Relationship between homocysteine levels and hypertension in systemic lupus erythematosus

High-sensitivity cardiac troponin I is a biomarker for increased arterial stiffness in systemic lupus erythematous women with normal kidney function

Cardiovascular disease (CVD) is a main cause of death in patients with systemic lupus erythematous (SLE). Algorithms for cardiovascular risk stratification in general population underestimate the risk for CVD in SLE. Our study aimed to determine whether serum high-sensitivity cardiac troponin I (hs-cTnI) might help to identify SLE patients with subclinical atherosclerosis. Arterial stiffness was assessed measuring the carotid-femoral pulse wave velocity (PWV) in 68 SLE women with a normal or almost normal kidney function and in 71 controls of similar characteristics. None of the participants had a history of an overt CVD. Serum hs-cTnI level was measured using the chemiluminescence method. Factors associated with an increased PWV (iPWV) were identified and multivariate analysis was performed. When detectable, patients tended to have had higher hs-cTnI levels than controls [2.9 (2.3-4.0) vs 2.4 (2.2-4.1); p = 0.098] and were more likely to have detectable hs-cTnI [50% vs 28%, odds ratio (OR) 7.0; 95% confidence interval (CI) 0.008-0.013]. Also, patients with iPWV were more likely to have detectable hs-cTnI than those with normal PWV (OR 6.4; 95% CI 0.019-0.026). In the multivariate analysis, the age at SLE diagnosis (OR 1.24; 95% CI 1.04-1.48), systolic blood pressure (OR 1.28; 95% CI 1.10-1.48) and detectable hs-cTnI level (OR 2.04; 95% CI 1.18-3.50) were independently associated with an iPWV. The negative predictive value of having an iPWV with undetectable hs-cTnI levels was 88%. Hs-cTnI may be a useful biomarker for the identification of SLE patients with iPWV as a surrogated marker of subclinical atherosclerosis. Specifically targeted prospective studies are needed to confirm this hypothesis.

Sclerostin as a biomarker of cardiovascular risk in women with systemic lupus erythematosus

Cardiovascular disease is one of the main causes of death in patients with systemic lupus erythematosus (SLE). On the other hand, sclerostin is a reliable and early biomarker of vascular calcification. This study aimed to estimate the association between sclerostin and two markers of cardiovascular risk, carotid atherosclerotic plaque (CP) and carotid-femoral pulse wave velocity (PWV), in women with SLE. The presence of CP (determined by carotid artery ultrasound) and PWV were measured in 68 women with SLE and preserved renal function. None of the participants had a history of cardiovascular disease. Serum levels of sclerostin were determined using the ELISA method. Other factors associated with increased cardiovascular risk were also measured. The association between sclerostin, CP and PWV was assessed using Receiver Operating Characteristic (ROC) curves and multivariate regression models. The area under the ROC curve was 0.785 (95% confidence interval [CI] 0.662-0.871) for CP and 0.834 (95% CI 0.729-0.916) for dichotomized PWV. After adjusting for other cardiovascular risk factors, it was found that a 10-units increase in sclerostin values was associated with a 44% increase in the odds of CP (95% CI 1-105), but no adjusted association was observed between sclerostin and PWV. Predictive models included age (for both outcomes), hypertension, Framingham risk score and C-reactive protein (for PWV), but not sclerostin. Sclerostin is associated with the presence of CP in women with SLE. Further research should confirm its possible role as a biomarker of cardiovascular risk in these patients.

Cardiovascular Complications in Systemic Lupus Erythematosus

Systemic lupus erythematosus (SLE) is an auto-immune disease of a relapsing-remitting nature that can cause multiorgan damage depending on several factors, mainly the disease activity. Young age women are the most likely to be affected by the disease and the female-to-male prevalence ratio is approximately 1:10. As the number of SLE patients has been increasing in the last few decades, the annual number of deaths due to the disease and its complications has increased as well, and one of the most important systems to which high mortality is attributed is the cardiovascular system, leading to premature atherosclerosis and other events such as endocarditis and valve disease. In addition to the classical cardiovascular risk factors, studies have found a positive correlation between SLE and other cardio-harmful diseases such as metabolic syndrome and dyslipidemia. Moreover, some of the medications used in the treatment of SLE place a heavy burden on the heart. The article reviews the shared pathophysiology of SLE and cardiovascular disease along with the most common SLE- associated cardiac risks, events, and management.

