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Lopes Almeida Gomes L, Forman Faden D, Xie L, Chambers S, Stone C, Werth VP, Williams KJ. Modern therapy of patients with lupus erythematosus must include appropriate management of their heightened rates of atherosclerotic cardiovascular events: a literature update. Lupus Sci Med 2025; 12:e001160. [PMID: 40204295 PMCID: PMC11979607 DOI: 10.1136/lupus-2024-001160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2024] [Accepted: 03/13/2025] [Indexed: 04/11/2025]
Abstract
Atherosclerotic cardiovascular disease (ASCVD) remains the biggest killer of patients with lupus erythematosus (LE) and the general non-autoimmune population. In this literature update on LE and ASCVD, we focused on published work since our earlier review article, meaning from 2021 to the present, with an emphasis on cutaneous LE. Several themes emerged. First, new work shows that patients with lupus still exhibit a high burden of conventional risk factors for ASCVD events. Second, recent studies continue to implicate possible effects of lupus disease activity to worsen rates of ASCVD events beyond predictions from conventional risk factors. Third, new work on estimating the risk of future ASCVD events in patients with lupus supports arterial-wall imaging, inclusion of lupus-specific factors, estimators of ASCVD event risk that take lupus status into account and considering lupus as a diabetes equivalent or even as a diabetes-plus-smoking equivalent in this context. Technologies for arterial-wall imaging continue to improve and will likely play an increasing role in ASCVD assessment and management. Fourth, purported cardiovascular benefits from certain disease-modifying antirheumatic drugs such as antimalarials have become less clear. Fifth, earlier treatment of atherosclerosis, which is a lifelong disease, can be accomplished with diet, exercise, smoking cessation and new classes of safe and effective medications for lipid-lowering and blood pressure control. Benefits on subclinical arterial disease by imaging and on ASCVD events have been reported, supporting the concept that ASCVD is eminently manageable in this autoimmune condition. Sixth, despite the heightened risk for ASCVD events in patients with lupus, available therapeutic approaches remain unused or underused and, accordingly, event rates remain high.Raising awareness among patients and healthcare providers about ASCVD assessment and management in patients with LE is essential. Greater vigilance is needed to prevent ASCVD events in patients with lupus by addressing dyslipidaemias, hypertension, smoking, obesity and physical inactivity.
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Affiliation(s)
- Lais Lopes Almeida Gomes
- Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Dermatology, Corporal Michael J Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
| | - Daniella Forman Faden
- Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Dermatology, Corporal Michael J Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
| | - Lillian Xie
- Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Dermatology, Corporal Michael J Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
| | - Shae Chambers
- Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Dermatology, Corporal Michael J Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
| | - Caroline Stone
- Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Dermatology, Corporal Michael J Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
| | - Victoria P Werth
- Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Dermatology, Corporal Michael J Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
| | - Kevin Jon Williams
- Departments of Cardiovascular Sciences and Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, USA
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Blachut D, Przywara-Chowaniec B, Tomasik A, Kukulski T, Morawiec B. Update of Potential Biomarkers in Risk Prediction and Monitoring of Atherosclerosis in Systemic Lupus Erythematosus to Prevent Cardiovascular Disease. Biomedicines 2023; 11:2814. [PMID: 37893187 PMCID: PMC10604001 DOI: 10.3390/biomedicines11102814] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 10/11/2023] [Accepted: 10/13/2023] [Indexed: 10/29/2023] Open
Abstract
Systemic lupus erythematosus is a chronic connective tissue disease associated with an increased risk of premature atherosclerosis. It is estimated that approximately 10% of SLE patients develop significant atherosclerosis each year, which is responsible for premature cardiovascular disease that is largely asymptomatic. This review summarizes the most recent reports from the past few years on biomarkers of atherosclerosis in SLE, mainly focusing on immune markers. Persistent chronic inflammation of the vascular wall is an important cause of cardiovascular disease (CVD) events related to endothelial dysfunction, cell proliferation, impaired production and function of nitric oxide and microangiopathic changes. Studies on pathogenic immune mediators involved in atherosclerosis will be crucial research avenues for preventing CVD.
