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Khayata M, Wang TKM, Chan N, Alkharabsheh S, Verma BR, Oliveira GH, Klein AL, Littlejohn E, Xu B. Multimodality Cardiac Imaging in Patients with Systemic Lupus Erythematosus. Curr Probl Cardiol 2023; 48:101048. [PMID: 34774920 DOI: 10.1016/j.cpcardiol.2021.101048] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 11/05/2021] [Indexed: 02/01/2023]
Abstract
Systemic lupus erythematous (SLE) is an autoimmune disease with a wide range of cardiovascular complications. The main manifestations include diseases of the coronary arteries, valves, pericardium, and myocardium. Multimodality cardiovascular imaging techniques are critical for evaluating the extent of cardiac manifestations in SLE patients, which can provide valuable prognostic information. However, their utility has previously not been well defined. This review provides a state-of-the-art update on the cardiovascular manifestations of lupus, as well as the role of multimodality cardiac imaging in guiding management of patients with SLE.
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Affiliation(s)
- Mohamed Khayata
- Department of Cardiovascular Sciences, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Tom Kai Ming Wang
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Section of Cardiovascular Imaging, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Nicholas Chan
- Department of Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Saqer Alkharabsheh
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Beni R Verma
- Department of Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Guilherme H Oliveira
- Department of Cardiovascular Sciences, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Allan L Klein
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Section of Cardiovascular Imaging, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Emily Littlejohn
- Department of Rheumatologic and Immunologic Disease, Cleveland Clinic, Ohio, USA
| | - Bo Xu
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Section of Cardiovascular Imaging, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA.
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Sexton G, McLoughlin J, Burke L, Doddakula K. Mitral valve replacement due to Libman-Sacks endocarditis: lower limb cellulitis as a red herring. BMJ Case Rep 2022; 15:e246078. [PMID: 35058285 PMCID: PMC8783826 DOI: 10.1136/bcr-2021-246078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/28/2021] [Indexed: 11/03/2022] Open
Abstract
A 56-year-old woman was admitted due to new ulceration and acute digital ischaemia on a background of chronic leg ulcers bilaterally. Vasculitis screening returned strongly positive lupus anticoagulant levels and elevated anticardiolipin antibodies; these remained elevated at repeat testing. A diagnosis of antiphospholipid syndrome was made. Transthoracic echocardiogram identified a mitral valve lesion suggestive of vegetation and mild mitral valve regurgitation. Blood cultures taken throughout her inpatient admission were negative. Mechanical mitral valve replacement was performed 3 months later, and subsequent culture of the excised tissue returned as sterile. Histological examination showed no morphological signs of infective endocarditis.
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Affiliation(s)
- Gerard Sexton
- General Medicine, Mercy University Hospital, Cork, Ireland
| | - Joseph McLoughlin
- Cardiothoracic Surgery, Cork University Hospital Group, Cork, Ireland
| | - Louise Burke
- Pathology, Cork University Hospital Group, Cork, Ireland
| | - Kishore Doddakula
- Cardiothoracic Surgery, Cork University Hospital Group, Cork, Ireland
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Assan F, de Zuttere D, Bottin L, Tavolaro S, Courvoisier DS, Barbaud A, Alamowitch S, Francès C, Chasset F. Echocardiographic features in antiphospholipid-negative Sneddon's syndrome and potential association with severity of neurological symptoms or recurrence of strokes: a longitudinal cohort study. Eur Heart J Cardiovasc Imaging 2021; 22:119-128. [PMID: 31898726 DOI: 10.1093/ehjci/jez312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Revised: 10/19/2019] [Accepted: 12/07/2019] [Indexed: 12/18/2022] Open
Abstract
AIMS Sneddon's syndrome (SS) may be classified as antiphospholipid positive (aPL+) or negative (aPL- SS). An association between Libman-Sacks (LS) endocarditis and strokes has been described in aPL+ patients. To describe cardiac involvement in aPL- SS and assess the potential association between LS endocarditis and severity or recurrence of neurological symptoms. METHODS AND RESULTS This longitudinal cohort study included aPL- SS patients followed in our departments between 1991 and June 2018. All patients underwent transthoracic 2D and Doppler echocardiography at diagnosis. Follow-up echocardiography was performed annually and the potential relationship between LS endocarditis development and neurovascular relapse as well as long-term cardiac worsening was prospectively assessed. We included 61 patients [52 women; median age 45 (range 24-60)]. For valvular involvement, 36 (59%) patients showed leaflet thickening; 18 (29.5%) had LS endocarditis at baseline. During a median follow-up of 72 months, LS endocarditis developed in eight (17.4%) patients, and 13 (28.3%) showed significant worsening of their cardiac status, including two who needed valvular replacement. After adjusting for baseline antithrombotic treatment regimen, neither the presence of LS endocarditis at baseline nor development during follow-up was associated with neurological relapse [hazard ratio (HR): 1.06, 95% confidence interval (CI): 0.33-4.74, P = 0.92] and [HR: 0.38, 95% CI: 0.02-1.89, P = 0.31], respectively. CONCLUSION A long-term follow-up is needed to detect cardiac complications in aPL- SS. No change in neurological relapse was observed in patients presenting LS endocarditis occurrence during follow-up without any modification in antithrombotic treatment. Further research is necessary to assess the usefulness of treatment escalation in these patients.