Modification of Platelet Count on the Association between Homocysteine and Blood Pressure: A Moderation Analysis in Chinese Hypertensive Patients

Background

Platelet consumption followed by homocysteine-induced endothelial injury suggests a crosstalk between platelet activation and homocysteine on hypertension. Platelet count has been found to modify the effect of folic acid on vascular health. However, whether platelet count could modify the contribution of homocysteine to blood pressure (BP) remains unclear.

Methods

Leveraging a community-based cross-sectional survey in 30,369 Chinese hypertensive patients (mean age 62 years, 52% female), we examined the moderation of platelet count on the association between serum homocysteine and BP by constructing hierarchical multiple regression models, adjusting for conventional risk factors. If adding the interaction term of homocysteine and platelet count could explain more variance in BP and the interaction is significant, then we believe that moderation is occurring.

Results

The association between serum homocysteine and diastolic BP was significantly stronger (β = 0.092 vs. 0.035, P = 0.004) in participants with low platelet count (<210 × 10⁹/L) than in those with high platelet count (≥210 × 10⁹/L). Adding the interaction term of homocysteine and platelet count additionally explained 0.05% of the variance in diastolic BP (P = 0.004) in participants with low platelet count (<210 × 10⁹/L) than in those with high platelet count (≥210 × 10⁹/L). Adding the interaction term of homocysteine and platelet count additionally explained 0.05% of the variance in diastolic BP (β = 0.092 vs. 0.035, P = 0.004) in participants with low platelet count (<210 × 10⁹/L) than in those with high platelet count (≥210 × 10⁹/L). Adding the interaction term of homocysteine and platelet count additionally explained 0.05% of the variance in diastolic BP (

Conclusions

The association between homocysteine and BP was significantly stronger in participants with low vs. high platelet count and was partially moderated by platelet count. These results indicate that platelet count may be useful in the identification of individuals who are most beneficial to reducing-homocysteine treatments but this usefullness still needs further investigation.

Serum/plasma homocysteine levels in patients with systemic lupus erythematosus: a systematic review and meta-analysis

Published studies have shown contradictory results in the association of serum/plasma levels of homocysteine (HCY) with systemic lupus erythematosus (SLE). This study is to systematically evaluate the association of serum/plasma HCY levels in SLE. A search was done using PubMed, Embase, Web of Science, and ScienceDirect databases up to 7 April 2019. Thirty-six articles including 2919 SLE patients and 3120 healthy controls were finally included in this meta-analysis. The HCY levels were significantly higher in SLE patients than in healthy controls (P < 0.001). The subgroup analysis revealed that Asian, African, Arab, Mixed, White and others as well as ages (< 35 and ≥ 35) had significant higher HCY levels in SLE patients than in the healthy controls. The study indicated that patients with disease activity index scores < 8 (P < 0.001) and ≥ 8 (P = 0.003) of SLE had significant higher HCY levels as compared with the healthy controls. It was also revealed that disease duration in SLE patients for < 10 and ≥ 10 years (P < 0.001) had significant higher HCY levels as compared with the healthy controls. A significant higher HCY level for body mass index (< 23 and ≥ 23) was found as well as measurement type in SLE patients than healthy controls. This meta-analysis demonstrated higher HCY levels in patients with SLE than healthy controls, suggesting a possible role of HCY in the disease.Key Points• Homocysteine (HCY) is closely related to the mechanisms of systemic lupus erythematosus (SLE).• This study reveals a significant correlation between HCY levels and the various indexes of disease activity.• This study reveals that medication may influence HCY levels in SLE.• This study also discovers that the subgroup analysis of all the factors influences the HCY levels in SLE patients.