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Affiliation(s)
- Dominika Blachut
- 2nd Department of Cardiology, Medical University of Silesia in Katowice, 41-800 Zabrze, Poland
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Zhao M, Feng R, Werth VP, Williams KJ. State of current management of the heightened risk for atherosclerotic cardiovascular events in an established cohort of patients with lupus erythematosus. Lupus Sci Med 2023; 10:e000908. [PMID: 37604650 PMCID: PMC10445381 DOI: 10.1136/lupus-2023-000908] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 07/28/2023] [Indexed: 08/23/2023]
Abstract
OBJECTIVE Patients with lupus erythematosus (LE) are at heightened risk for clinical events, chiefly heart attacks and strokes, from atherosclerotic cardiovascular disease (ASCVD). We recently proposed new guidelines to assess and manage ASCVD event risk specifically in LE. Here, we examined current cardiovascular management in light of these new recommendations. METHODS We studied our entire UPenn Longitudinal Lupus Cohort of patients with cutaneous LE, without (CLE-only) or with (CLE+SLE) concurrent systemic LE, for whom we had full access to medical records (n=370, LE-ASCVD Study Cohort). RESULTS Of our LE-ASCVD Study Cohort, 336 out of 370 (90.8%) had a designated primary-care physician. By the new guidelines, the most recent low-density lipoprotein (LDL) levels were above-goal for 249 out of 370 (67.3%). Two-hundred sixty-six (71.9%) had hypertension, which was undertreated or untreated in 198 out of 266 (74.4%). Of current smokers, 51 out of 63 (81.0%) had no documented smoking cessation counselling or referrals. Diabetes and triglyceridaemia were generally well managed. Of the cohort, 278 qualified for two widely used online estimators of ASCVD event risk in primary prevention: the ACC-ASCVD Risk Estimator Plus and QRisk3. We also stratified these 278 patients into our recently defined categories of ASCVD event risk in LE. These three methods for estimating ASCVD event risk showed clinically meaningful discordance for 169 out of 278 (60.8%). The documented rate of ASCVD events in the first 10 years after enrolment was 13.5% (95% CI 8.9%, 17.9%), similar between CLE-only and CLE+SLE, indicating an at-risk population despite the preponderance of women and an average age at enrolment of only 47 years. CONCLUSION Patients with CLE-only or CLE+SLE are undertreated compared with the new guidelines and, accordingly, they experience a significant burden of ASCVD events. Moreover, it is unclear how to accurately assess their future ASCVD event risk, except that it is substantial. Efforts are underway to improve ASCVD event risk estimation and guideline implementation in patients with lupus.
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Affiliation(s)
- Megan Zhao
- Corporal Michael J. Crescenz Veterans' Administration Medical Center, Philadelphia, Pennsylvania, USA
- Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Rui Feng
- Department of Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Victoria P Werth
- Corporal Michael J. Crescenz Veterans' Administration Medical Center, Philadelphia, Pennsylvania, USA
- Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Kevin Jon Williams
- Department of Cardiovascular Sciences, Department of Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, USA
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Drosos GC, Konstantonis G, Sfikakis PP, Tektonidou MG. Lipid management in systemic lupus erythematosus according to risk classifiers suggested by the European Society of Cardiology and disease-related risk factors reported by the EULAR recommendations. RMD Open 2023; 9:rmdopen-2022-002767. [PMID: 36759009 PMCID: PMC9923358 DOI: 10.1136/rmdopen-2022-002767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 01/26/2023] [Indexed: 02/11/2023] Open
Abstract
BACKGROUND The European Alliance of Associations for Rheumatology recommended that lipid-lowering therapy (LLT) in systemic lupus erythematosus (SLE) should follow general population guidelines. We examined the eligibility for LLT in SLE according to Systematic Coronary Risk Evaluation (SCORE), with and without the addition of vascular ultrasound (VUS) and disease-related features. METHODS 210 patients with SLE without prior cardiovascular events, diabetes or antiphospholipid syndrome underwent cardiovascular risk assessment with SCORE. LLT eligibility was evaluated in low-risk and moderate-risk patients following European Society of Cardiology (ESC) guidelines. Atherosclerotic plaques on carotid ultrasound (cUS)) and carotid and femoral ultrasound (cfUS), prolonged disease duration (PDD, ≥10 years), failure to achieve lupus low disease activity state (LLDASno), cumulative glucocorticoid 'cardiovascular harm' dose (GCCVH, optimal cut-off to predict ultrasound-detected plaques) and antiphospholipid antibody positivity (aPLpos) were tested as SCORE risk enhancers for classification ability (phi coefficient) and agreement (Cohen's kappa) using SCORE plus cfUS as a reference modality for LLT eligibility. RESULTS Plaques were detected in 9.9% of low-risk cases and 54.6% of moderate-risk cases. SCORE alone would indicate 0% of low-risk patients and 3% of moderate-risk patients for LLT eligibility. According to SCORE+cfUS, 9.9% of low-risk patients and 57.6% of moderate-risk patients, respectively, would be eligible for LLT based on ESC guidelines. Ιn low-risk/moderate-risk patients, phi values for SCORE+PDD, GCCVH (cut-off ≥11 g), LLDASno and aPLpos in antiplatelet-naïve antiphospholipid antibody-positive (aPLpos/APT-) cases were 0.06/0.13, 0.23/0.20, 0.07/0.16 and 0.06/0.33, respectively. Agreement for LLT eligibility to SCORE+cfUS was better for SCORE+PDD in moderate-risk patients and for SCORE+cUS in both groups of patients. SCORE+GCCVH and SCORE+aPLpos showed at least fair agreement (kappa ≥0.20) to SCORE+cfUS in low-risk or moderate-risk and in aPLpos/APT- moderate-risk patients, respectively. CONCLUSION Disease-related and VUS features, in addition to SCORE, may help to improve LLT decision making in SLE. GCCVH and aPLpos improve LLT eligibility similarly and to a greater degree than PDD or LLDASno.
