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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.

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SLE and Cardiovascular Disease

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  1. SLE and Cardiovascular Disease Mario J. Garcia, MD, FACC, FACP Chief, Division of Cardiology Professor of Medicine and Radiology

  2. Lupus and the Heart • SLE is a chronic, inflammatory disease with circulating Autoantibodies (“anti-self”); activated T cells (tissue autoimmunity); immune complexes (Antigen-Antibody) and inflammatory Cytokines (cell messenger proteins)‏ • Lupus Therapy over the last 4 decades has converted a rapidly fatal disease into a chronic condition

  3. Cardiac Involvement in Lupus All “layers” of the heart can be involved: • Pericardium • Myocardium • Valves • Electrical System • Coronary Vessels

  4. Pericarditis • 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

  5. Myocarditis • Inflammation (“Myocarditis”) occurs in 7-10% of cases (and is treated with Steroids)‏ • Can lead to Heart Failure

  6. Valvular Disease • 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

  7. Heart Block • Conduction “Block” rare in adults • Seen in 2% of children born to mothers with Anti-Ro/SSA positive Lupus

  8. Coronary Disease • 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

  9. Calcification Lipid Cor Inflammation Thrombus

  10. Coronary Calcium Score Moderate Calcification Normal Severe Calcification

  11. Roman; NEJM; 2003

  12. Coronary CTA

  13. Stress Testing

  14. Catheterization

  15. Coronary Bypass and Stents

  16. Carotid Ultrasound

  17. Carotid Ultrasound Lumen Lumen Stenosis IMT

  18. Asanuma; NEJM; Dec 18, 2003

  19. An Ounce of Prevention…

  20. Diet Modification: Healthy Choices • 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

  21. Cardiac (Exercise) Rehab • Prevents 23 deaths per 1000 patients • Safety: Mortality 1 / 784,000 pt-hours • Cost: $1200 / QOL-year (comparable to Left main surgery!) By comparison, Dialysis costs $40,000 / QOL-yr • Usually 3 x /week for 12-16 weeks

  22. Smoking Cessation • Smokers have 3 x the risk of MI of non-smokers • Cessation prevents 70 deaths per 1000 patients x 1 year

  23. Medical Treatment • 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

  24. 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% LDL Cholesterol Goals

  25. Other Cholesterol Goals • “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

  26. Treating Cholesterol • High Total and LDL Cholest Statins (zocor, lipitor, crestor)‏ • High Trig and Low HDL Cholest Fibrates (lopid, tricor)‏ • High LDL and Trig and low HDL CholestNiacin (niaspan)‏ • High Triglycerides  prescript. Fish oil (Omega 3 FAs) (lovaza)‏

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