1. SLE and Cardiovascular Disease Mario J. Garcia, MD, FACC, FACP Chief, Division of Cardiology Professor of Medicine and Radiology

2. Lupus and the Heart SLE is a chronic, inflammatory disease with circulating Autoantibodies (“anti-self”); activated T cells (tissue autoimmunity); immune complexes (Antigen- Antibody) and inflammatory Cytokines (cell messenger proteins)‏ Lupus Therapy over the last 4 decades has converted a rapidly fatal disease into a chronic condition

3. Cardiac Involvement in Lupus All “layers” of the heart can be involved: 1)Pericardium 2)Myocardium 3)Valves 4)Electrical System 5)Coronary Vessels

4. Pericarditis Inflammation of the Pericardium occurs in 11-54% of Lupus patients Often occurs at Onset or with Relapses Pericarditis is the most characteristic feature and is one of the ACR/ARA Classification Criteria for Lupus “Sharp” chest pain, fever Treated with NSAIDs or Steroids

5. Myocarditis Inflammation (“Myocarditis”) occurs in 7-10% of cases (and is treated with Steroids)‏ Can lead to Heart Failure

6. Valvular Disease Inflammatory lesions usually on Mitral or Aortic Valves (both active and healed)‏ “Verrucous” or Libman-Sacks lesions characteristic but not usual Valve Leaking or Stroke

7. Heart Block Conduction “Block” rare in adults Seen in 2% of children born to mothers with Anti-Ro/SSA positive Lupus

8. Coronary Disease Coronary Arteries carry blood supply the working muscle of the heart Coronary Artery Disease in 6-10%; Lupus patients have a 4-8 fold increased risk Smaller vessel inflammation (vasculitis)-usually in younger patients with active SLE Larger vessel inflammation (atherosclerosis)-usually in older patients with long-standing SLE

10. Calcification Lipid Cor Inflammation Thrombus

11. Coronary Calcium Score Moderate Calcification NormalSevere Calcification

12. Roman; NEJM; 2003

13. Coronary CTA

14. Stress Testing

15. Catheterization

16. Coronary Bypass and Stents

17. Carotid Ultrasound

18. Lumen IMT LumenStenosis

19. Asanuma; NEJM; Dec 18, 2003

21. An Ounce of Prevention…

22. Diet Modification: Healthy Choices Fruits and Vegetables Whole Grain and High Fiber Oily (cold water) fish 2 x / week Alcoholic drink not > 1/day Sodium (Na+) < 2.3 gram/day Saturated Fat < 10% of total calories Limit Trans-Fat: Baked Goods and Fried Foods

23. Cardiac (Exercise) Rehab Prevents 23 deaths per 1000 patients Safety: Mortality 1 / 784,000 pt-hours Cost: $1200 / QOL-year (comparable to Left main surgery!) By comparison, Dialysis costs $40,000 / QOL-yr Usually 3 x /week for 12-16 weeks

24. Smoking Cessation Smokers have 3 x the risk of MI of non-smokers Cessation prevents 70 deaths per 1000 patients x 1 year

25. Medical Treatment A—Aspirin and ACE Inhibitors B—Beta Blockers and Blood Pressure C—Cholesterol / Cigarettes / Clopidogrel D—Diet (for Weight and Diabetes)‏ E—Exercise and Education Conti, CR Clin. Cardiology 2007

26. LDL Cholesterol Goals < 10%<160 mg/dl0-1 Risk Factors 10-20%< 130 mg/dl2 or more Risk Factors > 20%< 100 mg/dlCHD or Equivalent 10 year event rateLDL GoalRisk Factor

27. Other Cholesterol Goals “Lupus” Lipid profile often has low HDL (“good” cholesterol), high Triglycerides and high Lp(a) (a lipoprotein that ties into the clotting cascade)‏ Lp(a) may be modifiable with exercise and Niacin

28. Treating Cholesterol High Total and LDL Cholest  Statins (zocor, lipitor, crestor)‏ High Trig and Low HDL Cholest  Fibrates (lopid, tricor)‏ High LDL and Trig and low HDL Cholest  Niacin (niaspan)‏ High Triglycerides  prescript. Fish oil (Omega 3 FAs) (lovaza)‏