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Affiliation(s)
- George C Drosos
- Cardiovascular Risk Research Laboratory, First Department of Propaedeutic Internal Medicine, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - George Konstantonis
- Cardiovascular Risk Research Laboratory, First Department of Propaedeutic Internal Medicine, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Petros P Sfikakis
- Cardiovascular Risk Research Laboratory, First Department of Propaedeutic Internal Medicine, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece,Rheumatology Unit, First Department of Propaedeutic and Internal Medicine, Laiko Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece,Joint Academic Rheumatology Program, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Maria G Tektonidou
- Cardiovascular Risk Research Laboratory, First Department of Propaedeutic Internal Medicine, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece .,Rheumatology Unit, First Department of Propaedeutic and Internal Medicine, Laiko Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece.,Joint Academic Rheumatology Program, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
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Hernández-Negrín H, Ricci M, Mancebo-Sevilla JJ, Sanz-Cánovas J, López-Sampalo A, Cobos-Palacios L, Romero-Gómez C, Pérez de Pedro I, Ayala-Gutiérrez MDM, Gómez-Huelgas R, Bernal-López MR. Obesity, Diabetes, and Cardiovascular Risk Burden in Systemic Lupus Erythematosus: Current Approaches and Knowledge Gaps-A Rapid Scoping Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:14768. [PMID: 36429489 PMCID: PMC9690813 DOI: 10.3390/ijerph192214768] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 10/29/2022] [Accepted: 11/01/2022] [Indexed: 06/16/2023]
Abstract
Obesity, diabetes mellitus, and cardiovascular risk are real challenges in systemic lupus erythematosus (SLE) clinical practice and research. The evidence of the burden of these health problems in SLE patients is determined by the methods used to assess them. Therefore, the aim of this scoping review is to map current approaches in assessing obesity, diabetes mellitus, and cardiovascular risk burden in SLE patients and to identify existing knowledge gaps in this field. This rapid scoping review was conducted according to the Joanna Briggs Institute methodology and identified 274 articles, of which 73 were included. Most studies were conducted at European institutions and patients were recruited from specialist hospital clinics, the majority of whom were women. The burden of obesity and diabetes mellitus for SLE patients was assessed mainly in terms of prevalence, impact on disease activity, and cardiometabolic risk. The burden of cardiovascular risk was assessed using multiple approaches, mainly imaging and laboratory methods, and risk factor-based scores, although there is great heterogeneity and uncertainty between the methods used. This review highlights the importance of improving and standardizing the approach to obesity, diabetes, and cardiovascular risk in SLE patients through a holistic assessment that includes lifestyle, clinical, biological, and social aspects.
