Heart failure risk in systemic lupus erythematosus compared to diabetes mellitus and general medicaid patients

https://doi.org/10.1016/j.semarthrit.2019.06.005Get rights and content

Abstract

Background

Patients with systemic lupus erythematosus (SLE) have a similar risk of myocardial infarction as those with diabetes mellitus (DM). Whether the risk of heart failure (HF) in SLE is similar to the elevated risk in DM is unknown. We sought to estimate the rates and risks for HF hospitalization among US Medicaid patients with SLE and to compare them to those for DM and the general Medicaid population.

Methods

Using U.S. Medicaid data from 2007–2010, we identified patients with SLE or DM, and a matched cohort from the general Medicaid population and calculated incidence rates (IR), incidence rate ratios (IRR) and adjusted hazard ratios (HR) of a first HF hospitalization.

Results

We identified 37,902 SLE (93% female, mean age 40.1 ± 12.1), 76,657 DM (93% female, mean age 40.0 ± 12.1), and 158,695 general Medicaid patients (93% female, mean age 40.2 ± 12.1). The IR per 1000-person years was 6.9 (95% CI 6.3–7.5) for SLE, 6.6 (95% CI 6.2–7.0) for DM, and 1.6 (95% CI 1.5–1.8) for general Medicaid patients. The highest IRR compared to general Medicaid was seen among SLE patients in age group 18–39 (14.7, 95% CI 13.9–15.5). Multivariable-adjusted HRs for HF compared to general Medicaid population were similar for SLE (2.7, 95% CI 2.3–3.1) and DM (3.0, 95% CI 2.6–3.4).

Conclusion

The incidence of HF among SLE patients was 2.7-fold higher than general Medicaid patients, and similar to DM. Further investigation into the biologic mechanism of HF among SLE compared to non-SLE and DM patients may shed light on the findings of this study.

Introduction

Atherosclerotic cardiovascular disease (ASCVD) risk and mortality are increased among patients with systemic lupus erythematosus (SLE), compared to patients without SLE [1], [2]. Most studies demonstrating this increased risk have focused on myocardial infarction (MI) and stroke as the primary outcomes [3]. In contrast, few studies among SLE patients have examined the incidence and risk of heart failure (HF) [4], [5], which is associated with high morbidity and mortality and is often the end-stage of cardiac disease [6].

Along with ischemic heart disease, hypertension, and smoking, type 2 diabetes mellitus (DM) is a strong risk factor for HF [7]. Patients with DM have been shown to have up to five-fold higher risk of HF compared to those without DM [8]. Recent studies have revealed that rates of ASCVD are similar among patients with SLE and age- and sex-matched DM patients, and both groups have rates that are higher than the general population [9], [10]. How the risk of HF among SLE patients compares to that among patients with DM and to the general population is unknown.

The aim of this study was to investigate rates and risks of incident HF in patients with SLE compared to two groups: patients with DM and to individuals from the general Medicaid population. We hypothesized that the risk of HF in patients with SLE would be similar to that observed in patients with diabetes, and that both groups would have a substantially higher risk than that observed in the general Medicaid population.

Section snippets

Data source

We employed data from the Medicaid Analytic eXtract which includes billing claims, demographic information, and medication dispensing data for patients in Medicaid, the U.S. health insurance for low-income individuals. We identified adults of ages 18–65 years residing in the 29 most populated states in the U.S., who were enrolled in Medicaid between January 1, 2007 and December 31, 2010. We excluded patients >65 years old as > 90% are dually enrolled in Medicare and thus not all claims are

Results

We identified 40,212 SLE patients, who were matched by age at index date and sex to 80,424 DM patients, and 160,848 general Medicaid patients (Table 1). After excluding patients with baseline history of hospitalization for HF (5.7% for SLE, 4.6% for DM, and 1.3% for general Medicaid), our cohorts consisted of 37,902 SLE patients (93% female, mean age 40.1 ± 12.1), 76,657 DM patients (93% female, mean age 40.0 ± 12.1), and 158,695 general Medicaid patients (93% female, mean age 40.2 ± 12.1).

Discussion

In this prospective cohort study of nearly 38,000 U.S. Medicaid patients with SLE, we found that the incidence rate of HF hospitalization was more than 4 times higher than among age- and sex- matched general Medicaid patients. Furthermore, SLE patients had a similar risk of HF hospitalization as patients with DM, a disease population with recognized elevated HF risk [8]. While the overall rate of HF was similar in patients with SLE and DM, the relative increase in HF risk for patients with SLE

Conclusions

In this large U.S. Medicaid cohort study, we found that the adjusted risk for incident HF hospitalization among patients with SLE was almost 3-fold higher than general Medicaid patients, and was very similar to that seen among patients with DM. In line with previous reports of elevated rates of MI and stroke in SLE patients, this study demonstrates that patients with SLE are at particularly high risk for HF, similar to patients with DM, and that this risk is concentrated among young patients.

Acknowledgments

We would like to thank Chang Lu for programming review, and Cameron Speyer for technical review of this article.

Sources of funding

This work was funded by NIH R01 AR057327 and K24 AR066109 (Dr. K Costenbader). Dr. Everett's effort on this study was supported by NIH/NHLBIR56 HL134810.

Disclosures

Dr. SK Chen received research support from T32 AR 7530-33. Dr. Barbhaiya is supported by the Rheumatology Research Foundation Investigator Award. Dr. CH Feldman is supported by NIH K23 AR071500. She also receives research support from BMS and Pfizer for unrelated studies. Dr. K Costenbader has received research support for this study from the NIH R01 AR057327 and K24 AR066109, and research support from Rheumatology Research Foundation, Lupus Foundation of America, Pfizer, Biogen Idec, Merck,

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