Endothelial dysfunction and arterial stiffness in patients with systemic lupus erythematosus: A systematic review and meta-analysis

BACKGROUND AND AIMS

Non-invasive surrogates of cardiovascular (CV) disease such as endothelial dysfunction (ED) and peripheral arterial stiffness (AS) have been evaluated in systemic lupus erythematosus (SLE) patients. The aim of this study was to systematically review and meta-analyze reports of cardiovascular disease (CVD) in SLE patients, as measured by ED and AS.

METHODS

Studies analyzing the relationship of SLE with ED (flow-mediated dilatation [FMD], nitroglycerin-mediated dilatation [NMD] and peripheral arterial tonometry [PAT]) and AS (augmentation index [AIx], pulse wave velocity [PWV]) were systematically searched for in PubMed, Cochrane library, EMBASE, VHL, SciELO and Web of Science databases. Inclusion criteria included peer-review and English language. Mean differences (MD) and 95% confidence intervals (CIs) were estimated using the random effect model. The study was registered with PROSPERO, number CRD42019121068.

RESULTS

The meta-analysis included 49 studies. FMD data from 18 studies including 943 SLE subjects (mean age = 38.71 [95%CI 36.21, 41.21] years) and 644 unaffected controls (mean age = 38.63 [95%CI 36.11, 41.15] years) were included. When compared with unaffected controls, FMD in SLE subjects was decreased by 4.3% (95%CI: -6.13%, -2.47%): p < 0.001). However, NMD did not significantly differ between SLE patients and controls (MD = - 2.68%; 95% CI -6.00, 0.62; p = 0.11). A significantly increased AS between SLE patients and controls according to overall PWV (MD = 1.12 m/s; 95% CI 0.72-1.52; p < 0.001) was observed, but not for the brachial-ankle PWV. AIx was also increased in SLE patients compared with healthy controls (MD = 4.55%; 95% CI 1.48-7.63; p = 0.003).

CONCLUSIONS

Overall, SLE patients showed impaired FMD, an independent predictor of CV events. There was a higher degree of AS in SLE patients compared with controls. ED and AS in SLE should be considered when planning preventive strategies and therapies.

The Relationships of High-Sensitivity C-Reactive Protein and Homocysteine Levels With Disease Activity, Damage Accrual, and Cardiovascular Risk in Systemic Lupus Erythematosus

RESULTS

hs-CRP correlated significantly with SLEDAI-2K (p = .036), SDI (p = .00), anti-dsDNA titers (p = .034), diabetes (p = .005), and obesity (p = .027). hs-CRP and Hcy correlated with triglyceride (TG) levels (p = .032 and p < .001, respectively), TG/high-density lipoprotein cholesterol index (p = .020 and p = .001, respectively), and atherogenic index of plasma (p = .006 and p = .016, respectively). hs-CRP levels >3 mg/L correlated with SDI score (p = .012) and several CVD risk factors.

DISCUSSION

Findings suggest SLE patients with elevated hs-CRP and/or Hcy have a higher prevalence of CVD risk factors.

Homocysteine levels are independently associated with damage accrual in systemic lupus erythematosus patients from a Latin-American cohort

OBJECTIVE

To determine the impact of homocysteine levels on damage accrual in systemic lupus erythematosus (SLE) patients.

METHODS

This longitudinal study was conducted in consecutive patients seen every 6 months at our Rheumatology Department since 2012. Patients with available homocysteine levels and who had at least one subsequent visit were included. Univariable and multivariable Cox regression models were done to determine if homocysteine levels were predictive of damage accrual as per the SLICC Damage Index (SDI). The multivariable model was adjusted for pertinent variables (age at diagnosis, gender, socioeconomic status, disease duration, disease activity (SLEDAI), Framingham score, antimalarial and immunosuppressive drug use, average daily dose, and exposure time to prednisone (PDN)).