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Affiliation(s)
- Halbert Hernández-Negrín
- Internal Medicine Clinical Management Unit, Hospital Regional Universitario de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA-Plataforma BIONAND), Avenida Carlos Haya S/N, 29010 Malaga, Spain
- Faculty of Medicine, Universidad de Málaga, Campus Teatinos, 29010 Malaga, Spain
| | - Michele Ricci
- Internal Medicine Clinical Management Unit, Hospital Regional Universitario de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA-Plataforma BIONAND), Avenida Carlos Haya S/N, 29010 Malaga, Spain
- Faculty of Medicine, Universidad de Málaga, Campus Teatinos, 29010 Malaga, Spain
| | - Juan José Mancebo-Sevilla
- Internal Medicine Clinical Management Unit, Hospital Regional Universitario de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA-Plataforma BIONAND), Avenida Carlos Haya S/N, 29010 Malaga, Spain
- Faculty of Medicine, Universidad de Málaga, Campus Teatinos, 29010 Malaga, Spain
| | - Jaime Sanz-Cánovas
- Internal Medicine Clinical Management Unit, Hospital Regional Universitario de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA-Plataforma BIONAND), Avenida Carlos Haya S/N, 29010 Malaga, Spain
- Faculty of Medicine, Universidad de Málaga, Campus Teatinos, 29010 Malaga, Spain
| | - Almudena López-Sampalo
- Internal Medicine Clinical Management Unit, Hospital Regional Universitario de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA-Plataforma BIONAND), Avenida Carlos Haya S/N, 29010 Malaga, Spain
- Faculty of Medicine, Universidad de Málaga, Campus Teatinos, 29010 Malaga, Spain
| | - Lidia Cobos-Palacios
- Internal Medicine Clinical Management Unit, Hospital Regional Universitario de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA-Plataforma BIONAND), Avenida Carlos Haya S/N, 29010 Malaga, Spain
- Faculty of Medicine, Universidad de Málaga, Campus Teatinos, 29010 Malaga, Spain
| | - Carlos Romero-Gómez
- Internal Medicine Clinical Management Unit, Hospital Regional Universitario de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA-Plataforma BIONAND), Avenida Carlos Haya S/N, 29010 Malaga, Spain
| | - Iván Pérez de Pedro
- Internal Medicine Clinical Management Unit, Hospital Regional Universitario de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA-Plataforma BIONAND), Avenida Carlos Haya S/N, 29010 Malaga, Spain
| | - María del Mar Ayala-Gutiérrez
- Internal Medicine Clinical Management Unit, Hospital Regional Universitario de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA-Plataforma BIONAND), Avenida Carlos Haya S/N, 29010 Malaga, Spain
| | - Ricardo Gómez-Huelgas
- Internal Medicine Clinical Management Unit, Hospital Regional Universitario de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA-Plataforma BIONAND), Avenida Carlos Haya S/N, 29010 Malaga, Spain
- Faculty of Medicine, Universidad de Málaga, Campus Teatinos, 29010 Malaga, Spain
- Centro de Investigación Biomédica en Red Fisiopatología de la Obesidad y Nutrición (CIBERobn), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - María Rosa Bernal-López
- Internal Medicine Clinical Management Unit, Hospital Regional Universitario de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA-Plataforma BIONAND), Avenida Carlos Haya S/N, 29010 Malaga, Spain
- Faculty of Medicine, Universidad de Málaga, Campus Teatinos, 29010 Malaga, Spain
- Centro de Investigación Biomédica en Red Fisiopatología de la Obesidad y Nutrición (CIBERobn), Instituto de Salud Carlos III, 28029 Madrid, Spain
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Masson W, Rossi E, Alvarado RN, Cornejo-Peña G, Damonte JI, Fiorini N, Mora-Crespo LM, Tobar-Jaramillo MA, Scolnik M. Rheumatoid Arthritis, Statin Indication and Lipid Goals: Analysis According to Different Recommendations. REUMATOLOGIA CLINICA 2022; 18:266-272. [PMID: 35568440 DOI: 10.1016/j.reumae.2021.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 02/13/2021] [Indexed: 06/15/2023]
Abstract
BACKGROUND Different strategies have been proposed for the cardiovascular risk management of patients with rheumatoid arthritis (RA). OBJECTIVES (1) To estimate the cardiovascular risk by different strategies in RA patients, analyzing which proportion of patients would be candidates to receive statin therapy; (2) to identify how many patients meet the recommended lipid goals. METHODS A cross-sectional study was performed from a secondary database. The QRISK-3 score, the Framingham score (adjusted for a multiplying factor×1.5), the ASCVD calculator and the SCORE calculator were estimated. The indications for statin therapy according to NICE, Argentine Consensus, ACC/AHA, and new European guidelines were analyzed. The recommended LDL-C goals were analyzed. RESULTS A total of 420 patients were included. In total, 24.7% and 48.7% of patients in primary and secondary prevention were receiving statins, respectively. Only 19.4% of patients with cardiovascular history received high intensity statins. Applying the ACC/AHA guidelines (based on ASCVD score), the Argentine Consensuses (based on adjusted Framingham score), the NICE guidelines (based on QRISK-3) and European recommendations (based on SCORE), 26.9%, 26.5%, 41.1% and 18.2% of the population were eligible for statin therapy, respectively. Following the new European recommendations, 50.0%, 46.2% and 15.9% of the patients with low-moderate, high or very high risk achieved the suggested lipid goals. CONCLUSION Applying four strategies for lipid management in our population, the cardiovascular risk stratification and the indication for statins were different. A significant gap was observed when comparing the expected and observed statin indication, with few patients achieving the LDL-C goals.
