our results suggest that strategies such as health education, enlistment of personal physicians, and limitation of time requirements may enhance recruitment of patients with SLE into clinical prevention trials.

Cardiac risk factor awareness and management in patients with systemic lupus erythematosus

OBJECTIVE

To assess awareness and management of traditional cardiac risk factors (CRFs) in patients with systemic lupus erythematosus (SLE) and physicians.

METHODS

SLE patients (n=110) completed a questionnaire concerning CRFs. Medical records were reviewed blinded to questionnaire results for the presence and management of 6 CRFs: hypertension, hypercholesterolemia, smoking, obesity, diabetes mellitus, and physical inactivity.

RESULTS

Subjects were predominantly female (97%), mean (+/-SD) age was 43.4 years (+/-11.8), mean SLE duration was 15.3 years (+/-7.2), and 51% had > or =2 CRFs by self report. Twenty-three percent had never had their cholesterol levels checked. Hypercholesterolemia was more frequently documented in the medical records than reported by the patient (33% versus 24%). Physical inactivity was more frequently self reported than documented (59% versus 23%). Rheumatologists and patients had low interrater reliability for the presence of hypercholesterolemia (kappa=0.26) and physical inactivity (kappa=-0.02). More than half (58%) of CRFs were treated, and 21% of subjects with elevated cholesterol received a medication.

CONCLUSION

Recognition, recording, and management of CRFs falls short given the significance of the problem.

Barriers to a trial of atherosclerosis prevention in systemic lupus erythematosus

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.

Coronary artery angiography in systemic lupus erythematosus patients with abnormal myocardial perfusion scintigraphy

OBJECTIVE

According to published studies, 16-82% of systemic lupus erythematosus (SLE) patients have abnormal findings on myocardial perfusion tests, but it has not been established whether these patients also have abnormal findings on coronary angiography. The aim of this study was to evaluate the frequency of abnormal findings on coronary angiography in SLE patients in whom myocardial perfusion scintigraphy revealed abnormalities.

METHODS

Ninety female SLE patients (ages 20-55 years, disease duration >5 years, and current or previous steroid treatment for >/=1 year) underwent myocardial perfusion scintigraphy with single-photon-emission computed tomography using (99m)Tc-sestamibi. Images were taken while the patient was at rest and after dipyridamole-induced stress. Myocardial perfusion defects were identified in 30 patients (33%). Twenty-one of these patients (mean +/- SD age 42 +/- 9; mean +/- SD disease duration 132 +/- 66 months) agreed to undergo coronary angiography.

RESULTS

Atherosclerotic plaques were identified by angiography in 8 of the 21 patients (38%). The majority of coronary abnormalities were localized in the anterior descending artery. The mean +/- SD number of risk factors for coronary artery disease (CAD) was significantly higher in the subgroup with (4.5 +/- 0.8) compared with the subgroup without (2.5 +/- 1.9) abnormal angiographic findings (P = 0.006). Arterial hypertension and postmenopause status were significantly associated with abnormal angiographic findings. Of the patients with at least 4 risk factors for CAD, coronary stenosis was present in 67% (P = 0.005). The number of American College of Rheumatology (ACR) criteria for SLE and scores on the SLE Disease Activity Index and the Systemic Lupus International Collaborating Clinics/ACR damage index were also higher in the subgroup with coronary stenosis (P < 0.05).

CONCLUSION

This is the first study to examine coronary angiography results in SLE patients with abnormal findings on myocardial scintigraphy. Our data suggest that myocardial scintigraphy can be used to screen SLE patients and that all patients with abnormal findings plus at least 4 risk factors for CAD should undergo coronary angiography.

SLE - Practical and theoretical barriers to the prevention of accelerated atherosclerosis in systemic lupus erythematosus

Accelerated atherosclerotic vascular disease (ASVD) is a major cause of death in systemic lupus erythematosus (SLE). Although many authorities are calling for aggressive assessment and management of cardiac risk factors in patients with SLE, both theoretical and practical barriers to this approach exist. It seems that SLE and/or its treatment are themselves strong risk factors for the development of ASVD and it is unclear how much this risk can be decreased by the control of traditional risk factors. Studies from several centers have shown that suboptimal risk factor management and barriers to acceptance of these measures must also be studied further.

Cardiovascular Complications of Collagen Vascular Disease

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.