Cardiac abnormalities in systemic lupus erythematosus: prevalence and relationship to disease activity

Cardiac Abnormalities in Relation to the Disease Activity Index Among Systemic Lupus Erythematosus Patients in a Tertiary Hospital: A Cross-Sectional Study

BACKGROUND

 Systemic lupus erythematosus (SLE) is a multisystem autoimmune connective tissue disorder involving multiple organs and systems. Cardiovascular involvement in SLE patients is a major cause of morbidity and mortality. Although subclinical cardiac abnormalities exist among SLE patients, they are rarely screened for. Echocardiography has been demonstrated to be a useful tool for the early diagnosis of cardiac abnormalities in SLE patients, many of which are clinically silent. Early recognition of cardiovascular abnormalities is vital for the prompt initiation of the appropriate management. This study aims to determine the prevalence of various structural and functional cardiac abnormalities among SLE patients and to determine its association with the modified SLE Disease Activity Index 2000 (modified SLEDAI-2K).

METHODS

 The study was a cross-sectional study of SLE patients at the Korle-Bu Teaching Hospital (KBTH), Accra, Ghana, from June to December 2021. The setting was the rheumatology outpatient clinic of the KBTH and included adult men and women, 18 years and above, diagnosed with SLE with no known cardiac abnormalities. The baseline demographic and clinical characteristics of the participants were determined. A detailed transthoracic echocardiogram was performed for all patients. The frequency of common cardiac pathologies was determined and compared between those with a high modified SLEDAI-2K and those with a low modified SLEDAI-2K.

RESULTS

 Ninety-nine SLE patients participated in the study with a mean age of 35.12 years. Females formed the majority (90.9%) of the participants. The mean age at diagnosis of SLE was 28.7 years and the mean disease duration was 4.6 years. All of the participants were on at least two disease-modifying medications. The mean modified SLEDAI-2K score was 9.1. Thirty-five percent (35%) of the patients had mild to moderately active disease and 39% had severely active disease. Sixty-six (66%) out of the severely active disease group had abnormal echocardiographic findings, while 28% of those with mild to moderate disease had abnormal echocardiographic findings. Echocardiographic abnormalities were found in 56 patients (47%), out of which 8.7% had valvular involvement, 15.7% had diastolic dysfunction, 5.2% had left ventricular hypertrophy (LVH), and 0.9% had left ventricular systolic dysfunction (LVSD). About 12% of the participants had pulmonary hypertension and 1% had pericardial involvement. The odds of echocardiographic abnormalities were 13.7 times higher in SLE patients with high disease activity compared to those with low disease activity (odds ratio (OR) = 13.714, 95% confidence interval (CI) = 3.804-49.442, p < 0.001). There was no significant association between cardiac abnormalities and SLE duration. No significant correlation between cardiac abnormalities and modified SLEDAI-2K score was found.  Conclusion: Cardiac abnormalities, especially left ventricular diastolic dysfunction (LVDD), valvular involvement, and pulmonary hypertension, are common in SLE patients. For SLE patients, especially those with active diseases, echocardiographic assessment should be considered in the management of SLE patients to enable early detection of cardiac abnormalities, early treatment, and thus a decrease in morbidity and mortality associated with cardiovascular involvement in SLE patients.

Diagnosis and Management of Cardioembolic Stroke

OBJECTIVE

Cardioembolic stroke accounts for nearly 30% of ischemic strokes. Prompt diagnosis of the underlying mechanism may improve secondary prevention strategies. This article reviews recent randomized trials, observational studies, case reports, and guidelines on the diagnosis and treatment of cardioembolic stroke.

LATEST DEVELOPMENTS

Several pathologies can lead to cardioembolic stroke, including atrial fibrillation, aortic arch atheroma, patent foramen ovale, left ventricular dysfunction, and many others. Secondary stroke prevention strategies differ across these heterogeneous mechanisms. In addition to medical treatment advances such as the use of direct oral anticoagulants in patients with atrial fibrillation, surgical treatments such as closure of patent foramen ovale have been shown to reduce the risk of recurrent stroke in select patients. Furthermore, left atrial appendage occlusion is a promising strategy for patients with atrial fibrillation who are candidates for short-term oral anticoagulation therapy but not long-term oral anticoagulation therapy.

