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Tselios K, Deeb M, Gladman DD, Harvey P, Akhtari S, Mak S, Butany J, Urowitz MB. Antimalarial-induced Cardiomyopathy in Systemic Lupus Erythematosus: As Rare as Considered? J Rheumatol 2018; 46:391-396. [PMID: 30323009 DOI: 10.3899/jrheum.180124] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/24/2018] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Antimalarials (AM) are recommended for all systemic lupus erythematosus (SLE) patients without specific contraindications. Their main adverse effect is retinal damage; however, heart disease has been described in isolated cases. The aim of our study is to describe 8 patients with AM-induced cardiomyopathy (AMIC) in a defined SLE cohort. METHODS Patients attending the Toronto Lupus Clinic and diagnosed with definite (based on endomyocardial biopsy; EMB) and possible AMIC were included [based on cardiac magnetic resonance imaging (cMRI) and other investigations]. RESULTS Eight female patients (median age 62.5 yrs, disease duration 35 yrs, AM use duration 22 yrs) were diagnosed with AMIC in the past 2 years. Diagnosis was based on EMB in 3 (extensive cardiomyocyte vacuolation, intracytoplasmic myelinoid, and curvilinear bodies). In 4 patients, cMRI was highly suggestive of AMIC (ventricular hypertrophy and/or atrial enlargement and late gadolinium enhancement in a nonvascular pattern). Another patient was diagnosed with complete atrioventricular block, left ventricular and septal hypertrophy, along with concomitant ocular toxicity. All patients had abnormal cardiac troponin I (cTnI) and brain natriuretic peptide (BNP), whereas 7/8 also had chronically elevated creatine phosphokinase. During followup, 1 patient died from refractory heart failure. In the remaining patients, hypertrophy regression and a steady decrease of heart biomarkers were observed after AM cessation. CONCLUSION Once considered extremely rare, AMIC seems to be underrecognized, probably because of the false attribution of heart failure or hypertrophy to other causes. Certain biomarkers (cTnI, BNP) and imaging findings may lead to early diagnosis and enhance survival.
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Affiliation(s)
- Konstantinos Tselios
- From the University of Toronto Lupus Clinic, Toronto Western Hospital, Centre for Prognosis Studies in the Rheumatic Diseases, University Health Network; University of Toronto, Krembil Research Institute; Department of Cardiology, University of Toronto, Women's College Hospital; Mecklinger Family and Posluns Family Cardiac Catheterization Research Laboratory, Department of Medicine, Division of Cardiology, Mount Sinai Hospital, University of Toronto; Department of Laboratory Medicine and Pathobiology, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada.,K. Tselios, MD, PhD, Clinical Research Fellow, University of Toronto Lupus Clinic, Toronto Western Hospital, Centre for Prognosis Studies in the Rheumatic Diseases; M. Deeb, MSc, Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Lupus Clinic, University Health Network; D.D. Gladman, MD, FRCPC, Professor of Medicine, University of Toronto, Senior Scientist, Krembil Research Institute, Co-Director, University of Toronto Lupus Clinic, Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital; P. Harvey, BMBS, PhD, FRACP, Department of Cardiology, University of Toronto, Women's College Hospital; S. Akhtari, MD, FRCPC, Department of Cardiology, University of Toronto, Women's College Hospital; S. Mak, MD, PhD, Mecklinger Family and Posluns Family Cardiac Catheterization Research Laboratory, Department of Medicine, Division of Cardiology, Mount Sinai Hospital, University of Toronto; J. Butany, MBBS, MS, FRCPC, Department of Laboratory Medicine and Pathobiology, University Health Network, Toronto General Hospital; M.B. Urowitz, MD, FRCPC, Professor of Medicine, University of Toronto, Senior Scientist, Krembil Research Institute, Director, University of Toronto Lupus Clinic, Centre for Prognosis Studies in the Rheumatic Diseases
| | - Mery Deeb