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Affiliation(s)
- Walter Masson
- Servicio de Cardiología, Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABB Ciudad Autónoma de Buenos Aires, Argentina.
| | - Emiliano Rossi
- Servicio de Cardiología, Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABB Ciudad Autónoma de Buenos Aires, Argentina
| | - Rodolfo N Alvarado
- Servicio de Reumatología, Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABB Ciudad Autónoma de Buenos Aires, Argentina
| | - Guillermo Cornejo-Peña
- Servicio de Cardiología, Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABB Ciudad Autónoma de Buenos Aires, Argentina
| | - Juan I Damonte
- Servicio de Cardiología, Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABB Ciudad Autónoma de Buenos Aires, Argentina
| | - Norberto Fiorini
- Servicio de Cardiología, Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABB Ciudad Autónoma de Buenos Aires, Argentina
| | - Lorena M Mora-Crespo
- Servicio de Cardiología, Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABB Ciudad Autónoma de Buenos Aires, Argentina
| | - Mayra A Tobar-Jaramillo
- Servicio de Reumatología, Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABB Ciudad Autónoma de Buenos Aires, Argentina
| | - Marina Scolnik
- Servicio de Reumatología, Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABB Ciudad Autónoma de Buenos Aires, Argentina
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Bolla E, Tentolouris N, Sfikakis PP, Tektonidou MG. Cardiovascular risk management in antiphospholipid syndrome: trends over time and comparison with rheumatoid arthritis and diabetes mellitus. Lupus Sci Med 2021; 8:e000579. [PMID: 34921093 PMCID: PMC8685967 DOI: 10.1136/lupus-2021-000579] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 11/30/2021] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Antiphospholipid syndrome (APS) is characterised by increased cardiovascular morbidity and mortality, related to thrombo-inflammatory and atherogenic mechanisms. We examined the achievement of traditional cardiovascular risk factor (CVRF) therapeutic goals in APS versus other high cardiovascular risk disorders such as rheumatoid arthritis (RA) and diabetes mellitus (DM), and trends over time. METHODS 122 patients with APS (74 primary APS, female 68%, mean age 44.5±11.3) were classified according to their first visit (2011-2015 and 2016-2020 APS subgroups, 61 patients in each subgroup) and matched 1:1 for age/sex with patients with RA and DM. Cardiovascular risk was estimated by the Systemic Coronary Risk Evaluation, and the CVRF therapeutic targets were defined according to the European Society of Cardiology (ESC) guidelines. Individual and multiple CVRF control was compared between APS subgroups, and in APS versus RA and DM. RESULTS We found a comparable or higher prevalence of CVRFs between APS and age-matched/sex-matched patients with RA and DM but low CVRF target attainment in APS according to the ESC guidelines. Despite improving trends between 2011-2015 and 2016-2020, CVRF control in high/very high-risk patients with APS was 12%, 18%, 24% and 35% for low-density lipoprotein, waist circumference, exercise and body mass index, respectively, and 59%-65% for triglycerides, high-density lipoprotein (HDL) and blood pressure, in 2016-2020 subgroup. CVRF control was worse in APS versus RA for smoking (p=0.014), HDL (p<0.001), waist circumference (p=0.042) and five CVRFs (p=0.030), and versus DM for exercise (p=0.077). Similar results were found in the sensitivity analysis. CONCLUSIONS Comparable prevalence of modifiable CVRFs to RA and DM but suboptimal CVRF target achievement was observed in APS, especially in high/very high-risk patients, highlighting the need for CVRF management strategies.