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Affiliation(s)
- Florence Assan
- Sorbonne Université, Faculté de Médecine Sorbonne Université, APHP Dermatology and Allergology Department, Hôpital Tenon, 4 rue de la Chine 75020 Paris, France
| | - Dominique de Zuttere
- Functional exploration Department, Hôpital Francp-Brittanique, 4 rue Kléber 92300 Levallois-Perret, France
| | - Laure Bottin
- Sorbonne Université, Faculté de Médecine Sorbonne Université, APHP Neurology Department, Hôpital Saint Antoine, 184 rue du Faubourg Saint-Antoine 75012 Paris, France
| | - Sebastian Tavolaro
- Sorbonne Université, Faculté de Médecine Sorbonne Université, APHP Radiology Department, Hôpital Tenon, 4 rue de la Chine 75020 Paris, France
| | - Delphine S Courvoisier
- Division of rheumatology, Department of Medicine, University of Geneva, 1205 Geneva, Switzerland
| | - Annick Barbaud
- Sorbonne Université, Faculté de Médecine Sorbonne Université, APHP Dermatology and Allergology Department, Hôpital Tenon, 4 rue de la Chine 75020 Paris, France
| | - Sonia Alamowitch
- Sorbonne Université, Faculté de Médecine Sorbonne Université, APHP Neurology Department, Hôpital Saint Antoine, 184 rue du Faubourg Saint-Antoine 75012 Paris, France
| | - Camille Francès
- Sorbonne Université, Faculté de Médecine Sorbonne Université, APHP Dermatology and Allergology Department, Hôpital Tenon, 4 rue de la Chine 75020 Paris, France
| | - François Chasset
- Sorbonne Université, Faculté de Médecine Sorbonne Université, APHP Dermatology and Allergology Department, Hôpital Tenon, 4 rue de la Chine 75020 Paris, France
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Allain JS, Paven E, Henriot B, Belhomme N, Le Bot A, Ballerie A, Jego P. [Libman-Sacks endocarditis under apixaban in a patient with a high-risk profile venous antiphospholipid syndrome]. Rev Med Interne 2020; 42:218-222. [PMID: 33153775 DOI: 10.1016/j.revmed.2020.08.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 06/23/2020] [Accepted: 08/03/2020] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Libman-Sacks endocarditis is a rare complication of antiphospholipid syndrome. Anti-vitamin K therapy is the standard treatment, although valvular replacement surgery may be required in some severe cases. In the latest EULAR recommendations, it is advised not to use direct oral anticoagulants in the management of antiphospholipid syndrome, especially of high-risk profile. CASE REPORT We present a case of a mitral Libman-Sacks endocarditis complicated with multiple strokes occurring in the setting of an antiphospholipid syndrome with triple positive antibody profile in a 63-year-old woman with multiple sclerosis. She was previously treated with apixaban for two years. Tinzaparin followed by prolonged warfarine treatment and two months of hydroxychloroquine resulted in valvular improvement. CONCLUSION To our knowledge, this is the first case of Libman-Sacks endocarditis occurring during apixaban therapy in a patient with antiphospholipid syndrome. This severe case highlights the inefficiency of direct oral anticoagulants to prevent thrombotic events in the antiphospholipid syndrome.
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Affiliation(s)
- J-S Allain
- Department of Internal Medicine and Clinical Immunology, Unité d'Investigation Clinique, Rennes University Hospital, Pontchaillou Hospital, 2, rue Henri-Le-Guilloux, 35 000 Rennes, France; Pole CVM, Paul Broussais General Hospital Center, Saint Malo, France; Clinical Investigation Center of Rennes, National Institute of Health and Scientific Research (CIC-INSERM 1414), Rennes, France.
| | - E Paven
- Department of Cardiology, Rennes University Hospital, Pontchaillou Hospital, Rennes, France
| | - B Henriot
- Pole CVM, Paul Broussais General Hospital Center, Saint Malo, France
| | - N Belhomme
- Department of Internal Medicine and Clinical Immunology, Unité d'Investigation Clinique, Rennes University Hospital, Pontchaillou Hospital, 2, rue Henri-Le-Guilloux, 35 000 Rennes, France
| | - A Le Bot
- Infectious Diseases and Intensive Care Unit, Rennes University Hospital, Pontchaillou Hospital, Rennes, France
| | - A Ballerie
- Department of Internal Medicine and Clinical Immunology, Unité d'Investigation Clinique, Rennes University Hospital, Pontchaillou Hospital, 2, rue Henri-Le-Guilloux, 35 000 Rennes, France; Inserm, EHESP, IRSET (institut de recherche en santé, Environnement et travail)-UMR_S 1085, Rennes 1 University, Rennes, France
| | - P Jego
- Department of Internal Medicine and Clinical Immunology, Unité d'Investigation Clinique, Rennes University Hospital, Pontchaillou Hospital, 2, rue Henri-Le-Guilloux, 35 000 Rennes, France; Inserm, EHESP, IRSET (institut de recherche en santé, Environnement et travail)-UMR_S 1085, Rennes 1 University, Rennes, France
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Slivka AP, Agriesti JE, Orsinelli DA. Natural history of nonbacterial thrombotic endocarditis treated with warfarin. Int J Stroke 2020; 16:519-525. [PMID: 33040698 DOI: 10.1177/1747493020961744] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We report on the natural history of a cohort of patients presenting with transient ischemic attack or stroke and nonbacterial thrombotic endocarditis treated with warfarin.Patients with valvular vegetations on echocardiography, stroke, or transient ischemic attack presenting to a single neurologist were included. All patients were treated with warfarin until the vegetation resolved or for two years, then were switched to aspirin and had at least one clinical and echocardiographic follow-up.Twenty-nine patients were included and followed for a median of 27 months. Average age was 42 years and 72% were female. Two patients had vegetations on two valves. Five patients (17%) had recurrent strokes, three had systemic lupus erythematosus and antiphospholipid antibodies, one had antiphospholipid antibodies alone and one had neither condition. Three of the five patients did not have resolution of the vegetation at the time of the event. The valvular vegetations resolved in 23 of the 31 affected valves (74%) after a median of 11 months (range 4.5-157.5). Eleven patients had at least one follow-up echocardiogram after resolution of the vegetation and none had recurrent vegetations after warfarin was stopped.This study should serve to provide general recommendations regarding treatment of patients with TIA/stroke with nonbacterial thrombotic endocarditis. Valvular vegetations resolve in most patients and the risk of recurrent stroke is low. Warfarin can safely be switched to aspirin in most patients when the vegetation resolves or after two years if it does not resolve. Prolonged warfarin may be warranted in patients with systemic lupus erythematosus, positive antiphospholipid antibodies, and a persistent vegetation.