- From the University of Toronto Lupus Clinic, Toronto Western Hospital, Centre for Prognosis Studies in the Rheumatic Diseases, University Health Network; University of Toronto, Krembil Research Institute; Department of Cardiology, University of Toronto, Women's College Hospital; Mecklinger Family and Posluns Family Cardiac Catheterization Research Laboratory, Department of Medicine, Division of Cardiology, Mount Sinai Hospital, University of Toronto; Department of Laboratory Medicine and Pathobiology, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada.,K. Tselios, MD, PhD, Clinical Research Fellow, University of Toronto Lupus Clinic, Toronto Western Hospital, Centre for Prognosis Studies in the Rheumatic Diseases; M. Deeb, MSc, Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Lupus Clinic, University Health Network; D.D. Gladman, MD, FRCPC, Professor of Medicine, University of Toronto, Senior Scientist, Krembil Research Institute, Co-Director, University of Toronto Lupus Clinic, Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital; P. Harvey, BMBS, PhD, FRACP, Department of Cardiology, University of Toronto, Women's College Hospital; S. Akhtari, MD, FRCPC, Department of Cardiology, University of Toronto, Women's College Hospital; S. Mak, MD, PhD, Mecklinger Family and Posluns Family Cardiac Catheterization Research Laboratory, Department of Medicine, Division of Cardiology, Mount Sinai Hospital, University of Toronto; J. Butany, MBBS, MS, FRCPC, Department of Laboratory Medicine and Pathobiology, University Health Network, Toronto General Hospital; M.B. Urowitz, MD, FRCPC, Professor of Medicine, University of Toronto, Senior Scientist, Krembil Research Institute, Director, University of Toronto Lupus Clinic, Centre for Prognosis Studies in the Rheumatic Diseases
| | - Dafna D Gladman
- From the University of Toronto Lupus Clinic, Toronto Western Hospital, Centre for Prognosis Studies in the Rheumatic Diseases, University Health Network; University of Toronto, Krembil Research Institute; Department of Cardiology, University of Toronto, Women's College Hospital; Mecklinger Family and Posluns Family Cardiac Catheterization Research Laboratory, Department of Medicine, Division of Cardiology, Mount Sinai Hospital, University of Toronto; Department of Laboratory Medicine and Pathobiology, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada.,K. Tselios, MD, PhD, Clinical Research Fellow, University of Toronto Lupus Clinic, Toronto Western Hospital, Centre for Prognosis Studies in the Rheumatic Diseases; M. Deeb, MSc, Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Lupus Clinic, University Health Network; D.D. Gladman, MD, FRCPC, Professor of Medicine, University of Toronto, Senior Scientist, Krembil Research Institute, Co-Director, University of Toronto Lupus Clinic, Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital; P. Harvey, BMBS, PhD, FRACP, Department of Cardiology, University of Toronto, Women's College Hospital; S. Akhtari, MD, FRCPC, Department of Cardiology, University of Toronto, Women's College Hospital; S. Mak, MD, PhD, Mecklinger Family and Posluns Family Cardiac Catheterization Research Laboratory, Department of Medicine, Division of Cardiology, Mount Sinai Hospital, University of Toronto; J. Butany, MBBS, MS, FRCPC, Department of Laboratory Medicine and Pathobiology, University Health Network, Toronto General Hospital; M.B. Urowitz, MD, FRCPC, Professor of Medicine, University of Toronto, Senior Scientist, Krembil Research Institute, Director, University of Toronto Lupus Clinic, Centre for Prognosis Studies in the Rheumatic Diseases
| | - Paula Harvey
- From the University of Toronto Lupus Clinic, Toronto Western Hospital, Centre for Prognosis Studies in the Rheumatic Diseases, University Health Network; University of Toronto, Krembil Research Institute; Department of Cardiology, University of Toronto, Women's College Hospital; Mecklinger Family and Posluns Family Cardiac Catheterization Research Laboratory, Department of Medicine, Division of Cardiology, Mount Sinai Hospital, University of Toronto; Department of Laboratory Medicine and Pathobiology, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada.,K. Tselios, MD, PhD, Clinical Research Fellow, University of Toronto Lupus Clinic, Toronto Western Hospital, Centre for