ESSENTIAL POINTS

A thorough diagnostic evaluation is essential to determine cardioembolic causes of stroke. In addition to risk factor management and lifestyle modifications, identification and targeting of the underlying cardioembolic stroke mechanisms will lead to improved stroke prevention strategies in patients with cardioembolic stroke.

A Meta-analysis and Systematic Review of Valvular Heart Disease in Systemic Lupus Erythematosus and Its Association With Antiphospholipid Antibodies

BACKGROUND

Valvular heart disease (VHD) is a known cardiac manifestation of systematic lupus erythematosus (SLE). This systematic review aims to pool data from studies to estimate the frequency of valvular lesions in SLE patients. It also aims to demonstrate the association between VHD in SLE and antiphospholipid antibodies positivity.

METHODS

We included 27 studies after identifying relevant abstracts from PubMed, Scopus, and Google Scholar from the time of inception of database to 2019. Inclusion criteria consisted of English-language case-control and cohort studies. Three reviewers independently performed study selection, data extraction, and quality assessment using the Newcastle-Ottawa Scale for assessing risk for bias.

RESULTS

For VHD in SLE patients, the most commonly involved valve was the mitral valve, with 19.7% lesions being mitral regurgitation. In terms of morphological lesions, valve thickening (11.06%) and vegetations (11.76%) were among the most prevalent. Other commonly encountered lesions were mitral valve prolapse and tricuspid regurgitation in 9.25% and 10.86% of patients, respectively. A meta-analysis of 21 studies with 2163 SLE patients, of which 23.3% had valvular lesions, showed a significant association of anticardiolipin antibodies positivity with VHD (relative risk, 1.55; confidence interval, 1.10-2.18).

CONCLUSIONS

Systemic lupus erythematosus is associated with VHD, and it should be considered a clinical manifestation of SLE in the absence of other valvular pathologies. There is a clear association between VHD in SLE and immunoglobulin G anticardiolipin antibodies positivity. This association suggests that this subgroup of SLE patients might benefit from a screening echocardiogram.

Non-coronary cardiac manifestations of systemic lupus erythematosus in adults: a comparative study

Cardiac manifestations develop in the majority of patients with systemic lupus erythematosus (SLE) at some time during the course of their disease. This study was designed to assess cardiac abnormalities in patients with SLE by echocardiography and to compare the 2 groups of patients with and without cardiac manifestations. It was a transversal, descriptive study, conducted in the Internal Medicine Department at the Military Hospital of Tunis from January 2016 to June 2018. Eighty lupus patients, diagnosed on the basis of ACR (American college of rheumatology) criteria, were enrolled in the study and were evaluated by standard echocardiography with color Doppler. Out of 80 patients 42 (52%) had abnormal echocardiographic findings. Pericardial effusion was found in 55%, valvular abnormalities in 52% and 38% had pulmonary hypertension. Patients with pleural effusion (45 vs 15%) were more vulnerable to cardiac involvement as well as renal impairment (57 vs 44%). The difference, however, were not statistically significant (p>0.05) in the renal involvement. Active disease with low complement (80%) was associated with higher frequency of cardiac involvement than disease in remission (64%) but the result was not statistically significant (p=0.11). Cardiac abnormalities are very common in lupus patients even when clinically asymptomatic form. Echocardiography is an excellent non-invasive tool for cardiac evaluation. Their research must be systematic with echocardiography in order to reduce subsequent cardiac morbidity and mortality among the lupus patients.

Heart failure in systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is an autoimmune disorder characterized by a constellation of cardiovascular (CV) and non-CV manifestations. Even though CV complications such as accelerated atherosclerosis and elevated risk of myocardial infarction (MI) have been recognized for many years, there is limited evidence regarding SLE and its association with heart failure (HF). Traditional risk factors of atherosclerotic CV disease, as well as various SLE manifestations and therapies, independently or together, increase the risk of HF in this population. There is a need for sufficiently powered intervention studies focusing on specific risk factors to improve CV outcomes in SLE patients.

