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PAINSCAN LITERATURE REVIEW
Issue 1, Volume 1
Systemic Lupus Erythematosus (SLE): Current Issues in Management
8 Articles in this Series
Introduction
Risk factors for cardiovascular mortality in patients with systemic lupus erythematosus, a prospective cohort study
Global Trend of Survival and Damage of Systemic Lupus Erythematosus: Meta-Analysis and Meta-Regression of Observational Studies from the 1950s to 2000s
Belimumab in the treatment of systemic lupus erythematosus: high disease activity predictors of response
Mycophenolate versus Azathioprine as Maintenance Therapy for Lupus Nephritis
Therapy of lupus nephritis: lessons learned from clinical research and daily care of patients
Effect of hydroxychloroquine treatment on pro-inflammatory cytokines and disease activity in SLE patients: data from LUMINA (LXXV), a multiethnic US cohort
How to treat refractory arthritis in lupus?
Weight loss and improvement in fatigue in systemic lupus erythematosus: a controlled trial of a low glycaemic index diet versus a calorie restricted diet in patients treated with corticosteroids

Risk factors for cardiovascular mortality in patients with systemic lupus erythematosus, a prospective cohort study

Arthritis Res Ther. 2012;[published online ahead of print March 5, 2012]:doi: 10.1186/ar3759

Introduction:  Cardiovascular disease (CVD) is a common and major cause of mortality in systemic lupus erythematosus (SLE).  While there are many studies on the morbidity of CVD, there is a dearth of studies on CVD and mortality in SLE.  Therefore, this study was done to examine the causes of death in SLE and to look at baseline predictors of non-vascular (N-VM), and cardiovascular (CVM) mortality.  The study was also done to evaluate the Systemic Coronary Risk Evaluation (SCORE), a tool to predict cardiovascular mortality over a 10 year period that takes into consideration the patient’s age, smoking, sex, systolic blood pressure, and cholesterol.

Methods:   208 patients from the Department of Rheumatology, Karolinska University Hospital who fulfilled 4 or more of the 1982 revised American College of Rheumatology Criteria for SLE classification were enrolled between 1995 to 1998.

At the time of inclusion, a evaluation of SLE activity and damage, traditional CVD risk factors, and novel biomarkers for CVD were measured.  

In 2010, death certificates and autopsy protocols were collected for the study participants, and causes of death were grouped into CVM, N-VM, and pulmonary hypertension.  Multivariate Cox regression was used to examine mortality predictors, and SCORE and standardized mortality ratio (SMR) were calculated.

Results:  Over the 12 years, 42 patients had died (36 women and 6 men) at a mean age of 62.  This was more deaths than expected (SMR=2.4; 95% confidence interval [CI], 1.7-3.0).

CVM caused 48% of those deaths.  The baseline SCORE underestimated CVM, but not at a significant level.

The strongest predictors for all-cause mortality were age, high cystatin C-levels (a marker of renal insufficiency), and established arterial disease.  Adjusting for these in multivariate analysis showed that smoking (the only traditional risk factor), high soluble vascular cells adhesion molecule-1 (sVCAM-1), high-sensitivity C-reactive protein (HsCRP), anti-beta2 glycoprotein-1 (abeta2GP1), and any antiphospholipid antibody (aPL) among biomarkers were still predictive of CVM.

Conclusions:  In SLE, the traditional risk factors do not capture the underlying risk factors for CVM.  Instead, to estimate an SLE patient’s cardiovascular risk non-traditional risk factors need to be considered.  These include markers of renal insufficiency, inflammation and endothelial dysfunction and anticardiolipid antibodies.

Commentary

In the past decade, premature cardiovascular disease has been identified as an important contributor to long-term morbidity and mortality in patients with SLE. It is not uncommon for women with SLE to develop cardiovascular disease in their 50’s, decades before it would typically be seen in healthy women. The cause of this is not fully elucidated, but it has been shown to not be fully explained by traditional risk factors for cardiovascular disease, including hypertension and high cholesterol. This study highlights these prior findings: more patients died with SLE over a 12 year period than would have been expected and almost half of these deaths were attributed to cardiovascular disease, with the average age of death in the low 60’s. Key predictors of cardiovascular risk were antiphospholipid antibodies (known to cause thrombosis), smoking, markers of endothelial dysfunction, renal insufficiency, and inflammation. Primary care physicians need to pay particular attention to the cardiovascular health of patients with SLE and emphasize control of blood pressure and cholesterol, cessation of smoking, and encourage exercise. In addition, possible signs and symptoms of angina or TIA’s should be taken very seriously even in younger women with SLE.

Next Article:
Global Trend of Survival and Damage of Systemic Lupus Erythematosus: Meta-Analysis and Meta-Regression of Observational Studies from the 1950s to 2000s
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