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Risk factors for cardiovascular mortality in patients with systemic lupus erythematosus, a prospective cohort study
Johanna T Gustafsson1, Julia F Simard, Iva Gunnarsson
1Rheumatology Unit, Department of Medicine, Karolinska University Hospital, Solna, Karolinska Institutet, SE-171 76 Stockholm, Sweden. johanna.gustafsson@karolinska.se
Insights
Systemic lupus erythematosus (SLE) patients have a higher mortality rate, with cardiovascular disease (CVD) being a major cause. Novel biomarkers like cystatin C, inflammatory markers, and antiphospholipid antibodies predict CVD mortality better than traditional risk factors.
Area of Science:
- Rheumatology
- Cardiology
- Immunology
Background:
- Systemic lupus erythematosus (SLE) is a chronic autoimmune disease associated with increased cardiovascular disease (CVD) risk and mortality.
- While cardiovascular morbidity in SLE is well-studied, data on cardiovascular mortality predictors are limited.
Purpose of the Study:
- To identify causes of death and baseline predictors of overall, non-vascular, and cardiovascular mortality in SLE patients.
- To evaluate the performance of the Systematic Coronary Risk Evaluation (SCORE) in predicting cardiovascular mortality in this cohort.
Main Methods:
- A cohort of 208 SLE patients was followed for 12 years, with clinical data, CVD risk factors, and biomarkers recorded at baseline.
- Causes of death were determined from death certificates and autopsy reports; mortality predictors were analyzed using multivariable Cox regression.
Main Results:
- 48% of deaths in the cohort were attributed to cardiovascular causes, with a standardized mortality ratio of 2.4.
- Traditional risk factors like smoking, along with cystatin C, soluble vascular cell adhesion molecule-1 (sVCAM-1), high-sensitivity C-reactive protein (hsCRP), and antiphospholipid antibodies (aPL), predicted cardiovascular mortality.
Conclusions:
- Traditional risk factors, except smoking, are insufficient for predicting cardiovascular mortality in SLE.
- Biomarkers including cystatin C, inflammatory/endothelial markers, and aPL are crucial for assessing cardiovascular prognosis in SLE patients.
Introduction:
Systemic lupus erythematosus (SLE) is a chronic autoimmune disease. Cardiovascular disease (CVD) is common and a major cause of mortality. Studies on cardiovascular morbidity are abundant, whereas mortality studies focusing on cardiovascular outcomes are scarce. The aim of this study was to investigate causes of death and baseline predictors of overall (OM), non-vascular (N-VM), and specifically cardiovascular (CVM) mortality in SLE, and to evaluate systematic coronary risk evaluation (SCORE).
Methods:
208 SLE patients were included 1995-1999 and followed up after 12 years. Clinical evaluation, CVD risk factors, and biomarkers were recorded at inclusion. Death certificates and autopsy protocols were collected. Causes of death were divided into CVM (ischemic vascular and general atherosclerotic diseases), N-VM and death due to pulmonary hypertension. Predictors of mortality were investigated using multivariable Cox regression. SCORE and standardized mortality ratio (SMR) were calculated.
Results:
During follow-up 42 patients died at mean age of 62 years. SMR 2.4 (CI 1.7-3.0). 48% of deaths were caused by CVM. SCORE underestimated CVM but not to a significant level. Age, high cystatin C levels and established arterial disease were the strongest predictors for all- cause mortality. After adjusting for these in multivariable analyses, only smoking among traditional risk factors, and high soluble vascular cell adhesion molecule-1 (sVCAM-1), high sensitivity C-reactive protein (hsCRP), anti-beta2 glycoprotein-1 (abeta2GP1) and any antiphospholipid antibody (aPL) among biomarkers, remained predictive of CVM.
Conclusion:
With the exception of smoking, traditional risk factors do not capture the main underlying risk factors for CVM in SLE. Rather, cystatin C levels, inflammatory and endothelial markers, and antiphospholipid antibodies (aPL) differentiate patients with favorable versus severe cardiovascular prognosis. Our results suggest that these new biomarkers are useful in evaluating the future risk of cardiovascular mortality in SLE patients.
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