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Affiliation(s)
- Andrew P Slivka
- Department of Neurology, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Julie E Agriesti
- Department of Neurology, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - David A Orsinelli
- Department of Internal Medicine, Division of Cardiovascular Medicine, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
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Yoo BW, Lee SW, Song JJ, Park YB, Jung SM. Clinical characteristics and long-term outcomes of Libman-Sacks endocarditis in patients with systemic lupus erythematosus. Lupus 2020; 29:1115-1120. [PMID: 32536317 DOI: 10.1177/0961203320930097] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Treatment of Libman-Sacks (LS) endocarditis in patients with systemic lupus erythematosus (SLE) is challenging due to the lack of data. This study aimed to identify the clinical characteristics of SLE patients and LS endocarditis, and to investigate the treatment and prognosis of LS endocarditis. METHODS Of all the patients with SLE who underwent echocardiography between 2010 and 2019, 11 and 29 patients with and without LS endocarditis, respectively, were included. We compared the inflammatory and thrombotic profiles between patients with and without LS endocarditis, and investigated the treatment and long-term outcome of LS endocarditis. RESULTS No significant differences were observed in disease activity, clinical characteristics and inflammatory marker levels between patients with and without LS endocarditis. Patients with LS endocarditis had a significantly higher prevalence of antiphospholipid antibody (aPL) but a lower prevalence of SLE-specific antibody. Triple positivity of aPL was found in 72.7% and 13.8% of patients with and without LS endocarditis, respectively. Of 11 patients with LS endocarditis, six patients received anticoagulation therapy, and five patients received augmented immunosuppressive therapies. One patient who did not receive anticoagulation therapy developed cerebral infarction. Nine (82%) patients with LS endocarditis were classified as having antiphospholipid syndrome (APS). Despite the residual vegetation and valve dysfunction, surgical intervention was not required during the follow-up period of 56.8 months. CONCLUSION A significant correlation was observed between APS and LS endocarditis. Anticoagulation therapy should be considered to prevent thromboembolic complications in SLE patients with LS endocarditis.
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Affiliation(s)
- Byung-Woo Yoo
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sang-Won Lee
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jason Jungsik Song
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yong-Beom Park
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seung Min Jung
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea.,Division of Rheumatology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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Jia E, Geng H, Liu Q, Xiao Y, Zhang Y, Xie J, Zhang L, Qiu X, Zhong L, Xiao M, Zhang J. Cardiac manifestations of Han Chinese patients with systemic lupus erythematosus: a retrospective study. Ir J Med Sci 2018; 188:801-806. [PMID: 30460452 DOI: 10.1007/s11845-018-1934-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 11/13/2018] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To investigate cardiac manifestations and the risk factors in Han Chinese patients with systemic lupus erythematosus (SLE). METHODS Seven hundred fifty SLE patients who were hospitalized at our department were recruited in the present study. The patients were divided into two groups-those with or without cardiac manifestations. Cardiac manifestations in those SLE patients, such as pericarditis, myocarditis, heart valve disease, arrhythmia, were analyzed. The risk and protective factors of cardiac diseases in patients with SLE, as well as the predictors of mortality, were assessed, respectively. RESULTS In all 750 SLE patients, there were 339 (45.20%) patients suffered from one or more cardiac manifestations, involving pericarditis in 9.5%, myocarditis in 5.7%, heart valve disease in 15.6%, arrhythmia in 16.67%, and cardiovascular diseases (CVD) in 14%. 15.7% of SLE patients were accompanied with pulmonary arterial hypertension (PAH), of which 13.7% were mild, 1.2% were moderate, and 0.8% were severe. No significant differences were found between the two groups in age, disease duration, gender, antibody, and Systemic Lupus Erythematosus Disease Activity Index (SLEDAI). The incidence of pericarditis, heart valve disease, arrhythmia, and PAH was positively correlated with age. The incidence of arrhythmia, CVD, and PAH was correlated with SLEDAI. PAH and myocarditis were the risk factors of mortality in SLE patients with disease duration ≤ 10 years (P = 0.034 and 0.001, respectively). CONCLUSION Cardiac involvement is common in Han Chinese SLE patients and associated with age and disease activity. PAH and myocarditis are the risk factors of mortality in SLE.
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Affiliation(s)
- Ertao Jia
- The Department of Rheumatology, Shenzhen Traditional Chinese Medicine Hospital, The Fourth Clinical Medical College of Guangzhou University of Chinese Medicine, No. 1, Fuhua Road, Futian District, Shenzhen, 518033, Guangdong, China.
| | - Hongling Geng
- The Department of Gynecology, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510120, Guangdong, China
| | - Qingping Liu
- The Department of Rheumatology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510405, Guangdong, China
| | - Yuya Xiao
- The Department of Rheumatology, Shenzhen Traditional Chinese Medicine Hospital, The Fourth Clinical Medical College of Guangzhou University of Chinese Medicine, No. 1, Fuhua Road, Futian District, Shenzhen, 518033, Guangdong, China
| | - Yanying Zhang
- The Department of Rheumatology, Shenzhen Traditional Chinese Medicine Hospital, The Fourth Clinical Medical College of Guangzhou University of Chinese Medicine, No. 1, Fuhua Road, Futian District, Shenzhen, 518033, Guangdong, China
| | - Jingjing Xie
- The Department of Rheumatology, Shenzhen Traditional Chinese Medicine Hospital, The Fourth Clinical Medical College of Guangzhou University of Chinese Medicine, No. 1, Fuhua Road, Futian District, Shenzhen, 518033, Guangdong, China
| | - Luhe Zhang
- The Department of Rheumatology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510405, Guangdong, China
| | - Xia Qiu
- The Department of Rheumatology, Shenzhen Traditional Chinese Medicine Hospital, The Fourth Clinical Medical College of Guangzhou University of Chinese Medicine, No. 1, Fuhua Road, Futian District, Shenzhen, 518033, Guangdong, China
| | - Li Zhong
- The Department of Rheumatology, Shenzhen Traditional Chinese Medicine Hospital, The Fourth Clinical Medical College of Guangzhou University of Chinese Medicine, No. 1, Fuhua Road, Futian District, Shenzhen, 518033, Guangdong, China
| | - Min Xiao
- The Department of Rheumatology, Shenzhen Traditional Chinese Medicine Hospital, The Fourth Clinical Medical College of Guangzhou University of Chinese Medicine, No. 1, Fuhua Road, Futian District, Shenzhen, 518033, Guangdong, China
| | - Jianyong Zhang
- The Department of Rheumatology, Shenzhen Traditional Chinese Medicine Hospital, The Fourth Clinical Medical College of Guangzhou University of Chinese Medicine, No. 1, Fuhua Road, Futian District, Shenzhen, 518033, Guangdong, China.
