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Lupus and Heart Health
LUPUS & HEART HEALTH
INTRODUCTION Lupus is a multi-organ autoimmune disease, commonly affecting young women of childbearing age. Classically, the involvement of kidneys (lupus nephritis) led to a more severe course in the disease. However, with the advancements in the diagnosis and treatment of lupus, kidney related complications have lessened. In fact, the involvement of heart and vascular systems have become prominent and often lead to increased suffering in lupus patients. Both stroke and myocardial infarction (“heart attack”) occur more frequently in premenopausal women with lupus compared with their counterparts. This makes up 30% of premature deaths in the first 5 years after diagnosis of lupus. The prevalence of coronary artery disease in lupus patients is 10-fold higher as compared to the general population and 50-fold higher in young women of childbearing age.
CLINICAL PRESENTATION Lupus can affect the heart in several ways, pericarditis, or inflammation of the outer lining of the heart being the most common. Approximately 1 in 4 patients with lupus develops symptoms of pericarditis in their lifetime. There can be involvement of the heart musculature (myocarditis), heart valves causing leaky valves. Patients can have increased heart rate, chest pain, decreased exercise tolerance and shortness of breath. Patients with lupus are advised to be extra vigilant about these symptoms and receive medical care at a timely fashion. Investigations like laboratory tests, chest x ray,
EKG, Ultrasound of the heart (Echocardiogram) can be very helpful and widely available. At times, more elaborate tests like cardiac stress test or cardiac MRI are required for the diagnosis.
RISK FACTORS It is important to understand that traditional risk factors for heart diseases like tobacco use, male gender, elevated blood pressures (hypertension), elevated cholesterol (hyperlipidemia), and obesity are prevalent in patients with lupus. But having said that, lupus itself can increase the risk of heart diseases because of inflammation, especially in younger females. Patients who have had lupus for a long time and had very active severe disease are at increased risk for heart diseases. These patients often have several symptoms due to involvement of various organ systems like kidneys, joints, lungs, brain, blood clots etc. They are often treated with prolonged courses of high dose prednisone which can cause weight gain, hypertension, hyperlipidemia and hence increases the risk for heart diseases. A previous history of blood clots puts a lupus patient at higher risk of having heart attack and stroke. Although men represent a small minority of patients with lupus, male sex is a strong risk factor for coronary artery disease in lupus.
LUPUS AND PREGNANCY In a pregnant lupus patient, your rheumatologist will check antibodies SSA and SSB which can potentially increase the risk of having the newborn with lupus (neonatal lupus). Newborns with neonatal lupus can have a body rash and electrical conduction defects in the heart (complete heart block). Close follow-up during pregnancy with rheumatologists and highrisk obstetricians is of utmost importance. Fetal echocardiograms are done routinely in high-risk pregnant mothers to detect heart abnormalities in the baby during the later period of pregnancy.
ANTIPHOSPHOLIPID ANTIBODIES Antiphospholipid antibodies syndrome (APLS) in particular can greatly increase the risk of blood clots, heart attacks and stroke. APLS can damage heart valves causing them to be leaky. Pregnant women with APLS are treated with blood thinners during pregnancy.
PREVENTION AND TREATMENT In common practice, a rheumatologist would like to see a lupus patient every 3-6 months in office for history, physical exam and obtaining labs. This helps to monitor and control the disease which is important to prevent cardiovascular complications. Hydroxychloroquine is comonly used in the treatment of lupus and is reported to be beneficial in reduction of cholesterol levels and incidence of blood clots. Use of hydroxychloroquine in expecting mothers can decrease the recurrence of neonatal lupus. When necessary, rheumatologists often use additional medications like azathioprine, methotrexate, belimumab and sometimes stronger medications like rituximab and cyclophosphamide in order to keep the lupus symptoms under control.
Regular health check-ups with your general practitioner can help detect high blood pressure, blood sugars or cholesterol levels. We often spend time in counseling patients for tobacco cessation since we see a much higher risk of heart attacks and stroke with tobacco use. In the current era of pandemic, with a large number of the population working from home, or struggling with stress and depression, increased weight gain can lead to more and more cardiovascular diseases. Keeping the body mass index (BMI) in the normal range of 18.5-24.9 is advised.
Therefore, regular exercise, a healthy balanced diet and adequate restful sleep are keys to a healthy heart.
