SLE and Cardiovascular Disease

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SLE and Cardiovascular Disease

• Mario J. Garcia, MD, FACC, FACP
• Chief, Division of Cardiology
• Professor of Medicine and Radiology

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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

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Cardiac Involvement in Lupus

• All layers of the heart
• can be involved

• Pericardium
• Myocardium
• Valves
• Electrical System
• Coronary Vessels

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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

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Myocarditis

• Inflammation (Myocarditis) occurs in 7-10 of
  cases (and is treated with Steroids)?
• Can lead to Heart Failure

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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

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Heart Block

• Conduction Block rare in adults
• Seen in 2 of children born to mothers with
  Anti-Ro/SSA positive Lupus

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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)-usual
  ly in older patients with long-standing SLE

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Coronary Calcium Score
Normal
Severe Calcification

• Moderate Calcification

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• Roman NEJM 2003

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Coronary CTA
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Stress Testing
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Catheterization
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Coronary Bypass and Stents
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Carotid Ultrasound
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Carotid Ultrasound
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Asanuma NEJM Dec 18, 2003
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An Ounce of Prevention
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Diet Modification Healthy Choices

• Fruits and Vegetables
• Whole Grain and High Fiber
• Oily (cold water) fish 2 x / week
• Alcoholic drink not gt 1/day
• Sodium (Na) lt 2.3 gram/day
• Saturated Fat lt 10 of total calories
• Limit Trans-Fat Baked Goods and Fried Foods

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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

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Smoking Cessation

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

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Medical Treatment

• AAspirin and ACE Inhibitors
• BBeta Blockers and Blood Pressure
• CCholesterol / Cigarettes / Clopidogrel
• DDiet (for Weight and Diabetes)?
• EExercise and Education

Conti, CR Clin. Cardiology 2007
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LDL Cholesterol Goals
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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

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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)?