Prognosis Studies in the Rheumatic Diseases; M. Deeb, MSc, Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Lupus Clinic, University Health Network; D.D. Gladman, MD, FRCPC, Professor of Medicine, University of Toronto, Senior Scientist, Krembil Research Institute, Co-Director, University of Toronto Lupus Clinic, Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital; P. Harvey, BMBS, PhD, FRACP, Department of Cardiology, University of Toronto, Women's College Hospital; S. Akhtari, MD, FRCPC, Department of Cardiology, University of Toronto, Women's College Hospital; S. Mak, MD, PhD, Mecklinger Family and Posluns Family Cardiac Catheterization Research Laboratory, Department of Medicine, Division of Cardiology, Mount Sinai Hospital, University of Toronto; J. Butany, MBBS, MS, FRCPC, Department of Laboratory Medicine and Pathobiology, University Health Network, Toronto General Hospital; M.B. Urowitz, MD, FRCPC, Professor of Medicine, University of Toronto, Senior Scientist, Krembil Research Institute, Director, University of Toronto Lupus Clinic, Centre for Prognosis Studies in the Rheumatic Diseases
| | - Shadi Akhtari
- From the University of Toronto Lupus Clinic, Toronto Western Hospital, Centre for Prognosis Studies in the Rheumatic Diseases, University Health Network; University of Toronto, Krembil Research Institute; Department of Cardiology, University of Toronto, Women's College Hospital; Mecklinger Family and Posluns Family Cardiac Catheterization Research Laboratory, Department of Medicine, Division of Cardiology, Mount Sinai Hospital, University of Toronto; Department of Laboratory Medicine and Pathobiology, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada.,K. Tselios, MD, PhD, Clinical Research Fellow, University of Toronto Lupus Clinic, Toronto Western Hospital, Centre for Prognosis Studies in the Rheumatic Diseases; M. Deeb, MSc, Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Lupus Clinic, University Health Network; D.D. Gladman, MD, FRCPC, Professor of Medicine, University of Toronto, Senior Scientist, Krembil Research Institute, Co-Director, University of Toronto Lupus Clinic, Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital; P. Harvey, BMBS, PhD, FRACP, Department of Cardiology, University of Toronto, Women's College Hospital; S. Akhtari, MD, FRCPC, Department of Cardiology, University of Toronto, Women's College Hospital; S. Mak, MD, PhD, Mecklinger Family and Posluns Family Cardiac Catheterization Research Laboratory, Department of Medicine, Division of Cardiology, Mount Sinai Hospital, University of Toronto; J. Butany, MBBS, MS, FRCPC, Department of Laboratory Medicine and Pathobiology, University Health Network, Toronto General Hospital; M.B. Urowitz, MD, FRCPC, Professor of Medicine, University of Toronto, Senior Scientist, Krembil Research Institute, Director, University of Toronto Lupus Clinic, Centre for Prognosis Studies in the Rheumatic Diseases
| | - Susanna Mak
- From the University of Toronto Lupus Clinic, Toronto Western Hospital, Centre for Prognosis Studies in the Rheumatic Diseases, University Health Network; University of Toronto, Krembil Research Institute; Department of Cardiology, University of Toronto, Women's College Hospital; Mecklinger Family and Posluns Family Cardiac Catheterization Research Laboratory, Department of Medicine, Division of Cardiology, Mount Sinai Hospital, University of Toronto; Department of Laboratory Medicine and Pathobiology, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada.,K. Tselios, MD, PhD, Clinical Research Fellow, University of Toronto Lupus Clinic, Toronto Western Hospital, Centre for Prognosis Studies in the Rheumatic Diseases; M. Deeb, MSc, Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Lupus Clinic, University Health Network; D.D. Gladman, MD, FRCPC, Professor of Medicine, University of Toronto, Senior Scientist, Krembil Research Institute, Co-Director, University of Toronto Lupus Clinic, Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital; P. Harvey, BMBS, PhD, FRACP, Department of Cardiology, University of Toronto, Women's College Hospital; S. Akhtari, MD, FRCPC, Department of Cardiology, University of Toronto, Women's College Hospital; S. Mak, MD, PhD, Mecklinger Family and Posluns Family Cardiac Catheterization Research Laboratory, Department of Medicine, Division of Cardiology, Mount Sinai Hospital, University of Toronto; J. Butany, MBBS, MS, FRCPC, Department of Laboratory Medicine and Pathobiology, University Health Network, Toronto General Hospital; M.B. Urowitz, MD, FRCPC, Professor of Medicine, University of Toronto, Senior Scientist, Krembil Research Institute, Director, University of Toronto Lupus Clinic, Centre for Prognosis Studies in the Rheumatic Diseases