A 24-year-old male with a painful and cold lower extremity

CLINICAL INTRODUCTION

A 24-year-old male presented to the emergency department with intense pain in his right lower extremity. He has a medical history significant for systemic lupus erythematosus and antiphospholipid syndrome. He also had four prior episodes of deep venous thromboses on rivaroxaban. The patient stated that early in the morning, he started to feel intense pain that started from his knee and progressed to his calf, with associated numbness and paraesthesia. On physical examination, the limb felt cold with absent right popliteal and dorsalis pedis pulses. He was immediately taken for embolectomy after discovery of a distal common femoral artery occlusion. The patient's blood cultures remained negative. X-plane imaging on real-time three-dimensional transoesophageal echocardiography (RT-3DTEE) of the aortic valve (figure 1A) and colour Doppler (figure 1B) are shown.

QUESTION

What is the diagnosis and management for this patient (assuming the patient will stay anticoagulated for life)? Infective endocarditis (IE); antibiotics and valve replacementLibman-Sacks endocarditis; corticosteroidsIE; antibiotics onlyLibman-Sacks endocarditis; valve replacementLibman-Sacks endocarditis; continuing anticoagulation only heartjnl;103/10/765/HEARTJNL2016310872F1F1HEARTJNL2016310872F1Figure 1Visualisation of the aortic valve on (A) X-plane imaging on real-time three-dimensional transoesophageal echocardiography (RT-3DTEE) and (B) colour Doppler.

Echocardiographic findings in asymptomatic systemic lupus erythematosus patients

The aim of this study is to use transthoracic echocardiographic (TTE) imaging methods to identify cardiac dysfunction in asymptomatic systemic lupus erythematosus (SLE) patients and to determine the association between echocardiographic findings and serology. This is a prospective cross-sectional study where 50 patients with confirmed diagnoses of SLE were recruited from rheumatology outpatient clinics. Clinical and serological evaluation to confirm the diagnosis of lupus was done in all patients. Fifty SLE patients, 46 (92%) females and 4 (8%) males, were recruited. Anti-double-stranded DNA (Anti-dsDNA), anticardiolipin, lupus anticoagulant, and anti-β2-glycoproteins were positive in 52.1, 32.6, 13.3, and 15.6%, respectively. Transthoracic echocardiogram revealed mitral regurgitation in 16 patients (32%), pericardial effusion in16 patients (32%), aortic regurgitation in five patients (10%), and tricuspid regurgitation in 10 patients (20%). Eleven patients had left ventricular hypertrophy (22%), and eight patients had ventricular systolic dysfunction (16%). Only four patients had ventricular diastolic dysfunction (8%). A significant association between mitral and tricuspid valve regurgitation and positive anti-dsDNA (p < 0.018, p < 0.006, respectively) was found. Positive anticardiolipin antibodies, lupus anticoagulant, and anti-β 2 glycoprotein antibodies were also associated with mitral valve regurgitation (p values 0.044, 0.006, and 0.023), respectively. Active disease assessed by Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) was found to be associated with increased risk of mitral valvular leaflet thickening (p value 0.028). Performing regular transthoracic echocardiogram in asymptomatic SLE patients is important for early detection and appropriate treatment of cardiac lesions. Clinically quiescent but serologically active disease and presence of antiphospholipid antibodies were associated with structural heart abnormalities.

Non-Bacterial Thrombotic Endocarditis in a Patient with Rheumatoid Arthritis

Rheumatoid arthritis (RA) is frequently associated with various extra-joint complications. Although rare, thromboembolic complications are associated with high morbidity and mortality. We experienced a very rare case of nonbacterial thrombotic endocarditis (NBTE) and subsequent embolic stroke in a patient with RA. A 72-year-old male with a 15-year history of RA suddenly developed neurologic symptoms of vomiting and dizziness. Brain magnetic resonance imaging revealed recently developed multiple cerebellar and cerebral lacunar infarctions. Echocardiography showed a pulsating mitral valve vegetation involving the posterior cusp of the mitral valve leaflet, which was confirmed as NBTE. Immediate anti-coagulation therapy was started. The NBTE lesion disappeared in follow-up echocardiography after 4 weeks of anti-coagulation treatment.