RESULTS

One hundred forty-five patients were included; their mean (SD) age at diagnosis was 43.70 (12.09) years, 136 (93.8%) were female, and nearly all were Mestizo. At baseline, disease duration was 7.55 (6.73) years; patients were followed for 3.54 (1.27) years. The SLEDAI was 5.60 (4.34), and the SDI 0.97 (1.35). The average daily PDN dose was 7.30 (5.78) mg/day and the time of PDN exposure was 7.36 (6.73) years. Mean homocysteine levels were 10.07 (3.71) μmol/L. The highest tertile of homocysteine levels predicted new damage accrual in the univariable and multivariable models [HR 1.78 (95% CI, 1.042-3.039); p = 0.035 and HR 2.045 (95% CI, 1.077-3.883); p = 0.029, respectively]. Increased levels (> 15 μmol/L) were found in 12 (8.3%) patients; 75 (51.7%) patients increased ≥ 1 SDI point.

CONCLUSION

In SLE patients, homocysteine levels predicted damage accrual independently of other well-known risk factors for such occurrence.

Association between ischemic heart disease and systemic lupus erythematosus-a large case-control study

Ischemic heart disease (IHD) is a well identified cause of mortality in systemic lupus erythematosus (SLE) patients due to an accelerated premature atherosclerosis. We investigated the proportion of comorbid IHD among SLE patients derived from a large, national real-life database. Using data from the largest HMO in Israel, the Clalit Health Services, we selected for patients with SLE. These patients were compared with age and sex matched controls with regards to the proportion of IHD in a case-control study. Chi-square and t tests were used for univariate analysis, and a logistic regression model was used for multivariate analysis. The study included 5018 patients with SLE and 25090 age and sex-frequency matched controls. The prevalence of IHD in patients with SLE was increased in comparison to controls (11.3 and 3.1%, P < 0.001). In a multivariate analysis, SLE was associated with IHD (OR 3.77, 95% confidence interval 3.34-4.26). We have confirmed that SLE patients suffer a high prevalence of IHD. Our data supports that SLE is an independent risk factor for IHD. When evaluating by gender, the risk seems even more substantial in females. No significant difference was found in the risk of IHD in SLE among the difference socioeconomic strata.

Cardiovascular disease in systemic lupus erythematosus: A comprehensive update

Heightened rates of both cardiovascular (CV) events and subclinical atherosclerosis, documented by imaging and vascular function techniques are well established in systemic lupus erythematosus (SLE). While traditional CV factors such as smoking, dyslipidemia, diabetes mellitus (DM), hypertension, central obesity and hyperhomocysteinemia have been reported to be prevalent in lupus patients, they do not fully explain the high rates of ischemic events so far reported, implying that other factors inherent to disease itself could account for the enhanced risk, including disease duration, activity and chronicity, psychosocial factors, medications, genetic variants and altered immunological mechanisms. Though the exact pathogenesis of atherosclerosis in the setting of lupus remains ill defined, an imbalance between endothelial damage and atheroprotection seems to be a central event. Insults leading to endothelial damage in the setting of lupus include oxidized low density lipoprotein (oxLDL), autoantibodies against endothelial cells and phospholipids, type I interferons (IFN) and neutrophil extracellular traps (NETs) directly or through activation of type I IFN pathway. Increased oxidative stress, reduced levels of the normally antioxidant high density lipoprotein (HDL), increased levels of proinflammatory HDL (piHDL) and reduced paraoxonase activity have been related to increased oxLDL levels. On the other hand, impaired atheroprotective mechanisms in lupus include decreased capacity of endothelial repair-partly mediated by type I IFN- and dampened production of atheroprotective autoantibodies. In the present review, traditional and disease related risk factors for CV disease (CVD) in the setting of chronic autoimmune disorders with special focus on SLE will be discussed.

