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Title: Early and Frequent Development of Atherosclerosis in Patients with Systemic Lupus Erythematosus Appears Disease Related

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N Engl J Med 2003;349:2407-15.
12/19/2003 09:49:00 AM
By Joene Hendry

Patients with systemic lupus erythematosus develop atherosclerosis at a younger age and more frequently than do individuals in the general population, in a manner that appears to be disease related, according to the findings of 2 studies. Between January 2000 and October 2002, Yu Asanuma, MD, PhD, of Vanderbilt University School of Medicine, Nashville, Tennessee, United States, and colleagues used electron-bean computed tomography (CT) to screen for coronary artery calcification in 65 patients who had lupus for a mean duration of 9.9 years, and 69 age, race, and sex matched controls. The mostly female study population had no history of cardiovascular disease and was an average age of 40 years. The lupus patients were more likely to smoke and have hypertension, and had significantly higher levels of triglycerides and homocysteine than did controls. However, the groups had similar levels of total, high-density lipoprotein, and low-density lipoprotein cholesterol and of Lp(a) lipoprotein. Overall, 31% of the lupus group compared with 9% of the controls had coronary artery calcification for an unadjusted odds ratio of 4.7. After controlling for age, sex, total pack-years of smoking, as well as the presence or absence of hypertension, and triglyceride and homocysteine levels, the odds ratio for calcification among lupus patients was 9.8. The lupus patients showed similar levels of disease activity regardless of the presence or absence of coronary artery calcification but those with calcification were more likely to be older ([P < .001) and male (P = .008). "Asymptomatic atherosclerosis is frequently present in patients with lupus," the authors conclude, adding that "Lupus should be added to the list of conditions that raise cardiovascular risk independent of conventional risk factors." In another study, Mary J. Roman, MD, of Weill Medical College of Cornell University, New York, and colleagues performed carotid ultrasonography and echocardiography, and assessed cardiovascular disease risk factors in 197 patients with lupus and in 197 age, sex, and race matched normotensive and hypertensive controls. The groups had similar characteristics except the controls had higher blood pressure than did the lupus group. The lupus patients had a higher overall prevalence of atherosclerosis, 37.1%, compared with 15.2% in controls, and among lupus patients younger than 40 years old the prevalence was 5.6 times as high as among same age controls. A multivariate analysis including age, status of hypertension, diabetes, smoking, and lupus, as well as fasting cholesterol level revealed the only independent factors associated with atherosclerosis were age " odds ratio 2.4 per 10 years; the presence of lupus " odds ratio 4.8; and serum cholesterol level " odds ratio 1.1 per 10 mg per decilitre. These results did not change after excluding patients and controls with clinical cardiovascular disease. The lupus patients with plaque were older and had a longer duration of disease and more disease-related damage compared with lupus patients without plaque, and were also less likely to have taken prednisone, cyclophosphamide, or hydroxychloroquine, or to have multiple autoantibodies. "The negative correlation between atherosclerosis and aggressive therapy suggests that more vigorous therapy might decrease the likelihood and burden of atherosclerosis in patients with lupus," Dr. Roman and colleagues write. In this study, the most important independent correlate of atherosclerosis, other than age, was the presence of systemic lupus erythematosus. The authors suggest that identification of biologic markers of disease activity associated with atherosclerosis may help optimise therapy for lupus patients. Related Study: Prevalence and Correlates of Accelerated Atherosclerosis in Systemic Lupus Erythematosus. N Engl J Med 2003;349:2399-406.

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