Long-term cardiac changes in patients with systemic lupus erythematosus

Background

The aim of this study was evaluate the late-onset repercussions of heart alterations of patients with systemic lupus erythematosus (SLE) after a 13-year follow up.

Methods

A historical prospective study was carried out involving the analysis of data from the charts of patients with a confirmed diagnosis of lupus in follow up since 1998. The 13-year evolution was systematically reviewed and tabulated to facilitate the interpretation of the data.

Results

Forty-eight patient charts were analyzed. Mean patient age was 34.5 ± 10.8 years at the time of diagnosis and 41.0 ± 10.3 years at the time of the study (45 women and 3 men). Eight deaths occurred in the follow-up period (two due to heart problems). Among the alterations found on the complementary exams, 46.2% of cases demonstrated worsening at reevaluation and four patients required a heart catheterization. In these cases, coronary angioplasty was performed due to the severity of the obstructions and one case required a further catheterization, culminating in the need for surgical myocardial revascularization.

Conclusion

The analysis demonstrated progressive heart impairment, with high rates of alterations on conventional complementary exams, including the need for angioplasty or revascularization surgery in four patients. These findings indicate the need for rigorous cardiac follow up in patients with systemic lupus erythematosus.

Frequency of established cardiovascular disease and its risk factors in Chinese patients with systemic lupus erythematosus

Cardiovascular disease (CVD) is one of the most serious complications of systemic lupus erythematosus (SLE). This study investigated the frequency of established CVD and its associated risk factors in Chinese patients with SLE. A retrospective, cross-sectional analysis was conducted of 1,072 consecutive patients with SLE from a single center. Patients with CVD were identified on the basis of medical record documentation. Stepwise multivariate logistic regression was used to assess the risk factors of CVD. Of the 1,072 patients with SLE, 71 (6.6%) had CVD. Patients with CVD were older than patients without CVD (39.0 ± 15.6 vs. 31.9 ± 13.3 years; P < 0.001), the frequency of CVD in patients aged ≤19 years, between 20 and 39 years, between 40 and 69 years, and greater than 60 years was increased by 3.4%, 5.5%, 9.2%, 20.4%, respectively. The frequency of CVD was higher in SLE patients with nephritis than without nephritis (7.6% vs. 3.8%; P = 0.026). Multivariate regression analyses confirmed that age ≥60 years (OR = 5.098; 95% CI 1.333, 19.488), higher diastolic blood pressure (OR = 1.050; 95% CI 1.022, 1.078), higher serum creatinine levels (OR = 1.002; 95% CI 1.000, 1.003), and long-term use of glucocorticoids (OR = 1.005; 95% CI 1.000, 1.010) were risk factors for CVD. HDL-C levels (OR = 0.121; 95% CI 0.041, 0.358) were negatively associated with CVD in patients with SLE. Our data suggest that the frequency of CVD was high in Chinese patients with SLE, and independent risk factors for CVD were increased age, higher diastolic blood pressure, higher serum creatinine levels, long-term use of glucocorticoids, and lower HDL-C levels.

Valvular Heart Disease and Systemic Lupus Erythematosus

Valvular involvement is the most encountered form of heart disease in systemic lupus erythematosus (SLE). Immunoglobulin and complement deposition in the valvular structure will subsequently lead to Libman-Sacks vegetations, valve thickening, and valve regurgitation. Valvular stenosis is rarely seen. Involvement of the mitral valve is most frequently encountered. Valve disease for most patients is mild and asymptomatic, but patients in whom severe mitral regurgitation develops will present with symptoms of congestive heart failure. A heart murmur will be heard in almost all patients with moderate or severe regurgitation. Transesophageal echocardiography is the most sensitive method to detect the valvular involvement. The valvular changes, the hemodynamic status, or the symptomatology have been shown to progress, remain stable, or sometimes improve. Severe regurgitation, infective endocarditis, and thromboembolic events (mostly stroke or transitory ischemic attacks) are complications of valvular involvement in SLE. In treatment of these patients, prophylaxis of infectious endocarditis, selective antiaggregant and anticoagulant medication, and valve replacement are currently offered. The role of corticosteroid treatment is still unclear in the outcome of SLE valvulopathy.