| | - Jagdish Butany
- From the University of Toronto Lupus Clinic, Toronto Western Hospital, Centre for Prognosis Studies in the Rheumatic Diseases, University Health Network; University of Toronto, Krembil Research Institute; Department of Cardiology, University of Toronto, Women's College Hospital; Mecklinger Family and Posluns Family Cardiac Catheterization Research Laboratory, Department of Medicine, Division of Cardiology, Mount Sinai Hospital, University of Toronto; Department of Laboratory Medicine and Pathobiology, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada.,K. Tselios, MD, PhD, Clinical Research Fellow, University of Toronto Lupus Clinic, Toronto Western Hospital, Centre for Prognosis Studies in the Rheumatic Diseases; M. Deeb, MSc, Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Lupus Clinic, University Health Network; D.D. Gladman, MD, FRCPC, Professor of Medicine, University of Toronto, Senior Scientist, Krembil Research Institute, Co-Director, University of Toronto Lupus Clinic, Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital; P. Harvey, BMBS, PhD, FRACP, Department of Cardiology, University of Toronto, Women's College Hospital; S. Akhtari, MD, FRCPC, Department of Cardiology, University of Toronto, Women's College Hospital; S. Mak, MD, PhD, Mecklinger Family and Posluns Family Cardiac Catheterization Research Laboratory, Department of Medicine, Division of Cardiology, Mount Sinai Hospital, University of Toronto; J. Butany, MBBS, MS, FRCPC, Department of Laboratory Medicine and Pathobiology, University Health Network, Toronto General Hospital; M.B. Urowitz, MD, FRCPC, Professor of Medicine, University of Toronto, Senior Scientist, Krembil Research Institute, Director, University of Toronto Lupus Clinic, Centre for Prognosis Studies in the Rheumatic Diseases
| | - Murray B Urowitz
- From the University of Toronto Lupus Clinic, Toronto Western Hospital, Centre for Prognosis Studies in the Rheumatic Diseases, University Health Network; University of Toronto, Krembil Research Institute; Department of Cardiology, University of Toronto, Women's College Hospital; Mecklinger Family and Posluns Family Cardiac Catheterization Research Laboratory, Department of Medicine, Division of Cardiology, Mount Sinai Hospital, University of Toronto; Department of Laboratory Medicine and Pathobiology, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada. .,K. Tselios, MD, PhD, Clinical Research Fellow, University of Toronto Lupus Clinic, Toronto Western Hospital, Centre for Prognosis Studies in the Rheumatic Diseases; M. Deeb, MSc, Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Lupus Clinic, University Health Network; D.D. Gladman, MD, FRCPC, Professor of Medicine, University of Toronto, Senior Scientist, Krembil Research Institute, Co-Director, University of Toronto Lupus Clinic, Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital; P. Harvey, BMBS, PhD, FRACP, Department of Cardiology, University of Toronto, Women's College Hospital; S. Akhtari, MD, FRCPC, Department of Cardiology, University of Toronto, Women's College Hospital; S. Mak, MD, PhD, Mecklinger Family and Posluns Family Cardiac Catheterization Research Laboratory, Department of Medicine, Division of Cardiology, Mount Sinai Hospital, University of Toronto; J. Butany, MBBS, MS, FRCPC, Department of Laboratory Medicine and Pathobiology, University Health Network, Toronto General Hospital; M.B. Urowitz, MD, FRCPC, Professor of Medicine, University of Toronto, Senior Scientist, Krembil Research Institute, Director, University of Toronto Lupus Clinic, Centre for Prognosis Studies in the Rheumatic Diseases.