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Affiliation(s)
- Eleana Bolla
- First Department of Propaedeutic Internal Medicine, Joint Academic Rheumatology Program, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Nikolas Tentolouris
- First Department of Propaedeutic Internal Medicine, Joint Academic Rheumatology Program, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Petros P Sfikakis
- First Department of Propaedeutic Internal Medicine, Joint Academic Rheumatology Program, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria G Tektonidou
- First Department of Propaedeutic Internal Medicine, Joint Academic Rheumatology Program, Medical School, National and Kapodistrian University of Athens, Athens, Greece
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8
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Keyes E, Grinnell M, Jacoby D, Vazquez T, Diaz D, Werth VP, Williams KJ. Assessment and management of the heightened risk for atherosclerotic cardiovascular events in patients with lupus erythematosus or dermatomyositis. Int J Womens Dermatol 2021; 7:560-575. [PMID: 35024413 PMCID: PMC8721062 DOI: 10.1016/j.ijwd.2021.08.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 08/27/2021] [Accepted: 08/31/2021] [Indexed: 01/05/2023] Open
Abstract
For patients with lupus erythematosus (LE) or dermatomyositis (DM), there is an urgent need to address a heightened risk of clinical events, chiefly heart attacks and strokes, caused by atherosclerotic cardiovascular disease (ASCVD). Patients with LE or DM frequently exhibit high levels of conventional risk factors for ASCVD events, particularly dyslipoproteinemia and hypertension; an amplified burden of atherosclerotic plaques; and increased age- and sex-adjusted rates of ASCVD events compared with the general population. The rate of ASCVD events exceeds what would be expected from conventional risk factors, suggesting that disease-specific autoimmune processes exacerbate specific, known pathogenic steps in atherosclerosis. Importantly, despite their heightened risk, patients with LE or DM are often undertreated for known causative agents and exacerbators of ASCVD. Herein, we propose an approach to assess and manage the heightened risk of ASCVD events in patients with LE or DM. Our approach is modeled in large part on established approaches to patients with diabetes mellitus or stage 3 or 4 chronic kidney disease, which are well-studied conditions that also show heightened risk for ASCVD events and have been explicitly incorporated into standard clinical guidelines for ASCVD. Based on the available evidence, we conclude that patients with LE or DM require earlier and more aggressive screening and management of ASCVD. We suggest that physicians consider implementing multipliers of conventional risk calculators to trigger earlier initiation of lifestyle modifications and medical therapies in primary prevention of ASCVD events, employ vascular imaging to quantify the burden of subclinical plaques, and treat to lower lipid targets using statins and newer therapies, such as PCSK9 inhibitors, that decrease ASCVD events in nonautoimmune cohorts. More clinical vigilance is needed regarding surveillance, prevention, risk modification, and treatment of dyslipidemias, hypertension, and smoking in patients with LE or DM. All of these goals are achievable.
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Affiliation(s)
- Emily Keyes
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Corporal Michael J. Crescenz VAMC, Philadelphia, Pennsylvania
| | - Madison Grinnell
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Corporal Michael J. Crescenz VAMC, Philadelphia, Pennsylvania
| | - Douglas Jacoby
- Cardiovascular Division, Department of Medicine, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Thomas Vazquez
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Corporal Michael J. Crescenz VAMC, Philadelphia, Pennsylvania
| | - DeAnna Diaz
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Corporal Michael J. Crescenz VAMC, Philadelphia, Pennsylvania
| | - Victoria P. Werth
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Corporal Michael J. Crescenz VAMC, Philadelphia, Pennsylvania
| | - Kevin Jon Williams
- Department of Cardiovascular Sciences, Department of Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
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Abstract
Cardiovascular disease risk is evident during childhood for patients with juvenile systemic lupus erythematosus, juvenile dermatomyositis, and juvenile idiopathic arthritis. The American Heart Association defines cardiovascular health as a positive health construct reflecting the sum of protective factors against cardiovascular disease. Disease-related factors such as chronic inflammation and endothelial dysfunction increase cardiovascular disease risk directly and through bidirectional relationships with poor cardiovascular health factors. Pharmacologic and nonpharmacologic interventions to improve cardiovascular health and long-term cardiovascular outcomes in children with rheumatic disease are needed.
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Pezoulas VC, Papaloukas C, Veyssiere M, Goules A, Tzioufas AG, Soumelis V, Fotiadis DI. A computational workflow for the detection of candidate diagnostic biomarkers of Kawasaki disease using time-series gene expression data. Comput Struct Biotechnol J 2021; 19:3058-3068. [PMID: 34136104 PMCID: PMC8178098 DOI: 10.1016/j.csbj.2021.05.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 05/17/2021] [Accepted: 05/20/2021] [Indexed: 12/15/2022] Open
Abstract
Unlike autoimmune diseases, there is no known constitutive and disease-defining biomarker for systemic autoinflammatory diseases (SAIDs). Kawasaki disease (KD) is one of the "undiagnosed" types of SAIDs whose pathogenic mechanism and gene mutation still remain unknown. To address this issue, we have developed a sequential computational workflow which clusters KD patients with similar gene expression profiles across the three different KD phases (Acute, Subacute and Convalescent) and utilizes the resulting clustermap to detect prominent genes that can be used as diagnostic biomarkers for KD. Self-Organizing Maps (SOMs) were employed to cluster patients with similar gene expressions across the three phases through inter-phase and intra-phase clustering. Then, false discovery rate (FDR)-based feature selection was applied to detect genes that significantly deviate across the per-phase clusters. Our results revealed five genes as candidate biomarkers for KD diagnosis, namely, the HLA-DQB1, HLA-DRA, ZBTB48, TNFRSF13C, and CASD1. To our knowledge, these five genes are reported for the first time in the literature. The impact of the discovered genes for KD diagnosis against the known ones was demonstrated by training boosting ensembles (AdaBoost and XGBoost) for KD classification on common platform and cross-platform datasets. The classifiers which were trained on the proposed genes from the common platform data yielded an average increase by 4.40% in accuracy, 5.52% in sensitivity, and 3.57% in specificity than the known genes in the Acute and Subacute phases, followed by a notable increase by 2.30% in accuracy, 2.20% in sensitivity, and 4.70% in specificity in the cross-platform analysis.