Mitral valve prolapse in systemic lupus erythematosus patients: clinical and immunological aspects

Mitral valve prolapse (MVP) has been reported to be associated with systemic lupus erythematosus (SLE). The aim of the present study was to determine the prevalence of MVP in SLE patients, assess its clinical significance and examine the possible association of this entity with other autoimmune indices. Eighty-seven consecutive SLE patients attending the rheumatology clinic and 73 normal control subjects were examined by M-mode, two-dimensional color-Doppler echocardiography. Serum samples were examined for various organ and non-organ specific autoantibodies. MVP was detected in 19/87 patients with SLE and in four of the healthy controls(P = 0.0057). SLE patients with MVP were younger (33.6 +/- 12.4 years) than those without MVP (41. +/- 12.9, P = 0.04) and with shorter duration of the disease (P = 0.03). We found a statistically higher prevalence of anticardiolipin antibodies (aCL) in SLE patients with prolapse (11/19) compared with SLE patients without prolapse (15/68, P = 0.04). This association was independent of age. The aCL-lgG levels were significantly higher in SLE patients with MVP (32.37 +/- 43.26) compared with SLE patients without MVP (22.24 +/- 29.95, P = 0.04). Thyroid autoantibodies tended to be more common in S LE patients with MVP. Th e prevalence of MVP is increased in SLE patients. The presence of aCL and of organ-specific autoantibodies in SLE patients with MVP might indicate the autoimmune origin of MVP. The possibility that SLE patients with MVP may be predisposed to further autoimmune diseases should be considered.

Transesophageal and transthoracic echocardiography and Doppler-examinations in systemic lupus erythematosus

OBJECTIVE

To search for cardiac abnormalities in systemic lupus erythematosus (SLE).

METHODS

35 patients examined by 2-D transthoracal Doppler and transesophageal echocardiography.

RESULTS

Mitral and aortic valve abnormalities were seen in 12 patients (34%) respectively, and occurred altogether in 16 patients (46%). They were in general significantly associated with longer disease duration, but not with anticardiolipin antibodies (aCL), disease activity, or any other variable, except for time on corticosteroids. which was significantly longer in patients with aortic valve calcifications.

CONCLUSION

Valve masses and valve thickening--often in combination--are the most frequent structural findings in SLE, occurring more often on the aortic than on the mitral valves. Factors other than antiphospholipid antibodies, medication, hypertension, or coronary heart disease seem to be responsible for this phenomenon. Drugs that modulate inflammation in endo- and pericardial tissue may, at least in part, be responsible for the observed mitral valve calcifications and pericardial fibrosis.

Echocardiography and pulmonary function testing in childhood onset systemic lupus erythematosus

The aim of this paper was to investigate the frequency of echocardiography (ECHO) and pulmonary function test (PFT) abnormalities in childhood onset systemic lupus erythematosus (SLE), and to determine the relationship of these abnormalities to disease activity. The charts of 50 patients with childhood onset SLE attending a pediatric rheumatology clinic were reviewed for ECHO and PFT studies. The frequency and description of ECHO and PFT abnormalities were documented. Possible associations of PFT and ECHO abnormalities with clinical cardiopulmonary disease, radiographic findings, and measures of lupus disease activity were evaluated. Forty patients (80%) had at least one ECHO study. Twenty-seven (68%) had an abnormal initial study. Nine of 14 patients with an initial abnormal ECHO had normal findings on repeated study. Three abnormalities were considered moderately severe. Thirty-three patients (66%) had at least one PFT performed. Sixteen (48%) were abnormal initially. Four of these 'abnormal' studies were repeated and the abnormalities persisted. Nine patients (27%) were considered to have a severe abnormality. Thirty-one children (62%) had both studies performed. An initial abnormal ECHO and abnormal PFT was found in 10 (32%) of these children. No relationship between ECHO or PFT abnormality and any measure of disease activity (physician's global assessment, anti DNA, C3 or ESR) could be found. Occult cardiac and pulmonary disease as demonstrated by ECHO or PFT occurs frequently in childhood onset SLE. If we wish to understand the natural history of these abnormal heart and lung findings, it will be necessary to do serial testing with ECHO and PFTs in this population.