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Tselios K, Gladman DD, Harvey P, Akhtari S, Su J, Urowitz MB. Abnormal Cardiac Biomarkers in Patients with Systemic Lupus Erythematosus and No Prior Heart Disease: A Consequence of Antimalarials? J Rheumatol 2018; 46:64-69. [PMID: 30068764 DOI: 10.3899/jrheum.171436] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2018] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Cardiac involvement in systemic lupus erythematosus (SLE) is often undiagnosed in its early phases. Specific heart biomarkers may identify patients at risk. We sought to investigate the prevalence and associated factors for such biomarkers in SLE. METHODS Brain natriuretic peptide (BNP) and cardiac troponin I (cTnI) were measured simultaneously in 151 consecutive patients with no history of heart disease or pulmonary arterial hypertension (PAH). None had electrocardiographic abnormalities suggestive of acute coronary syndrome. Cross-sectional comparisons and logistic regression analyses were performed. Patients with abnormal biomarkers were investigated to delineate the specific cause. RESULTS Sixteen patients (16/151, 10.6%) had elevated BNP, and 9 of them also had abnormal cTnI. Compared to subjects with normal biomarkers, they were older, had longer disease and antimalarial (AM) use duration, and more frequently persistent creatine phosphokinase (CPK) elevation. Multivariable regression analysis showed prolonged AM treatment (> 5.6 yrs) and persistent CPK elevation to be important predictors for elevated cardiac biomarkers. Six patients were diagnosed with definite (based on endomyocardial biopsy, n = 2) or possible (based on cardiac magnetic resonance after exclusion of other causes) AM-induced cardiomyopathy (AMIC); all had both BNP and cTnI elevated. Alternative causes were identified in 5, while no definitive diagnosis could be made in the remaining patients. CONCLUSION About 10% of patients with SLE had elevated myocardial biomarkers, in the absence of prior cardiac disease or PAH. One-third of them were diagnosed with AMIC. Prolonged AM therapy and persistent CPK elevation conferred an increased risk for abnormal BNP and cTnI, which might predict AMIC.
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Affiliation(s)
- Konstantinos Tselios
- From the Toronto Lupus Clinic, Centre for Prognosis Studies in Rheumatic Diseases, University Health Network; Cardiology Department, Women's College Hospital, University of Toronto, Toronto, Ontario, Canada.,K. Tselios, MD, PhD, Toronto Lupus Clinic, Centre for Prognosis Studies in Rheumatic Diseases, University Health Network; D.D. Gladman, MD, FRCPC, Toronto Lupus Clinic, Centre for Prognosis Studies in Rheumatic Diseases, University Health Network; P. Harvey, BMBS, PhD, FRACP, Cardiology Department, Women's College Hospital, University of Toronto; S. Akhtari, MD, FRCPC, Cardiology Department, Women's College Hospital, University of Toronto; J. Su, MB, BSc, Toronto Lupus Clinic, Centre for Prognosis Studies in Rheumatic Diseases, University Health Network; M.B. Urowitz, MD, FRCPC, Toronto Lupus Clinic, Centre for Prognosis Studies in Rheumatic Diseases, University Health Network
| | - Dafna D Gladman
- From the Toronto Lupus Clinic, Centre for Prognosis Studies in Rheumatic Diseases, University Health Network; Cardiology Department, Women's College Hospital, University of Toronto, Toronto, Ontario, Canada.,K. Tselios, MD, PhD, Toronto Lupus Clinic, Centre for Prognosis Studies in Rheumatic Diseases, University Health Network; D.D. Gladman, MD, FRCPC, Toronto Lupus Clinic, Centre for Prognosis Studies in Rheumatic Diseases, University Health Network; P. Harvey, BMBS, PhD, FRACP, Cardiology Department, Women's College Hospital, University of Toronto; S. Akhtari, MD, FRCPC, Cardiology Department, Women's College Hospital, University of Toronto; J. Su, MB, BSc, Toronto Lupus Clinic, Centre for Prognosis Studies in Rheumatic Diseases, University Health Network; M.B. Urowitz, MD, FRCPC, Toronto Lupus Clinic, Centre for Prognosis Studies in Rheumatic Diseases, University Health Network