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Affiliation(s)
- Vasileios C. Pezoulas
- Unit of Medical Technology and Intelligent Information Systems, Department of Materials Science and Engineering, University of Ioannina, Ioannina GR45110, Greece
| | - Costas Papaloukas
- Unit of Medical Technology and Intelligent Information Systems, Department of Materials Science and Engineering, University of Ioannina, Ioannina GR45110, Greece
- Department of Biological Applications and Technology, University of Ioannina, Ioannina GR45100, Greece
| | - Maëva Veyssiere
- INSERM U976, Human Immunology, Physiopathology and Immunotherapy, Paris, France
| | - Andreas Goules
- Department of Pathophysiology, School of Medicine, University of Athens, Athens GR15772, Greece
| | - Athanasios G. Tzioufas
- Department of Pathophysiology, School of Medicine, University of Athens, Athens GR15772, Greece
| | - Vassili Soumelis
- INSERM U976, Human Immunology, Physiopathology and Immunotherapy, Paris, France
- Hôpital Saint Louis, Saint Louis Research Institute, Paris, France
| | - Dimitrios I. Fotiadis
- Unit of Medical Technology and Intelligent Information Systems, Department of Materials Science and Engineering, University of Ioannina, Ioannina GR45110, Greece
- Department of Biomedical Research, FORTH (Foundation for Research & Technology)-IMBB (Institute of Molecular Biology and Biotechnology), Ioannina GR45110, Greece
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Masson W, Rossi E, Alvarado RN, Cornejo-Peña G, Damonte JI, Fiorini N, Mora-Crespo LM, Tobar-Jaramillo MA, Scolnik M. Rheumatoid Arthritis, Statin Indication and Lipid Goals: Analysis According to Different Recommendations. REUMATOLOGIA CLINICA 2021; 18:S1699-258X(21)00056-5. [PMID: 33745866 DOI: 10.1016/j.reuma.2021.02.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 01/20/2021] [Accepted: 02/13/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND Different strategies have been proposed for the cardiovascular risk management of patients with rheumatoid arthritis (RA). OBJECTIVES (1) To estimate the cardiovascular risk by different strategies in RA patients, analyzing which proportion of patients would be candidates to receive statin therapy; (2) to identify how many patients meet the recommended lipid goals. METHODS A cross-sectional study was performed from a secondary database. The QRISK-3 score, the Framingham score (adjusted for a multiplying factor×1.5), the ASCVD calculator and the SCORE calculator were estimated. The indications for statin therapy according to NICE, Argentine Consensus, ACC/AHA, and new European guidelines were analyzed. The recommended LDL-C goals were analyzed. RESULTS A total of 420 patients were included. In total, 24.7% and 48.7% of patients in primary and secondary prevention were receiving statins, respectively. Only 19.4% of patients with cardiovascular history received high intensity statins. Applying the ACC/AHA guidelines (based on ASCVD score), the Argentine Consensuses (based on adjusted Framingham score), the NICE guidelines (based on QRISK-3) and European recommendations (based on SCORE), 26.9%, 26.5%, 41.1% and 18.2% of the population were eligible for statin therapy, respectively. Following the new European recommendations, 50.0%, 46.2% and 15.9% of the patients with low-moderate, high or very high risk achieved the suggested lipid goals. CONCLUSION Applying four strategies for lipid management in our population, the cardiovascular risk stratification and the indication for statins were different. A significant gap was observed when comparing the expected and observed statin indication, with few patients achieving the LDL-C goals.