Prevalence of infective endocarditis in patients with systemic lupus erythematosus

BACKGROUND

Compared with the general population, patients with systemic lupus erythematosus, or SLE, have an increased prevalence of functionally impaired cardiac valves due to the presence of Libman-Sacks lesions. These lesions may place patients with SLE at risk of developing infective endocarditis, or IE.

METHODS

The authors performed a retrospective chart review to determine the association between SLE with valvulopathy and IE. They reviewed the records of 361 patients from two health care facilities who had the diagnostic code of SLE.

RESULTS

Of the 275 records that met the 1982 revised American Rheumatism Association criteria for SLE, 51 (18.5 percent) were for patients who had a clinically detectable heart murmur that resulted in echocardiography being performed. Nine (3.3 percent) of the 275 patients had a clinically significant valvular abnormality, three (1.1 percent) had a potentially significant valvular abnormality, and one (0.4 percent) had a history of IE that was diagnosed two years before her diagnosis of SLE was made.

CONCLUSIONS

The findings suggest that 18.5 percent of this cohort of patients with SLE had a clinically detectable heart murmur that would require further investigation to determine its significance. Furthermore, between 3.3 and 4.4 percent of the study population had cardiac valve abnormalities that potentially required antibiotic prophylaxis before certain dental procedures. However, the authors identified no cases that demonstrated an association between IE and diagnosed SLE.

CLINICAL IMPLICATIONS

Dentists should query their patients with SLE about their cardiac status and consult with the patient's physician if the cardiac status is unknown. Patients with confirmed valvular abnormalities should receive antibiotic prophylaxis for designated bacteremia-producing dental procedures.

Valvular disease associated with systemic illness

The connective tissue diseases are immune-mediated inflammatory diseases that manifest predominantly with symptoms and signs of musculoskeletal and mucocutaneous inflammation. They frequently affect the heart valves, pericardium, and myocardium. In patients with AKS, the aortic root and conduction system are also frequently involved. Echocardiographic series in these patients have demonstrated that valvular disease is highly prevalent and associated with substantial morbidity and mortality (Table 1). The prevalence rates of clinically detected valvular disease, however, are either unknown or low. This discrepancy is related to lack of awareness, overshadowing of the cardiovascular manifestations by the inflammatory symptoms and signs of the musculoskeletal system, lack of systematic application of the history and cardiovascular physical examination, and high sensitivity of echocardiography for detecting subclinical abnormalities. Several valvular abnormalities have been identified as unique to a specific disease. Libman-Sacks vegetations, valve nodules, and subaortic bump are characteristic of SLE, RA, and AKS (see Table 1). The valvular complications and respective therapy are similar to those of other causes of valvular disease; however, the associated morbidity and mortality of these complications in these patients are high. The worse prognosis of valvular disease in these patients is related to the chronicity and debilitating nature of their illness, their high prevalence of multisystem disease, and immunosuppression. These factors underscore the importance of early recognition, prevention of complications, and proper clinical or echocardiographic follow-up. The distinctive echocardiographic characteristics of the valve abnormalities associated with the connective tissue diseases may allow their differentiation from other common valvulopathies, such as infective endocarditis, rheumatic valvular disease, and degenerative valvular disease (Table 2). Despite the clinical and prognostic implications of valvular disease associated with the connective tissue diseases, incomplete data are available about pathogenesis, relation to clinical features of the primary disease, evolution, and effect of steroid or cytotoxic therapy. Echocardiography, especially TEE, has the potential to redefine the prevalence rates and to characterize better the valve abnormalities associated with these conditions. Finally, future large cross-sectional and longitudinal studies using clinical and echocardiographic data may help to define better the presence, evolution, and therapy of the valvular disease associated with the connective tissue diseases.

An echocardiographic study of valvular heart disease associated with systemic lupus erythematosus

BACKGROUND

Valvular heart disease is the most important cardiac manifestation of systemic lupus erythematosus. We performed a study to determine the relation of valvular disease to other clinical features of lupus, whether or not the valve disease progresses, and the associated morbidity and mortality.