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Les endocardites non infectieuses. Rev Med Interne 2018; 39:782-791. [DOI: 10.1016/j.revmed.2018.03.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2017] [Revised: 02/05/2018] [Accepted: 03/03/2018] [Indexed: 12/18/2022]
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Vivero F, Gonzalez-Echavarri C, Ruiz-Estevez B, Maderuelo I, Ruiz-Irastorza G. Prevalence and predictors of valvular heart disease in patients with systemic lupus erythematosus. Autoimmun Rev 2016; 15:1134-1140. [PMID: 27639157 DOI: 10.1016/j.autrev.2016.09.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Accepted: 07/25/2016] [Indexed: 12/27/2022]
Abstract
OBJECTIVES We aimed to study the frequency, severity and predictors of valvular heart disease (VHD) in our lupus cohort. MATERIAL AND METHODS 211 patients were included. A transthoracic echocardiogram was used for this study. Significant valvular lesions were classified into two groups: valvular thickening and valvular dysfunction. Univariate logistic regression was performed in order to find associations with valvular thickening and dysfunction. Those variables with a p value ≤0.1 in the univariate analysis were subsequently included in multiple logistic regression models. RESULTS Significant valve lesions were found in 53 patients (25%). The independent predictors of valvular thickening were the age at the time of the echocardiogram (OR 1.05, 95% CI 1.02-1.7), lymphopenia (OR 3.6, 95%CI 1.4-9.5), thrombocytopenia (OR 2.65, 95%CI 1.24-5.72), and anti-Sm antibodies (OR 3.28, 95%CI 1.44-7.33). The independent predictors of valvular dysfunction were age at the time of the echocardiogram (OR 1.045, 95%CI 1.009-1.083), thrombocytopenia (OR 5, 95%CI 1.66-14.86), hypertension (OR 6.2, 95%CI 2.1-18.4) and aPL (OR 6.2, 95%CI 2.1-18.4). Regarding the latter, the independent relation with valvular dysfunction was only seen for the double positivity aCL/LA, (OR 13.2, 95%CI 3.8-45.2, p<0.0001). CONCLUSIONS Our study confirms the high prevalence of significant VHD in SLE patients. Clinical variables related with persistent inflammatory activity were associated with VHD. The association between VHD and aPL positivity was confirmed. Double-positive aCL/LA patients were most likely to suffer from valvular dysfunction.
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Affiliation(s)
- Florencia Vivero
- Autoimmune Diseases Research Unit, Department of Internal Medicine, BioCruces Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, Bizkaia, The Basque Country, Spain; Autoimmune Diseases Unit, Hospital Privado de Comunidad, Mar del Plata, Argentina
| | - Cristina Gonzalez-Echavarri
- Autoimmune Diseases Research Unit, Department of Internal Medicine, BioCruces Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, Bizkaia, The Basque Country, Spain
| | - Beatriz Ruiz-Estevez
- Autoimmune Diseases Research Unit, Department of Internal Medicine, BioCruces Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, Bizkaia, The Basque Country, Spain; Department of Internal Medicine, Hospital Puerta del Mar, Cadiz, Andalucia, Spain
| | - Irene Maderuelo
- Autoimmune Diseases Research Unit, Department of Internal Medicine, BioCruces Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, Bizkaia, The Basque Country, Spain; Department of Internal Medicine, Hospital San Agustin, Aviles, Asturias, Spain
| | - Guillermo Ruiz-Irastorza
- Autoimmune Diseases Research Unit, Department of Internal Medicine, BioCruces Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, Bizkaia, The Basque Country, Spain.
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Roldan CA, Tolstrup K, Macias L, Qualls CR, Maynard D, Charlton G, Sibbitt WL. Libman-Sacks Endocarditis: Detection, Characterization, and Clinical Correlates by Three-Dimensional Transesophageal Echocardiography. J Am Soc Echocardiogr 2015; 28:770-9. [PMID: 25807885 DOI: 10.1016/j.echo.2015.02.011] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2014] [Indexed: 10/23/2022]
Abstract
BACKGROUND Libman-Sacks endocarditis, characterized by Libman-Sacks vegetations, is common in patients with systemic lupus erythematosus and is commonly complicated with embolic cerebrovascular disease. Thus, accurate detection of Libman-Sacks vegetations may lead to early therapy and prevention of their associated complications. Although two-dimensional (2D) transesophageal echocardiography (TEE) has high diagnostic value for detection of Libman-Sacks vegetations, three-dimensional (3D) TEE may allow improved detection, characterization, and clinical correlations of Libman-Sacks vegetations. METHODS Twenty-nine patients with systemic lupus erythematosus (27 women; mean age, 34 ± 12 years) prospectively underwent 40 paired 3D and 2D transesophageal echocardiographic studies and assessment of cerebrovascular disease manifested as acute clinical neurologic syndromes, neurocognitive dysfunction, or focal brain injury on magnetic resonance imaging. Initial and repeat studies in patients were intermixed in a blinded manner with paired studies from healthy controls, deidentified, coded, and independently interpreted by experienced observers unaware of patients' clinical and imaging data. RESULTS The results of 3D TEE compared with 2D TEE were more often positive for mitral or aortic valve vegetations, and 3D TEE detected more vegetations per study and determined larger sizes of vegetations (P ≤ .03 for all). Also, 3D TEE detected more vegetations on the anterior mitral leaflet, anterolateral and posteromedial scallops, and ventricular side or both atrial and ventricular sides of the leaflets (P < .05 for all). In addition, 3D TEE detected more vegetations on the aortic valve left and noncoronary cusps, coronary cusps' tips and margins, and aortic side or both aortic and ventricular sides of the cusps (P ≤ .01 for all). Furthermore, 3D TEE more often detected associated mitral or aortic valve commissural fusion (P = .002). Finally, 3D TEE detected more vegetations in patients with cerebrovascular disease (P = .01). CONCLUSIONS Three-dimensional TEE provides clinically relevant additive information that complements 2D TEE for the detection, characterization, and association with cerebrovascular disease of Libman-Sacks endocarditis.