| | - Paula Harvey
- From the Toronto Lupus Clinic, Centre for Prognosis Studies in Rheumatic Diseases, University Health Network; Cardiology Department, Women's College Hospital, University of Toronto, Toronto, Ontario, Canada.,K. Tselios, MD, PhD, Toronto Lupus Clinic, Centre for Prognosis Studies in Rheumatic Diseases, University Health Network; D.D. Gladman, MD, FRCPC, Toronto Lupus Clinic, Centre for Prognosis Studies in Rheumatic Diseases, University Health Network; P. Harvey, BMBS, PhD, FRACP, Cardiology Department, Women's College Hospital, University of Toronto; S. Akhtari, MD, FRCPC, Cardiology Department, Women's College Hospital, University of Toronto; J. Su, MB, BSc, Toronto Lupus Clinic, Centre for Prognosis Studies in Rheumatic Diseases, University Health Network; M.B. Urowitz, MD, FRCPC, Toronto Lupus Clinic, Centre for Prognosis Studies in Rheumatic Diseases, University Health Network
| | - Shadi Akhtari
- From the Toronto Lupus Clinic, Centre for Prognosis Studies in Rheumatic Diseases, University Health Network; Cardiology Department, Women's College Hospital, University of Toronto, Toronto, Ontario, Canada.,K. Tselios, MD, PhD, Toronto Lupus Clinic, Centre for Prognosis Studies in Rheumatic Diseases, University Health Network; D.D. Gladman, MD, FRCPC, Toronto Lupus Clinic, Centre for Prognosis Studies in Rheumatic Diseases, University Health Network; P. Harvey, BMBS, PhD, FRACP, Cardiology Department, Women's College Hospital, University of Toronto; S. Akhtari, MD, FRCPC, Cardiology Department, Women's College Hospital, University of Toronto; J. Su, MB, BSc, Toronto Lupus Clinic, Centre for Prognosis Studies in Rheumatic Diseases, University Health Network; M.B. Urowitz, MD, FRCPC, Toronto Lupus Clinic, Centre for Prognosis Studies in Rheumatic Diseases, University Health Network
| | - Jiandong Su
- From the Toronto Lupus Clinic, Centre for Prognosis Studies in Rheumatic Diseases, University Health Network; Cardiology Department, Women's College Hospital, University of Toronto, Toronto, Ontario, Canada.,K. Tselios, MD, PhD, Toronto Lupus Clinic, Centre for Prognosis Studies in Rheumatic Diseases, University Health Network; D.D. Gladman, MD, FRCPC, Toronto Lupus Clinic, Centre for Prognosis Studies in Rheumatic Diseases, University Health Network; P. Harvey, BMBS, PhD, FRACP, Cardiology Department, Women's College Hospital, University of Toronto; S. Akhtari, MD, FRCPC, Cardiology Department, Women's College Hospital, University of Toronto; J. Su, MB, BSc, Toronto Lupus Clinic, Centre for Prognosis Studies in Rheumatic Diseases, University Health Network; M.B. Urowitz, MD, FRCPC, Toronto Lupus Clinic, Centre for Prognosis Studies in Rheumatic Diseases, University Health Network
| | - Murray B Urowitz
- From the Toronto Lupus Clinic, Centre for Prognosis Studies in Rheumatic Diseases, University Health Network; Cardiology Department, Women's College Hospital, University of Toronto, Toronto, Ontario, Canada. .,K. Tselios, MD, PhD, Toronto Lupus Clinic, Centre for Prognosis Studies in Rheumatic Diseases, University Health Network; D.D. Gladman, MD, FRCPC, Toronto Lupus Clinic, Centre for Prognosis Studies in Rheumatic Diseases, University Health Network; P. Harvey, BMBS, PhD, FRACP, Cardiology Department, Women's College Hospital, University of Toronto; S. Akhtari, MD, FRCPC, Cardiology Department, Women's College Hospital, University of Toronto; J. Su, MB, BSc, Toronto Lupus Clinic, Centre for Prognosis Studies in Rheumatic Diseases, University Health Network; M.B. Urowitz, MD, FRCPC, Toronto Lupus Clinic, Centre for Prognosis Studies in Rheumatic Diseases, University Health Network.
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