Case 2: An Afro-Caribbean female with atypical chest pain An Afro-Caribbean female presented with neuropsychiatric lupus at the age of 28 years and was treated with intravenous cyclophosphamide. Her neuropsychiatric symptoms settled, and she was managed on low dose prednisolone and azathioprine. She had infrequent joint and skin flares, occasionally bad enough to require rituximab. She developed diabetes mellitus aged 43 years. Two years later she telephoned to report atypical chest pain that was not related to exertion. She had no risk factors for cardiovascular disease apart from lupus and diabetes mellitus. She was referred to cardiology where a CT coronary angiogram showed 70% left anterior descending artery stenosis. She had emergency percutaneous transluminal coronary angioplasty and has been well since.

Case 3: A white Eastern European female admitted with lupus flare and pericarditis A patient of white eastern European ethnicity presented with lupus at the age of 32 years in 1995. Over the next 20 years her joint and skin symptoms were very difficult to control, but she did not have any major organ involvement. Over time, she was treated with prednisolone, cyclophosphamide, mycophenolate, tacrolimus, azathioprine, methotrexate and rituximab, all of which were either ineffective or caused side-effects. In 2008 she was reviewed by cardiology due to atypical chest pain and no abnormality was found. In 2012 she underwent carotid and femoral ultrasound scanning as part of a research study. She had no cardiovascular symptoms at that time but had plaque at three bifurcations and total plaque area of 149 mm². She had insulin dependent diabetes and was a smoker. Four years later she was admitted to hospital with a lupus flare and pericarditis. While having an echocardiogram she developed sudden left ventricular failure and an urgent coronary angiogram showed 80% stenosis in the left anterior descending artery, which was treated by balloon angioplasty. Since then, her lupus has been brought under control with belimumab and she has had no further cardiovascular events.

References

1. Papazoglou N, Kravvariti E, Konstantonis G, et al. The impact of traditional cardiovascular risk factor control on 7-year follow-up atherosclerosis progression in systemic lupus erythematosus. Rheumatology (Oxford). 2024;63(1):50–57. doi: 10.1093/rheumatology/kead184.

2. Bakshi J, Croca SC, Griffin M, et al. Extent of vascular plaque predicts future cardiovascular events in patients with systemic lupus erythematosus. Rheumatology (Oxford). 2022;62(1):225–33. doi: 10.1093/rheumatology/keac259.

Learning Objectives At the end of this workshop participants will be able to:

• Recognise that patients with lupus can develop coronary disease suddenly with atypical presentation

• Explain the importance of controlling traditional cardiovascular risk factors in patients with lupus

• Discuss how non-invasive imaging such as vascular ultrasound may help to predict which patients with lupus are most likely to develop cardiovascular disease