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Affiliation(s)
- Carlos A Roldan
- Department of Medicine and Divisions of Cardiology and Rheumatology, University of New Mexico School of Medicine and New Mexico VA Health Care Center, Albuquerque, New Mexico.
| | - Kirsten Tolstrup
- Department of Medicine and Divisions of Cardiology and Rheumatology, University of New Mexico School of Medicine and New Mexico VA Health Care Center, Albuquerque, New Mexico
| | - Leonardo Macias
- Department of Medicine and Divisions of Cardiology and Rheumatology, University of New Mexico School of Medicine and New Mexico VA Health Care Center, Albuquerque, New Mexico
| | - Clifford R Qualls
- Department of Medicine and Divisions of Cardiology and Rheumatology, University of New Mexico School of Medicine and New Mexico VA Health Care Center, Albuquerque, New Mexico
| | - Diana Maynard
- Department of Medicine and Divisions of Cardiology and Rheumatology, University of New Mexico School of Medicine and New Mexico VA Health Care Center, Albuquerque, New Mexico
| | - Gerald Charlton
- Department of Medicine and Divisions of Cardiology and Rheumatology, University of New Mexico School of Medicine and New Mexico VA Health Care Center, Albuquerque, New Mexico
| | - Wilmer L Sibbitt
- Department of Medicine and Divisions of Cardiology and Rheumatology, University of New Mexico School of Medicine and New Mexico VA Health Care Center, Albuquerque, New Mexico
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Libman-Sacks endocarditis and embolic cerebrovascular disease. JACC Cardiovasc Imaging 2014; 6:973-83. [PMID: 24029368 DOI: 10.1016/j.jcmg.2013.04.012] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Revised: 04/18/2013] [Accepted: 04/23/2013] [Indexed: 11/23/2022]
Abstract
OBJECTIVES The aim of this study was to determine whether Libman-Sacks endocarditis is a pathogenic factor for cerebrovascular disease (CVD) in systemic lupus erythematosus (SLE). BACKGROUND A cardioembolic pathogenesis of SLE CVD manifested as: 1) neuropsychiatric systemic lupus erythematosus (NPSLE), including stroke and transient ischemic attacks (TIA); 2) neurocognitive dysfunction; and 3) magnetic resonance imaging of focal brain lesions has not been established. METHODS A 6-year study of 30 patients with acute NPSLE (27 women, 38 ± 12 years of age), 46 age- and sex-matched SLE controls without NPSLE (42 women, 36 ± 12 years of age), and 26 age- and sex-matched healthy controls (22 women, 34 ± 11 years of age) who underwent clinical and laboratory evaluations, transesophageal echocardiography, carotid duplex ultrasound, transcranial Doppler ultrasound, neurocognitive testing, and brain magnetic resonance imaging/magnetic resonance angiography. Patients with NPSLE were re-evaluated after 4.5 months of therapy. All patients were followed clinically for a median of 52 months. RESULTS Libman-Sacks vegetations (87%), cerebromicroembolism (27% with 2.5 times more events per hour), neurocognitive dysfunction (60%), and cerebral infarcts (47%) were more common in NPSLE than in SLE (28%, 20%, 33%, and 0%) and healthy controls (8%, 0%, 4%, and 0%, respectively) (all p ≤ 0.009). Patients with vegetations had 3 times more cerebromicroemboli per hour, lower cerebral blood flow, more strokes/TIA and overall NPSLE events, neurocognitive dysfunction, cerebral infarcts, and brain lesion load than those without (all p ≤ 0.01). Libman-Sacks vegetations were independent risk factors of NPSLE (odds ratio [OR]: 13.4; p < 0.001), neurocognitive dysfunction (OR: 8.0; p = 0.01), brain lesions (OR: 5.6; p = 0.004), and all 3 outcomes combined (OR: 7.5; p < 0.001). Follow-up re-evaluations in 18 of 23 (78%) surviving patients with NPSLE demonstrated improvement of vegetations, microembolism, brain perfusion, neurocognitive dysfunction, and lesion load (all p ≤ 0.04). Finally, patients with vegetations had reduced event-free survival time to stroke/TIA, cognitive disability, or death (p = 0.007). CONCLUSIONS The presence of Libman-Sacks endocarditis in patients with SLE was associated with a higher risk for embolic CVD. This suggests that Libman-Sacks endocarditis may be a source of cerebral emboli.
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Koarada S, Tsuneyoshi N, Haruta Y, Tada Y, Mitamura M, Inoue H, Ohta A, Fukudome K, Nagasawa K. Effect of disease activity and corticosteroids on serum levels of soluble endothelial cell protein C receptor in patients with systemic lupus erythematosus. Mod Rheumatol 2014. [DOI: 10.3109/s10165-008-0143-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Syuichi Koarada
- Division of Rheumatology, Department of Internal Medicine, Saga University,
5-1-1 Nabeshima, Saga 849-8501, Japan
| | - Naoko Tsuneyoshi
- Department of Immunology, Faculty of Medicine, Saga University,
5-1-1 Nabeshima, Saga 849-8501, Japan
| | - Yoshio Haruta
- Division of Rheumatology, Department of Internal Medicine, Saga University,
5-1-1 Nabeshima, Saga 849-8501, Japan
| | - Yoshifumi Tada
- Division of Rheumatology, Department of Internal Medicine, Saga University,
5-1-1 Nabeshima, Saga 849-8501, Japan
| | - Mio Mitamura
- Division of Rheumatology, Department of Internal Medicine, Saga University,
5-1-1 Nabeshima, Saga 849-8501, Japan
| | - Hisako Inoue
- Division of Rheumatology, Department of Internal Medicine, Saga University,
5-1-1 Nabeshima, Saga 849-8501, Japan
| | - Akihide Ohta
- Division of Rheumatology, Department of Internal Medicine, Saga University,
5-1-1 Nabeshima, Saga 849-8501, Japan
| | - Kenji Fukudome
- Department of Immunology, Faculty of Medicine, Saga University,
5-1-1 Nabeshima, Saga 849-8501, Japan
| | - Kohei Nagasawa
- Division of Rheumatology, Department of Internal Medicine, Saga University,
5-1-1 Nabeshima, Saga 849-8501, Japan
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Abstract
Ischemic stroke is increased in systemic lupus erythematosus (SLE) patients. The differential diagnosis of stroke in SLE is complex. Transient ischemic attack and ischemic stroke share pathophysiologic mechanisms, but prognosis may vary depending on severity and cause, and definitions are dependent on the timing and extent of the diagnostic evaluation. In SLE patients with a history of transient ischemic attacks, stroke occurred in 57%. Cerebrovascular events account for 20% to 30% of deaths in patients with SLE. In SLE, both disease-specific and traditional stroke risk factors are important.
