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Atherosclerotic vascular disease in systemic lupus erythematosus
Matthew H Liang1, Lisa A Mandl, Karen Costenbader
1Department of Medicine, Robert B. Brigham Arthritis and Musculoskeletal Diseases Clinical Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, USA. mliang@partners.org
Insights
Systemic lupus erythematosus (SLE) accelerates atherosclerotic vascular disease (ASVD), especially in African Americans. Glucocorticoids and SLE itself are key risk factors, necessitating improved prevention strategies for this vulnerable population.
Area of Science:
- Rheumatology
- Cardiovascular Medicine
- Epidemiology
Background:
- Systemic lupus erythematosus (SLE) is a chronic autoimmune disease with significant long-term morbidity.
- Atherosclerotic vascular disease (ASVD) is a major, accelerated complication in SLE patients, particularly premenopausal women.
- ASVD in SLE may differ from that in the general population, with higher incidence rates of myocardial infarction and stroke.
Purpose of the Study:
- To review the current understanding of ASVD risk factors in SLE patients.
- To highlight the disproportionate impact of SLE on African Americans and the lack of specific data for this demographic.
- To emphasize the need for improved management and prevention strategies for ASVD in SLE.
Main Methods:
- Review of existing literature on ASVD in SLE.
- Analysis of risk factors identified in retrospective, single-center studies.
- Assessment of current management practices and adherence to guidelines.
Main Results:
- Known general population risk factors for ASVD are also present in SLE patients.
- SLE itself and its treatment, particularly glucocorticoids, are identified as the most significant risk factors, even after accounting for traditional factors.
- Current management of cardiovascular risk factors and adherence to prevention guidelines in SLE patients are suboptimal.
Conclusions:
- There is a critical need to prioritize research into the prevention of ASVD in SLE, with a focus on African Americans.
- Improved management of cardiovascular risk factors in SLE patients is essential.
- Further investigation is required to determine if enhanced management strategies can prevent adverse cardiovascular outcomes in SLE.
Abstract:
In the United States, systemic lupus erythematosus (SLE) disproportionately affects African Americans. It has become a chronic disease with long-term morbidity including chronic renal disease, osteoporosis, cataracts, psychosocial impairment, and importantly, atherosclerotic vascular disease (ASVD). The latter (myocardial infarction, angina, peripheral vascular disease and stroke) are strikingly accelerated, occurring in subjects who are predominantly premenopausal women at an age when ASVD is rare or unusual. Although much is known about the biology, risk factors, and the prevention of atherosclerosis in normal individuals, little work has been done in SLE. In fact, ASVD in people with SLE may be a different disease. Approximately 1.5% of SLE patients per year will have a myocardial infarction or equivalent; about 0.5% of SLE patients per year will have a stroke. The risk factors for ASVD in SLE are based on small, retrospective, single center studies. These suggest that the risk factors known for the general population (i.e., smoking, obesity, sedentary lifestyle, high LDL cholesterol, etc.) are also observed in SLE. The best study of risk factors shows that even accounting for the known factors, SLE and/or its treatment (glucocorticoids) is by far the most important. Our current management of cardiovascular risk factors in SLE patients with ASVD is substandard and our adherence to national guidelines for prevention is substandard. It is not known whether improving either will prevent these disastrous outcomes. Very little is known about the risk factors in African Americans with SLE, although there is data to suggest that they may not be identical to those seen in Caucasian populations. The study of the best and most effective means to prevent ASVD in SLE and in African Americans with SLE and in African Americans with SLE should be a major priority.