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Accelerated atheroma in lupus--background
1The University of Toronto Lupus Clinic, Toronto Western Hospital, Ontario, Canada.
Insights
Systemic lupus erythematosus (SLE) patients face accelerated atherosclerosis, a major cause of death. Key risks include hypercholesterolemia, hypertension, and lupus itself, with corticosteroids worsening lipid levels.
Area of Science:
- Rheumatology
- Cardiology
- Immunology
Background:
- Systemic lupus erythematosus (SLE) is linked to accelerated atherosclerosis, a significant cause of mortality and morbidity.
- Coronary artery disease in premenopausal women with SLE led to the concept of a bimodal mortality pattern, confirmed by epidemiological and autopsy studies.
- Hypercholesterolemia, hypertension, and SLE disease activity are identified as key risk factors for atherosclerosis in SLE patients.
Purpose of the Study:
- To review the established risk factors for accelerated atherosclerosis in SLE.
- To evaluate the impact of corticosteroid and antimalarial therapies on lipid profiles in SLE patients.
- To compare the prevalence of atherosclerotic disease in SLE using clinical outcomes versus sensitive imaging techniques.
Main Methods:
- Observational cohort studies
- Autopsy and epidemiological studies
- Clinical outcome assessments (angina, myocardial infarction)
- Sensitive investigations (myocardial perfusion imaging, carotid ultrasound)
Main Results:
- Hypercholesterolemia (especially persistent), hypertension, and SLE are significant risk factors for accelerated atherosclerosis.
- Corticosteroids elevate plasma lipids, while antimalarials reduce cholesterol and LDL, particularly in steroid-induced hyperlipidemia.
- Clinical studies show 6-12% prevalence of atherosclerotic disease, whereas sensitive imaging reveals a 40% prevalence in SLE patients.
Conclusions:
- Accelerated atherosclerosis is a critical concern in SLE, influenced by disease activity, traditional risk factors, and medication.
- Sensitive imaging techniques reveal a higher prevalence of atherosclerosis in SLE patients than previously recognized.
- Further research into SLE's immunological factors may clarify atherosclerosis pathogenesis in both SLE and the general population.
Abstract:
Observational cohort studies in SLE have led to the description of accelerated atherosclerosis as an important cause of mortality and morbidity in this disease. The clinical observation of coronary artery disease occurring in premenopausal females with SLE gave rise to the concept of the bimodal mortality pattern. This pattern was confirmed in autopsy and epidemiological studies. These studies identified hypercholesterolemia and particularly its persistence in the first three years of disease, hypertension, and lupus itself as important risk factors for the development of accelerated atherosclerosis in these patients. It also became evident that corticosteroid therapy plays an important role in the elevation of plasma lipids while antimalarials resulted in a reduction of plasma cholesterol, LDL, and VLDL, especially in steroid-induced hyperlipidemia. Studies of clinical outcomes for atherosclerotic disease (angina, myocardial infarction) have shown a prevalence of 6-12% in a number of SLE cohorts. However, more sensitive investigations including myocardial perfusion imaging and carotid ultrasound have demonstrated a prevalence of atherosclerotic disease in 40% of patients studied. Further studies of SLE disease process, including immunological factors, may more clearly define the pathogenesis of accelerated atherosclerosis in patients with SLE, and may help elucidate mechanisms of atherosclerosis in the general population.