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Affiliation(s)
- H Timlin
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - M Petri
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
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14
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Multimodality Imaging, The Wave of the Future. JACC Cardiovasc Imaging 2013; 6:984-6. [DOI: 10.1016/j.jcmg.2013.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Accepted: 06/13/2013] [Indexed: 11/20/2022]
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Berlacher MD, Vieth JA, Heflin BC, Gay SR, Antczak AJ, Tasma BE, Boardman HJ, Singh N, Montel AH, Kahaleh MB, Worth RG. FcγRIIa Ligation Induces Platelet Hypersensitivity to Thrombotic Stimuli. THE AMERICAN JOURNAL OF PATHOLOGY 2013; 182:244-54. [DOI: 10.1016/j.ajpath.2012.09.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2012] [Revised: 09/07/2012] [Accepted: 09/13/2012] [Indexed: 01/18/2023]
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Rodriguez CJ, Bartz TM, Longstreth WT, Kizer JR, Barasch E, Lloyd-Jones DM, Gottdiener JS. Association of annular calcification and aortic valve sclerosis with brain findings on magnetic resonance imaging in community dwelling older adults: the cardiovascular health study. J Am Coll Cardiol 2011; 57:2172-80. [PMID: 21596233 DOI: 10.1016/j.jacc.2011.01.034] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2010] [Revised: 12/10/2010] [Accepted: 01/02/2011] [Indexed: 10/18/2022]
Abstract
OBJECTIVES The objective of this study was to investigate the associations of mitral annular calcification, aortic annular calcification, and aortic valve sclerosis with covert magnetic resonance imaging (MRI)-defined brain infarcts. BACKGROUND Clinically silent brain infarcts defined by MRI are associated with increased risk for cognitive decline, dementia, and future overt stroke. Left-sided cardiac valvular and annular calcifications are suspected as risk factors for clinical ischemic stroke. METHODS A total of 2,680 CHS (Cardiovascular Health Study) participants without clinical histories of stroke or transient ischemic attack underwent brain MRI in 1992 and 1993, 1 to 2 years before echocardiographic exams (1994 to 1995). RESULTS The mean age of the participants was 74.5 ± 4.8 years, and 39.3% were men. The presence of any annular or valvular calcification (mitral annular calcification, aortic annular calcification, or aortic valve sclerosis), mitral annular calcification alone, or aortic annular calcification alone was significantly associated with a higher prevalence of covert brain infarcts in unadjusted analyses (p < 0.01 for all). In models adjusted for age, sex, race, body mass index, physical activity, creatinine, systolic blood pressure, total cholesterol, high-density lipoprotein cholesterol, smoking, diabetes, coronary heart disease, and congestive heart failure, the presence of any annular or valve calcification remained associated with covert brain infarcts (risk ratio: 1.24; 95% confidence interval: 1.05 to 1.47). The degree of annular or valvular calcification severity showed a direct relation with the presence of covert MRI findings. CONCLUSIONS Left-sided cardiac annular and valvular calcifications are associated with covert MRI-defined brain infarcts. Further study is warranted to identify mechanisms and determine whether intervening in the progression of annular and valvular calcification could reduce the incidence of covert brain infarcts as well as the associated risk for cognitive impairment and future stroke.
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Affiliation(s)
- Carlos J Rodriguez
- Department of Epidemiology and Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina 27157, USA.
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18
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Increased Risk for Heart Valve Disease Associated With Antiphospholipid Antibodies in Patients With Systemic Lupus Erythematosus. Circulation 2011; 124:215-24. [DOI: 10.1161/circulationaha.111.028522] [Citation(s) in RCA: 121] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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19
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Rajamani K, Chaturvedi S, Jin Z, Homma S, Brey RL, Tilley BC, Sacco RL, Thompson JLP, Mohr JP, Levine SR. Patent foramen ovale, cardiac valve thickening, and antiphospholipid antibodies as risk factors for subsequent vascular events: the PICSS-APASS study. Stroke 2009; 40:2337-42. [PMID: 19498198 DOI: 10.1161/strokeaha.108.539171] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND AND PURPOSE We sought to estimate risk of recurrent stroke/TIA/death in the subgroup of the Patent Foramen Ovale in the Cryptogenic Stroke Study (PICSS) cohort with patent foramen ovale (PFO) and antiphospholipid antibodies (aPL) and to estimate risk of recurrent stroke/TIA/death in aPL-positive patients who have thickened left-side heart valves (VaT). PFO is associated with cryptogenic ischemic stroke. Also, the presence of aPL is associated with ischemic cerebrovascular disease. METHODS Combined data from 2 major substudies of the Warfarin Aspirin Recurrent Stroke Trial (WARSS) were evaluated. PICSS subjects were included if they were enrolled in the Antiphospholipid Antibodies and Stroke Study (APASS) and underwent a baseline aPL test (lupus anticoagulant, anticardiolipin antibodies, or both) within 1 month of the stroke. All patients in PICSS underwent transesophageal echocardiography for PFO as well as VaT, which was performed blinded to aPL status and treatment arm (325 mg/day aspirin or adjusted dose warfarin; target international normalized ratio, 1.4-2.8). The primary outcome event was the 2-year risk of recurrent stroke/TIA/death and was evaluated using Cox proportional hazards model. Because there was no treatment effect, warfarin and aspirin groups were combined to increase power. For the combined end point, power to detect HR of 2 was 47.8% for the PFO and aPL-positive group, and 75.3% for the valve thickening and aPL-positive group, assuming 2-sided type I error of 0.05. RESULTS Five hundred twenty-five subjects were tested for the combined presence of PFO and aPL and were available for evaluation. The primary outcome event rate was 23.9% (HR, 1.39; 95% CI, 0.75-2.59) in the PFO-positive/aPL-positive group, compared to 13.9% (HR, 0.83; 95% CI, 0.44-1.56) in the PFO-positive/aPL-negative group, and 19.9% (HR, 1.16; 95% CI, 0.68-1.90) in the PFO-negative/aPL-positive group. Five hundred forty-five subjects tested for combined presence of aPL and left-side cardiac VaT were available for evaluation. The primary event rate was 22.6% (HR, 1.65; 95% CI, 0.88-3.09) in the VaT-positive/aPL-positive group, compared to 19.4% (HR, 1.50; 95% CI, 0.82-2.75) in the VaT-positive/aPL-negative group, and 20.2% (HR, 1.63; 95% CI, 0.81-3.25) in the VaT-negative/aPL-positive group. CONCLUSIONS The combined presence of aPL either with a PFO or with left-side cardiac VaT did not significantly increase risk of subsequent cerebrovascular events in this PICCS/APASS cohort of patients.