METHODS

We performed transesophageal echocardiography and rheumatologic evaluations in 69 patients with systemic lupus erythematosus. The echocardiographic findings were compared with those in 56 healthy volunteers. Fifty-eight patients (84 percent) had second evaluations a mean (+/-SD) period of 29 +/- 13 months later. The patients and controls were followed for 57 months.

RESULTS

Valvular abnormalities were common on the initial and the follow-up echocardiograms (in 61 and 53 percent of the patients, respectively). Valvular thickening was the predominant finding initially and on follow-up (in 51 and 52 percent of the patients, respectively), followed by vegetations (in 43 and 34 percent), valvular regurgitation (in 25 and 28 percent), and stenosis (in 4 and 3 percent). Valvular abnormalities frequently resolved, appeared for the first time, or persisted but changed in appearance or size between the two studies. Mild or moderate valvular regurgitation did not progress to become severe, and new stenoses did not develop. Neither the presence of valvular disease nor changes in the echocardiographic findings were temporally related to the duration, activity, or severity of lupus or to its treatment. The combined incidence of stroke, peripheral embolism, heart failure, infective endocarditis, and the need for valve replacement was 22 percent in the patients with valvular disease, but only 8 percent in those without it. A total of seven patients died during follow-up, in most cases as a result of valvular disease. Valvular abnormalities and complications were uncommon in the controls (occurring in 9 and 2 percent, respectively).

CONCLUSIONS

Valvular heart disease is common in patients with systemic lupus erythematosus, frequently changes over time, appears to be temporally unrelated to other clinical features of lupus, and is associated with substantial morbidity and mortality.

Regression of lupus endocarditis after treatment of an arteriovenous fistula

A young woman with systemic lupus erythematosus (SLE) and antiphospholipid antibodies was referred to our Cardiology Department. She had a large vegetation on the mitral valve, along with significant mitral regurgitation, pulmonary hypertension and slight signs of heart failure on physical examination and chest X-ray. A previously undetected iatrogenic arteriovenous fistula was surgically corrected, with subsequent normalization of pulmonary arterial pressure. Surprisingly, the mitral valve recovered a normal appearance in 21 days. We interpret the hemodynamic disturbances as a consequence of the high-output situation created by the fistula, and the regression of the vegetation as the lysis of a thrombus versus a silent embolism.

Flail Aortic Valve in Systemic Lupus Erythematosus: Diagnosis by Transesophageal Echocardiography

This case report describes a patient with systemic lupus erythematosus who demonstrated by transesophageal echocardiography (TEE) a flail right coronary cusp of the aortic valve causing severe aortic regurgitation. This finding was confirmed at surgery, which showed near detachment of the right coronary leaflet near the commissure. Destruction of areas of the aortic valve has been reported in one previous case report in the absence of infective endocarditis or a traumatic process. This is the second case to our knowledge and the first to describe identification by TEE. (ECHOCARDIOGRAPHY, Volume 13, July 1996)

SLE myocarditis. Detection by Ga-67 citrate scintigraphy

Cardiac uptake of Ga-67 in myocarditis has been described in association with a number of disease entities. However, there are no reports in the current literature describing Ga-67 uptake in myocarditis due to systemic lupus erythematosus, a disease that often involves the heart. The authors present the case of a patient with a long history of systemic lupus erythematosus in whom new ECG changes and left ventricular wall motion abnormality developed, and who demonstrated significant global myocardial uptake on Ga-67 scintigraphy. Other etiologies including myocardial infarction, epicardial coronary disease, pericarditis, endocarditis, dilated cardiomyopathy, and viral infection were excluded during extensive work-up.

Cardiac valve involvement in systemic lupus erythematosus and primary antiphospholipid syndrome: lack of correlation with antiphospholipid antibodies

