Premature Atherosclerosis in Systemic Lupus Erythematosus

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Systemic lupus erythematosus and coronary artery disease: epidemiologic evidence of association

The first cases suggesting an association between SLE and atherosclerotic CAD were reported in the 1960s [2]. In 1976, Urowitz et al [3] described the bimodal pattern of mortality in SLE based on a case series of 11 deaths among 81 patients followed for 5 years at the University of Toronto Rheumatic Disease Unit. Six of the 11 deaths occurred within the first year after diagnosis in patients who had active disease. In four of the six early deaths, a major septic episode contributed to the

Atherosclerosis in noncoronary vessels: a link with coronary artery disease

AS often affects multiple vessel territories in the same patient. Studies have shown that in patients who have diabetes, a classic risk factor for cardiovascular disease, AS in one vessel territory is a risk factor for presence of AS in other vascular territories [11]. Similarly in patients who do not have diabetes, coronary and cerebral arterial disease often coexist with small studies showing up to 20% to 40% prevalence of silent cardiac ischemia in patients who have a history of stroke,

Subclinical atherosclerosis in systemic lupus erythematosus: prevalence and methods of detection

Many patients who have SLE have subclinical AS with no history of MI or stroke. Detection of subclinical AS is not only important in determining the true prevalence of AS in SLE but also provides a window of opportunity for prevention of subsequent ischemic events. In addition, studying the natural history of subclinical disease may provide valuable insight in to means of attenuating risk and enhancing protective factors for adverse future outcomes.

Factors associated with coronary artery disease in systemic lupus erythematosus: interplay between disease, therapy, and conventional cardiovascular risk factors

Defining risk factors associated with premature AS in SLE is fundamental to understanding the pathogenesis of this complication and prevention of ischemic events and cardiovascular mortality in this disease. The large population-based Framingham Study has identified major risk factors for the development of CAD in the general population [36], [37]. These risk factors include hypertension, hypercholesterolemia (> 5.2 mmol/L), low HDL cholesterol (< 0.9 mmol/L), current smoking, diabetes

Novel risk factors for coronary artery disease in systemic lupus erythematosus

There has been much interest in identification of novel risk factors for CAD. Although many such risk factors have been proposed, most have yet to be linked conclusively to CAD in patients who have SLE, or indeed, in the general population.

Role of antiphospholipid antibodies in atherogenesis in systemic lupus erythematosus

Antiphospholipid antibodies (aPLs) are the hallmark of the antiphospholipid syndrome, which is characterized by arterial and venous thrombosis. Up to 47% of patients who have SLE have elevated levels of aPL [66]. High levels of aPLs have been linked to MI in young patients in several prospective studies [67], [68], [69] and shown to be an independent risk factor for MI and cardiac death in middle-aged men [70], [71]. Studies have also shown a link between anti-B2GPI antibodies and ischemic

New tools for cardiovascular risk profiling and their use in systemic lupus erythematosus

With advances in the understanding of vessel physiology and applications of ultrasound technology, there has been a trend away from invasive angiographic assessment of flow-limiting coronary lesions toward measuring earlier changes in structural and functional aspects of vessels potentially amenable to reversal with intervention.

Continuum of vascular disease in systemic lupus erythematosus and the concept of nonocclusive coronary artery disease

In the study by Sella et al [31], only 8 of 21 patients with myocardial perfusion defects and no history of CAD had coronary plaques identified on angiography. The investigators have also noted similar findings where of 21 patients with perfusion defects on MPS (10 of whom were symptomatic for CAD), 14 (67.0%) had no occlusive lesions on angiography [91]. In a descriptive study of 35 patients who had SLE and underwent coronary angiography in the course of routine clinical care in a 25-year

An approach to screening patients who had systemic lupus erythematosus for risk of future ischemic events

As discussed, several conventional cardiovascular risk factors have been shown to be associated with the development of clinical CAD in prospective cohort studies. All patients who have SLE should, therefore, be regularly screened for the presence of cardiovascular risk factors. The first tier of screening must include obtaining history in relation to smoking and measurement of body weight, blood pressure, serum cholesterol (including HDL and LDL), triglycerides, and blood glucose, as well as

Modifying risk factors for coronary artery disease in systemic lupus erythematosus

In the Toronto Risk Factor Study, a prospective cohort-control study of 250 women who had SLE without clinical CAD, compared with 250 age-matched controls, hypertension (RR 2.59, 95% CI 1.79–3.75, P = 0.001), and diabetes (RR 6.00, 95% CI 1.36–26.53, P = 0.0066) were significantly more common among patients who had SLE [44]. SLE patients also had higher levels of VLDL cholesterol and total triglycerides, and higher levels of homocysteine. Premature menopause, sedentary lifestyle, and an at-risk

Summary

The association between SLE and premature CAD has been well established. Longitudinal cohort studies have estimated the prevalence of CAD in SLE to be at least 10%. However, despite variations in the technique used, the prevalence of subclinical CAD is close to 35%, indicating that the burden of this complication is in fact greater than may at first appear. Clinicians must therefore have a low threshold for cardiac evaluation in patients who have SLE, including premenopausal women who present

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  • Cited by (81)

    • Acute Myocardial Infarction Outcomes in Systemic Lupus Erythematosus (from the Nationwide Inpatient Sample)

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      Autoimmune vascular damage may contribute to accelerated atherosclerosis, coronary vasculitis, and arterial thrombosis. Therefore, the etiology of acute coronary syndromes may vary from nonocclusive coronary artery or thrombotic occlusion with angiographically normal or mildly diseased coronary vasculature to vascular wall inflammation in young patients and coronary atherosclerosis in older patients.21 Based on the results of our analysis, AMI in SLE did not necessarily translate into a higher in-hospital mortality rate.

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      On the other hand, however, both lesions may coexist in the same coronary arteries, as suggested in an autopsy study by Takayanagi et al., who reported that atherosclerotic lesions and inflammatory lesions coexisted in the coronary arteries [10]. Although coronary angiography may be useful for distinguishing between these conditions, it does not allow imaging of the coronary microvasculature where the pathophysiology may lie [11]. Thus, it may be difficult to clearly differentiate between them, and we assume that both lesions may coexist in many cases of CHD in patients with SLE.

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    This work was supported by the Geoff Carr Lupus Fellowship from the Ontario Lupus Association.

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