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Affiliation(s)
- Kumar Rajamani
- Department of Neurology, Wayne State University, Detroit, MI 48201, USA.
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Koarada S, Tsuneyoshi N, Haruta Y, Tada Y, Mitamura M, Inoue H, Ohta A, Fukudome K, Nagasawa K. Effect of disease activity and corticosteroids on serum levels of soluble endothelial cell protein C receptor in patients with systemic lupus erythematosus. Mod Rheumatol 2008; 19:173-9. [PMID: 19067109 DOI: 10.1007/s10165-008-0143-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2008] [Accepted: 11/04/2008] [Indexed: 12/01/2022]
Abstract
To assess the effects of disease activity of systemic lupus erythematosus (SLE) and high-dose corticosteroids on endothelial injuries, the significance of soluble endothelial cell protein C receptor (sEPCR) and soluble thrombomodulin (sTM) was analyzed. Serum levels of sEPCR and sTM were measured by enzyme-linked immunosorbent assay (ELISA) cross-sectionally in 97 SLE patients, 49 patients with other rheumatic diseases and 22 normal subjects. The changes in these levels upon corticosteroid treatment were also analyzed in 41 patients. The levels of sEPCR and sTM were both higher in SLE and other rheumatic disease patients than in normal subjects. When low-dose corticosteroids were used, both the level of sEPCR and the ratio of positive tests for sEPCR were significantly higher in active SLE patients than in inactive patients [median 2.30 ng/ml (range 0.00-147.10 ng/ml) vs 0.00 ng/ml (0.00-58.90 ng/ml) and 53.5 vs 13.0%, respectively] (P < 0.005). Moreover, the ratio of positive tests for sEPCR was higher after corticosteroid treatment in 9 of 19 (47.3%) SLE patients compared to other rheumatic diseases (3/22; 13.6%). Although the mean level of sTM was significantly higher in active SLE patients than in inactive patients, the ratio of positive tests for sTM was not affected by disease activity or corticosteroids. In conclusion, the positive test for sEPCR is a more sensitive biomarker than that for sTM in reflecting endothelial injuries caused by active disease and often by corticosteroids in SLE.
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Affiliation(s)
- Syuichi Koarada
- Division of Rheumatology, Department of Internal Medicine, Saga University, 5-1-1 Nabeshima, Saga 849-8501, Japan.
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Okajima K, Abe Y, Suzuki K, Salameh MJ, Di Tullio MR, Jin Z, Sacco RL, Mohr JP, Homma S. Impact of Valvular Thickness on Stroke Recurrence in Medically Treated Patients with Stroke. Cerebrovasc Dis 2007; 24:375-80. [PMID: 17804905 DOI: 10.1159/000107918] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2007] [Accepted: 03/07/2007] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND It remains controversial whether left-sided valvular thickening (VaT) is a risk factor for ischemic stroke. Little is known about the relationship between VaT and the recurrent adverse event rate in medically treated patients with stroke. METHODS We examined the outcomes of 627 noncardioembolic stroke patients who were double-blindly assigned to either warfarin or aspirin therapy and assessed VaT using transesophageal echocardiography. Endpoints were recurrent ischemic stroke or death from any cause. The Cox proportional hazards model was used to adjust for covariates. RESULTS VaT was present in 57.3% of the patients (359/627), 34.6% (271/627) involving the aortic valve and 46.4% (291/627) involving the mitral valve. There was no difference in the time to primary endpoints between those with and without VaT of the aortic valve (p = 0.49; hazard ratio, HR: 1.17; 95% CI: 0.74-1.85; 2-year event rates: 18.9 vs. 13.2%) or mitral valve (p = 0.66; HR: 0.91; 95% CI: 0.60-1.38; 2-year event rates: 16.9 vs. 14.7%). Among the patients with VaT, there was no significant difference in the time to primary endpoints between those treated with warfarin and those with aspirin (p = 0.13, HR: 0.65, 95% CI: 0.37-1.14, 2-year event rates: 15.2 vs. 22.7% for the aortic valve; p = 0.22, HR: 0.70, 95% CI: 0.40-1.23, 2-year event rates: 14.2 vs. 19.6% for the mitral valve). CONCLUSIONS VaT does not appear to increase recurrent adverse event rates in medically treated patients with ischemic stroke, regardless of warfarin or aspirin therapy.
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Affiliation(s)
- K Okajima
- Department of Medicine, Columbia University, New York, NY 10032, USA.
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Abstract
Systemic lupus erythematosus is an autoimmune connective-tissue disorder with a wide range of clinical features, which predominantly affects women, especially from certain ethnic groups. Diagnosis is based on clinical assessment supported by investigations, including the finding of autoantibodies. Treatments range from antimalarial agents to corticosteroids and immunosuppressive agents. This Seminar draws attention to advances in the epidemiology, genetics, cardiovascular risks, lupus nephritis, CNS disease, the antiphospholipid syndrome, assessment of disease activity and damage, and pregnancy related and quality of life issues. New therapeutic approaches, such as biological agents and mycophenolate mofetil, will also be discussed.
