Download SLE and Cardiovascular Disease

SLE and Cardiovascular
Disease
Mario J. Garcia, MD, FACC, FACP
Chief, Division of Cardiology
Professor of Medicine and Radiology
Lupus and the Heart
• SLE is a chronic, inflammatory disease with circulating
Autoantibodies (“anti-self”); activated T cells (tissue
autoimmunity); immune complexes (AntigenAntibody) and inflammatory Cytokines (cell
messenger proteins)
• Lupus Therapy over the last 4 decades has converted
a rapidly fatal disease into a chronic condition
Cardiac Involvement in Lupus
All “layers” of the heart
can be involved:
1)
Pericardium
2)
Myocardium
3)
Valves
4)
Electrical System
5)
Coronary Vessels
Pericarditis
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Inflammation of the Pericardium
occurs in 11-54% of Lupus patients
Often occurs at Onset or with
Relapses
Pericarditis is the most
characteristic feature and is one of
the ACR/ARA Classification Criteria
for Lupus
“Sharp” chest pain, fever
Treated with NSAIDs or Steroids
Myocarditis
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Inflammation (“Myocarditis”) occurs in 7-10% of cases (and is treated with Steroids)
Can lead to Heart Failure
Valvular Disease
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Inflammatory lesions usually
on Mitral or Aortic Valves
(both active and healed)
“Verrucous” or Libman-Sacks
lesions characteristic but
not usual
Valve Leaking or Stroke
Heart Block
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Conduction “Block” rare in
adults
Seen in 2% of children born
to mothers with Anti-Ro/SSA
positive Lupus
Coronary Disease
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Coronary Arteries carry blood supply
the working muscle of the heart
Coronary Artery Disease in 6-10%;
Lupus patients have a 4-8 fold
increased risk
Smaller vessel inflammation
(vasculitis)-usually in younger
patients with active SLE
Larger vessel inflammation
(atherosclerosis)-usually in older
patients with long-standing SLE
Calcification
Lipid Cor
Inflammation
Thrombus
Coronary Calcium Score
Normal
Moderate
Calcification
Severe Calcification
Roman; NEJM; 2003
Coronary CTA
Stress Testing
Catheterization
Coronary Bypass and Stents
Carotid Ultrasound
Carotid Ultrasound
Lumen
IMT
Lumen
Stenosis
Asanuma; NEJM; Dec 18, 2003
T able 1
An Ounce of Prevention…
Accelerated atherosclerosis in systemic lupus
erythematosus: implications for patient
management.
S almon, J ane; R oman, Mary
C urrent Opinion in R heumatology. 13(5):341-344,
S eptember 2001.
Table 1 . S trategies to reduce atherosclerotic
cardiovascular disease in patients with systemic
lupus erythematosusAS C VD, atherosclerotic
cardiovascular disease; B P , blood pressure; L DL ,
low-density lipoprotein.
Diet Modification: Healthy Choices
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Fruits and Vegetables
Whole Grain and High Fiber
Oily (cold water) fish 2 x / week
Alcoholic drink not > 1/day
Sodium (Na+) < 2.3 gram/day
Saturated Fat < 10% of total calories
Limit Trans-Fat: Baked Goods and Fried Foods
Cardiac (Exercise) Rehab
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Prevents 23 deaths per 1000 patients
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Safety: Mortality 1 / 784,000 pt-hours
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Cost: $1200 / QOL-year (comparable to Left main surgery!) By
comparison, Dialysis costs $40,000 / QOL-yr
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Usually 3 x /week for 12-16 weeks
Smoking Cessation
• Smokers have 3 x the risk of MI of non-smokers
• Cessation prevents 70 deaths per 1000
patients x 1 year
Medical Treatment
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A—Aspirin and ACE Inhibitors
B—Beta Blockers and Blood Pressure
C—Cholesterol / Cigarettes / Clopidogrel
D—Diet (for Weight and Diabetes)
E—Exercise and Education
Conti, CR Clin. Cardiology 2007
LDL Cholesterol Goals
Risk Factor
LDL Goal
10 year event rate
CHD or Equivalent
< 100 mg/dl
> 20%
2 or more Risk Factors
< 130 mg/dl
10-20%
0-1 Risk Factors
<160 mg/dl
< 10%
Other Cholesterol Goals
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“Lupus” Lipid profile often has low HDL (“good” cholesterol),
high Triglycerides and high Lp(a) (a lipoprotein that ties into the
clotting cascade)
•
Lp(a) may be modifiable with exercise and Niacin
Treating Cholesterol
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High Total and LDL Cholest  Statins
(zocor, lipitor, crestor)
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High Trig and Low HDL Cholest  Fibrates (lopid, tricor)
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High LDL and Trig and low HDL Cholest Niacin (niaspan)
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High Triglycerides  prescript. Fish oil (Omega 3 FAs) (lovaza)