Interactions of hyperhomocysteinemia and T cell immunity in causation of hypertension

Although hyperhomocysteinemia (HHcy) is an independent risk factor for cardiovascular diseases (CVD), there is a debate on whether HHcy is a risk factor or just a biomarker. Interestingly, homocysteine lowering strategies in humans had very little effect on reducing the cardiovascular risk, as compared with animals; this may suggest heterogeneity in human population and epigenetic alterations. Moreover, there are only few studies that suggest the idea that HHcy contributes to CVD in the presence of other risk factors such as inflammation, a known risk factor for CVD. Elevated levels of homocysteine have been shown to contribute to inflammation. Here, we highlight possible relationships between homocysteine, T cell immunity, and hypertension, and summarize the evidence that suggested these factors act together in increasing the risk for CVD. In light of this new evidence, we further propose that there is a need for evaluation of the causes of HHcy, defective remethylation or defective transsulfuration, which may differentially modulate hypertension progression, not just the homocysteine levels.

Nighttime Blood Pressure Patterns and Subclinical Atherosclerosis in Women with Systemic Lupus Erythematosus

Objective.

To compare 24-h ambulatory blood pressure (BP) monitoring (ABPM) values and patterns in women with systemic lupus erythematosus (SLE) with those of a matched control group and their relationship with the presence of subclinical atherosclerosis.

Methods.

ABPM was assessed in 70 women with SLE and in 65 sex- and age-matched controls without a history of clinic cardiovascular disease (CVD). Carotid-femoral pulse wave velocity (PWV), which is a marker of subclinical atherosclerosis and a predictor of future CVD, was measured. Multivariate logistic analysis was used to determine which explanatory variables were independently associated with the non-dipper pattern and the presence of nocturnal hypertension (HTN) in women with SLE.

Results.

No differences in PWV were found between patients and controls [median 7.3, interquartile range (IQR) 6.5–8.1 m/s vs median 7.1, IQR 6.5–7.8 m/s, p = 0.474]. The frequency of nondipper pattern (p = 0.025) and nocturnal HTN (p = 0.004) was significantly higher in women with SLE than in controls. White-coat and masked HTN were present in 10% and 11% of patients and in 20% and 8% of controls, respectively (p > 0.05 in all cases). The concordance between office and ambulatory HTN in the SLE and control groups was modest (κ = 0.325 and κ = 0.451, respectively). PWV and chronic kidney disease, and PWV and the Systemic Lupus Erythematosus Disease Activity Index were found to be independently associated with nocturnal HTN and nondipper pattern, respectively.

Conclusion.

Women with SLE were more likely to have an altered nighttime BP pattern than controls. In women with SLE, nondipper pattern and nocturnal HTN were independently associated with increased subclinical atherosclerosis measured by PWV.

Osteoporosis in rheumatic diseases

Rheumatic diseases, characterized by chronic inflammation and damage to various organs and systems, include systemic lupus erythematosus, rheumatoid arthritis, ankylosing spondylitis and other connective tissue diseases. Bone is a target in many inflammatory rheumatic diseases. In recent years, the survival of patients with rheumatic diseases has increased markedly and the relationship between rheumatic diseases and osteoporosis (OP) has become more prominent. OP and related fragility fractures increase the morbidity and mortality of rheumatic disease. The cause of OP in rheumatic diseases is complex. The pathogenesis of OP in rheumatic diseases is multifactorial, including disease and treatment-related factors. Osteoimmunology, a crosstalk between inflammatory and bone cells, provides some insight into the pathogenesis of bone loss in systematic inflammatory diseases. The aim of this article is to review different risk factors in rheumatic diseases. Several factors play a role, such as chronic inflammation, immunological factors, traditional factors, metabolism and drug factors. Chronic inflammation is the most important risk factor and drug treatment is complex in patients with OP and rheumatic disease. Attention should be paid to bone loss in rheumatic disease. Optimal treatment of the underlying rheumatic disease is the first step towards prevention of OP and fractures. Apart from that, a healthy lifestyle is important as well as calcium and vitamin D supplementation. Bisphosphonates or denosumab might be necessary for patients with a low T score.