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Affiliation(s)
- David P D'Cruz
- Lupus Research Unit, Rayne Institute, St Thomas' Hospital, London SE1 7EH, UK. david.d'
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Roldan CA, Gelgand EA, Qualls CR, Sibbitt WL. Valvular heart disease by transthoracic echocardiography is associated with focal brain injury and central neuropsychiatric systemic lupus erythematosus. Cardiology 2007; 108:331-7. [PMID: 17299260 DOI: 10.1159/000099104] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2006] [Accepted: 10/07/2006] [Indexed: 11/19/2022]
Abstract
BACKGROUND Previous studies using transesophageal echocardiography (TEE) report an association of valvular heart disease (VHD) with cerebral infarcts and central neuropsychiatric systemic lupus erythematosus (NPSLE). However, TEE cannot be routinely used. AIM To determine if VHD detected by transthoracic echocardiography (TTE) is associated with focal brain injury on magnetic resonance imaging (MRI) and secondarily with central NPSLE. METHODS Sixty-nine patients with systemic lupus erythematosus underwent general clinical, neuropsychiatric and laboratory evaluations followed by MRI of the brain and TTE. RESULTS Forty-one patients (59%) had NPSLE (stroke, transient ischemic attack, cognitive dysfunction, acute confusional state, seizures or psychosis); 46 (67%) had focal brain injury on MRI (cerebral infarcts, white matter lesions or small punctate lesions); 38 (55%) had VHD (vegetations, thickening or regurgitation). VHD was more common in patients with than in those without focal brain injury and NPSLE (all p < 0.05); focal brain lesions were more common in patients with than in those without NPSLE (all p < 0.04); and VHD was an independent predictor of focal brain lesions and NPSLE (both p < 0.04). CONCLUSION In patients with systemic lupus erythematosus, VHD detected by TTE is associated with focal brain injury and NPSLE.
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Affiliation(s)
- Carlos A Roldan
- Veterans Affairs Medical Center and University of New Mexico Health Sciences Center, Albuquerque, NM 87108, USA.
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Roldan CA, Gelgand EA, Qualls CR, Sibbitt WL. Valvular heart disease is associated with nonfocal neuropsychiatric systemic lupus erythematosus. J Clin Rheumatol 2006; 12:3-10. [PMID: 16484873 DOI: 10.1097/01.rhu.0000200378.42836.7f] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Central nonfocal neuropsychiatric systemic lupus erythematosus (NPSLE) manifests as cognitive dysfunction, acute confusional state, seizures, and psychosis. Valvular heart disease (VHD) is currently not a causal consideration of nonfocal NPSLE. OBJECTIVE The objective of this study was to determine whether VHD is associated with nonfocal NPSLE. METHODS Twenty-eight patients with SLE underwent: 1) clinical and laboratory evaluations; 2) neuropsychiatric evaluation; 3) brain magnetic resonance imaging (MRI); and 4) transesophageal echocardiography (TEE). Their findings were compared with those of 28 age- and-sex matched healthy volunteers. RESULTS Eighteen patients (64%) had nonfocal NPSLE. Cerebral infarcts on MRI were more common in patients with than without NPSLE (50% vs 10%, P=0.048) and antiphospholipid antibodies (aPL) were associated with old cerebral infarcts (P=0.03). Valvular heart disease was detected in 20 patients (71%) of whom 20 (71%) had valve thickening, 17 (61%) had valve regurgitation, and 15 (53%) had valve vegetations (12 on the mitral valve). Mitral valve vegetations were more common in patients with than without nonfocal NPSLE and in those with old cerebral infarcts (61% vs 10% and 75% vs 30%, respectively, P<or=0.02 for both). The nonneurologic activity of SLE and mitral valve vegetations were the only independent predictors of NPSLE (odds ratio [OR], 1.27 per unit value; confidence interval [CI], 1.1-1.6; P=0.03; and OR, 16.5; CI, 1.26-217; P=0.03, respectively). Among controls, none had neuropsychiatric syndromes, 4 (15%) had MRI abnormalities, and 3 (11%) had VHD (all P<or=0.001 vs patients). CONCLUSIONS Nonfocal NPSLE, cerebral infarcts, and VHD were highly associated and mitral valve vegetations were independent predictors of NPSLE. Thus, VHD exacerbated by hypercoagulability may cause thromboembolic ischemic brain injury and nonfocal NPSLE.
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Affiliation(s)
- Carlos A Roldan
- Veterans Affairs Medical Center and University of New Mexico Health Sciences Center, Albuquerque, New Mexico 87108, USA.
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Laskin CA, Clark CA, Spitzer KA. Antiphospholipid syndrome in systemic lupus erythematosus: is the whole greater than the sum of its parts? Rheum Dis Clin North Am 2005; 31:255-72, vi. [PMID: 15922145 DOI: 10.1016/j.rdc.2005.01.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
This article compares the manifestations of systemic lupus erythematosus (SLE) in the presence and absence of antiphospholipid antibodies (aPLs), the hallmark autoantibodies of antiphospholipid syndrome (APS). The combination of SLE and APS appears to be of greater concern than either entity alone. APS complicates SLE by adding a vaso-occlusive factor to the inflammatory component that adversely affects the prognosis of those who have lupus and aPLs. The increase in both morbidity and mortality when both are present has significant therapeutic implications. Anticoagulation may be a safer and more appropriate therapeutic option than instituting a regimen of corticosteroids and immunosuppressive agents with all their attendant adverse effects. It falls upon the physician to clearly define the disease entity and fully evaluate the disease process.
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Affiliation(s)
- Carl A Laskin
- Division of Rheumatology, Department of Medicine, University of Toronto Faculty of Medicine, Toronto, ON M5G 2K4, Canada.
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Roldan CA, Gelgand EA, Qualls CR, Sibbitt WL. Valvular heart disease as a cause of cerebrovascular disease in patients with systemic lupus erythematosus. Am J Cardiol 2005; 95:1441-7. [PMID: 15950567 DOI: 10.1016/j.amjcard.2005.02.010] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2004] [Revised: 02/10/2005] [Accepted: 02/08/2005] [Indexed: 11/18/2022]
Abstract
Thirty-seven patients with systemic lupus erythematosus underwent complete clinical and laboratory evaluations, including antiphospholipid antibodies and lupus anticoagulant, magnetic resonance imaging of the brain, and transesophageal echocardiography. Cerebrovascular disease manifested as stroke, transient ischemic attack, or cerebral infarcts in patients with nonfocal neurologic deficits was detected in 19 patients (51%), and significant left-sided valvular heart disease in 25 (68%). Valve vegetations, valve thickening, valve regurgitation, and lupus anticoagulant antibody occurred 2 to 3 times more often in patients with than without cerebrovascular disease (all p < or =0.04) and were the only independent predictors of cerebrovascular disease (odd ratios 5.3 to 10.6, all p < or =0.03). Thus, valvular heart disease probably exacerbated by hypercoagulability appears to be a source of embolic ischemic brain injury and cerebrovascular disease.
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Affiliation(s)
- Carlos A Roldan
- Veterans Affairs Medical Center and University of New Mexico Health Sciences Center, Albuquerque, New Mexico 87108, USA.
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