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Affiliation(s)
- Walter Masson
- Servicio de Cardiología, Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABB Ciudad Autónoma de Buenos Aires, Argentina.
| | - Emiliano Rossi
- Servicio de Cardiología, Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABB Ciudad Autónoma de Buenos Aires, Argentina
| | - Rodolfo N Alvarado
- Servicio de Reumatología, Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABB Ciudad Autónoma de Buenos Aires, Argentina
| | - Guillermo Cornejo-Peña
- Servicio de Cardiología, Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABB Ciudad Autónoma de Buenos Aires, Argentina
| | - Juan I Damonte
- Servicio de Cardiología, Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABB Ciudad Autónoma de Buenos Aires, Argentina
| | - Norberto Fiorini
- Servicio de Cardiología, Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABB Ciudad Autónoma de Buenos Aires, Argentina
| | - Lorena M Mora-Crespo
- Servicio de Cardiología, Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABB Ciudad Autónoma de Buenos Aires, Argentina
| | - Mayra A Tobar-Jaramillo
- Servicio de Reumatología, Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABB Ciudad Autónoma de Buenos Aires, Argentina
| | - Marina Scolnik
- Servicio de Reumatología, Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABB Ciudad Autónoma de Buenos Aires, Argentina
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Barbhaiya M, Feldman CH, Chen SK, Guan H, Fischer MA, Everett BM, Costenbader KH. Comparative Risks of Cardiovascular Disease in Patients With Systemic Lupus Erythematosus, Diabetes Mellitus, and in General Medicaid Recipients. Arthritis Care Res (Hoboken) 2020; 72:1431-1439. [PMID: 32475049 DOI: 10.1002/acr.24328] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 05/19/2020] [Indexed: 01/06/2023]
Abstract
OBJECTIVE Cardiovascular disease (CVD) risk is elevated in patients with systemic lupus erythematosus (SLE) and diabetes mellitus (DM), but whether risk of CVD in patients with SLE is as high as in those with DM is unknown. The present study was undertaken to compare CVD risks between patients with SLE and DM and general population US Medicaid recipients. METHODS In a cohort study, we identified age- and sex-matched adults (1:2:4) with SLE or DM and those from the general population using Medicaid Analytic eXtract, 2007-2010. We collected data on baseline sociodemographic factors, comorbidities, and medications. We used Cox regression models to calculate hazard ratios (HRs) of hospitalized nonfatal CVD events (combined myocardial infarction [MI] and stroke) and MI and stroke separately, accounting for competing risk of death and adjusting for covariates. We compared risks in age-stratified models. RESULTS We identified 40,212 SLE patients, 80,424 DM patients, and 160,848 general population patients; 92.5% were female, and the mean ± SD age was 40.3 ± 12.1 years. Nonfatal CVD incidence rate per 1,000 person-years was 8.99 for patients with SLE, 7.07 for those with DM, and 2.36 for the general population. Nonfatal CVD risk was higher in SLE compared to DM (HR 1.27 [95% confidence interval (95% CI) 1.15-1.40]), driven by excess risk at ages 18-39 years (HR 2.22 [95% CI 1.81-2.71]). Patients with SLE had higher risk of CVD compared to the general population (HR 2.67 [95% CI 2.38-2.99]). CONCLUSION SLE patients had a 27% higher risk of nonfatal CVD events compared to age- and sex-matched patients with DM and more than twice the risk of the Medicaid general population. The highest relative risk occurred at ages 18-39 years. These high risks merit aggressive evaluation for modifiable factors and research to identify prevention strategies.
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Affiliation(s)
- Medha Barbhaiya
- Barbara Volcker Center for Women and Rheumatic Diseases, Hospital for Special Surgery and Weill Cornell Medical College, New York, New York, United States
| | - Candace H Feldman
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, United States
| | - Sarah K Chen
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, United States
| | - Hongshu Guan
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, United States
| | | | | | - Karen H Costenbader
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, United States
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Cure E, Cumhur Cure M. Comment on "Cardiovascular risk stratification and appropriate use of statins in patients with systemic lupus erythematosus according to different strategies". Clin Rheumatol 2020; 39:615-616. [PMID: 31927712 DOI: 10.1007/s10067-019-04897-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Revised: 12/08/2019] [Accepted: 12/12/2019] [Indexed: 02/07/2023]
Affiliation(s)
- Erkan Cure
- Erkan Cure Department of Internal Medicine, Ota&Jinemed Hospital, Muradiye Mahallesi Nuzhetiye Cad, Deryadil Sokagi No:1, 34357, Istanbul, Besiktas, Turkey.
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Comment on "Cardiovascular risk stratification and appropriate use of statins in patients with systemic lupus erythematosus according to different strategies". Clin Rheumatol 2020. [PMID: 31927712 DOI: 10.1007/s10067-019-04897-4.] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2022]
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