The aim of this study was to determine the prevalence of cardiac valve disease in systemic lupus erythematosus or in patients with primary antiphospholipid syndrome and to assess the role of the antiphospholipid antibodies as risk factor for endocardial lesions. We studied 39 consecutive patients with systemic lupus erythematosus (mean age 34 +/- 12 years, 38 female and one male), 20 women with primary antiphospholipid syndrome (mean age 32 +/- 4 years) and 20 normal subjects (mean age 35 +/- 8 years, 15 female and five male). All patients with primary antiphospholipid syndrome had increased levels of serum anticardiolipin antibodies and recurrent fetal abortions; some of them also had arterial and/or venous thrombosis and/or thrombocytopenia. M-mode, two-dimensional and Doppler echocardiography were performed in all patients. IgG anticardiolipin antibodies were measured by an enzyme-linked immunosorbent assay. Valvular lesions were observed in 15 patients (38%) with systemic lupus erythematosus. These abnormalities included: mitral valve thickening or vegetation, mitral valve prolapse and aortic valve vegetation; mitral, aortic and tricuspid regurgitation; mitral stenosis. None of the patients with primary antiphospholipid syndrome and of the normal subjects was found to have valvular abnormalities. In systemic lupus erythematosus, high levels of anticardiolipin antibodies were detected in 73% of the patients with valvular lesions and in 67% of the patients without valvular lesions (P > 0.05). We conclude that valvular involvement is frequent in patients with systemic lupus erythematosus but it is apparently unrelated to antiphospholipid autoimmunization.

Five-year follow-up study of the prevalence and progression of pulmonary hypertension in systemic lupus erythematosus

The purpose of this study was to determine the prevalence and progression of pulmonary hypertension over a 5-year follow-up period in 28 patients with systemic lupus erythematosus (SLE) who were originally enrolled in an echocardiographic study of pulmonary hypertension in 1985 and 1986. Twenty healthy volunteers without cardiac or pulmonary disease participated as normal controls. Each patient and control underwent a complete Doppler echocardiographic study. Doppler echocardiographic recordings of tricuspid insufficiency, with saline contrast enhancement when necessary, were used to calculate pulmonary artery systolic pressure according to the modified Bernoulli equation. Doppler echocardiographic measurement of cardiac output was performed at rest for each subject, and pulmonary resistance was calculated by dividing the pulmonary artery systolic pressure by the cardiac output. These results were compared to results of the original studies to detect serial changes in pulmonary pressure and pulmonary resistance; results were also compared to the group of normal controls. The prevalence of pulmonary hypertension increased from 14% at the first study to 43% at follow-up. A significant increase in mean systolic pulmonary artery pressure was detected in the SLE patients during the follow-up period: 23.4 vs 27.5 mm Hg (p < 0.005). In addition, a significantly higher pulmonary artery pressure was detected in the SLE patients compared with the normal controls (p < 0.005).(ABSTRACT TRUNCATED AT 250 WORDS)

Dissecting aortic aneurysm in systemic lupus erythematosus

Many cardiovascular manifestations have been described in systemic lupus erythematosus (SLE). Aortic involvement, however, is very rare. We describe a 30-year-old woman with SLE who presented with extensive aortic dissection, and review the few reported cases. We discuss possible pathogenic mechanisms for aortic involvement in lupus and the appropriate diagnostic work-up.

Lupus anticoagulant and cardiac manifestations in systemic lupus erythematosus

The occurrence of cardiac manifestations and their relationship with the lupus anticoagulant (LA) in SLE was studied in 74 patients who were followed up for 22 years (median), of which 16 years were after the initial LA testing. Pericarditis was the most common cardiac event occurring in 16 (22%) patients but it did not correlate with LA. Valvular heart disease, coronary artery disease, left ventricular failure and/or cor pulmonale were observed in 16 (22%) patients. Taken together, their occurrence was associated with a history of leg ulcers (odds 3.8, P = 0.028) but not with LA or other common clinical manifestations of the antiphospholipid syndrome. Valvular heart disease in five patients was significantly associated with LA (P = 0.05). Cor pulmonale due to chronic pulmonary embolism was present in two patients with LA. Myocardial infarctions in five patients occurred late in the course of disease but in relatively young patients (mean 43 years). Fatal myocardial infarction in the absence of atherosclerosis in two LA-positive patients supports a pathogenetic role for LA in these cases. In conclusion, of the various cardiac complications in SLE, valvular heart disease and cor pulmonale appear to be connected with the antiphospholipid syndrome. Both conditions should be actively sought in patients with LA to decrease possible adverse events (arterial emboli and right ventricular failure) affecting the patients' prognosis.