NEW YORK — Young women bear the greatest relative risk of atherosclerotic disease in lupus. However, advice on managing cardiovascular disease is not evidence based. Rather, rheumatologists must rely largely on data from studies of heart disease in other high-risk groups and on the collective wisdom of rheumatologists who are experienced in managing cardiovascular disease in patients with lupus.
Consider giving lupus patients a baby aspirin a day, as she does, Dr. Susan Manzi suggested at a rheumatology seminar sponsored by New York University Hospital for Joint Diseases. Although the data have not shown it to lessen the MI risk in women as it does in men, it does protect them somewhat against stroke.
Despite the scant data on effective management of cardiovascular disease (CVD) in lupus, there are ample data on CVD prevalence among women in general and those with lupus in particular. About one-third of deaths in lupus occur in patients who are younger than 45 years of age. And one-third of those deaths are due to atherosclerosis. In some of her earlier epidemiologic research, Dr. Manzi, director of the Lupus Center of Excellence at the University of Pittsburgh, compared the rate of MI in a cohort of 498 women with lupus to that reported among 2,208 women in the Framingham heart study who did not have lupus. (Am. J. Epidemiol. 1997;145:408-15). In 35- to 44-year-olds, lupus women had a 50-fold increased risk of MI. After age 44, as women entered menopause, those with lupus were still two to four times more likely to have an MI as were those without lupus, she said.
Subclinical atherosclerotic disease is likewise more prevalent in patients with lupus. In one study of 197 lupus patients and a equal number of controls, findings from carotid ultrasonography showed that 37% of lupus patients vs. 15% of controls had asymptomatic carotid plaque (N. Engl. J. Med. 2003;349:2399-406).
Other data show that women with lupus are more likely than their lupus-free peers to have progressive atherosclerosis. Serial carotid artery ultrasound exams of 217 patients with lupus (mean age at baseline, 45 years) and 104 age- and sex-matched controls showed that plaque was present at baseline in 31% of the lupus patients and 17% of controls. At follow-up, 40% of lupus patients had plaque, compared with 20% of controls; interval between scans was 4 years for patients and 5 years for controls. Plaque had progressed in 27% of the lupus patients and only 10% of controls (Arthritis Rheum. 2008;58:835-42).
The ultimate question has been whether atherosclerotic disease detected on imaging predicts future events in patients with lupus. In a study recently presented at the ACR meeting in 2008, the presence of carotid plaque and greater intima-media thickness predicted the time to incident stroke, MI, cardiovascular accident, or coronary artery bypass graft over a 10-year period in 289 patients with lupus. This suggests that these measures may be used as surrogate end points in future clinical trials.