SAN DIEGO—To manage patients with systemic lupus erythematous (SLE), rheumatologists must be aware of potentially serious complications affecting many organ systems. On Nov. 7 at the 2017 ACR/ARHP Annual Meeting, two experts offered insights on cardiovascular and hematological complications of lupus.
Myocardial Disease in Lupus
Lupus patients are at increased risk for heart-related complications, especially during times of high disease activity, said Susan Manzi, MD, MPH, director of the Lupus Center for Excellence at Allegheny Health Network in Pittsburgh.
Endomyocardial biopsy is the gold standard for diagnosing myocarditis in these patients, and it can show signs of fibrosis or inflammation. “Myocarditis tends to be patchy, so endomyocardial biopsies can be tricky. That’s why the recommendation is to do multiple biopsies,” said Dr. Manzi. “The problem is that endomyocardial biopsies are invasive, if relatively safe.” Cardiac magnetic resonance imaging (MRI) is a diagnostic alternative to identify problems in the myocardium.
“Myocardial disease can be caused by ischemia, including ischemia of the epicardial vasculature or the coronary arteries, but also ischemia of the coronary microvasculature,” said Dr. Manzi. Microvascular dysfunction, previously called Syndrome X, is seen more in women and people with autoimmune diseases. Symptoms include chest pain and ischemic changes to normal coronary arteries. Infections and drugs are other possible causes of myocardial dysfunction.
Heart failure is also more common in lupus, said Dr. Manzi. In a new, large study of 48 million American adults, including 95,000 with SLE, “you see a dramatic increase of heart failure in lupus compared to the general population.1 You don’t see heart failure in the general population until people are in their 50s or 60s, but in lupus, the relative risk is dramatically increased,” even among people in their 20s. Patients with lupus nephritis have a tenfold increased relative risk for heart failure, she said.
“What were the independent predictors of heart failure in lupus patients? Even after you control for general risk factors, lupus remains an independent risk factor. Also, coronary artery disease, hypertension and valvular disease all influence rates of heart failure, and all of those are increased in lupus.”
Lupus patients are at increased risk of epicardial vascular disease and atherosclerotic cardiovascular disease, even in their 20s.2 Younger women with SLE have about a two- to tenfold increased risk of myocardial infarction, including before or shortly after their lupus diagnosis, she said.3 Cardiac MRI can help confirm a previous MI in these patients.