Subclinical Carotid Atherosclerosis in a Patient with Systemic Lupus Erythematosus

Deborah Alpert; Adrienne Davis; Doruk Erkan; Mary J Roman; Jane E Salmon

Disclosures

Nat Clin Pract Rheumatol. 2007;3(8):473-478. 

In This Article

Discussion of Risk Factors

Many studies have demonstrated an increased prevalence of traditional risk factors for atherosclerosis in patients with SLE ( Table 3 ). Notable risk factors in the case patient were her overweight status at the first study visit, a family history of premature CAD, and her hypercholesterolemia; however, traditional risk factors alone do not completely account for the increased risk of cardiovascular disease in patients with SLE. Indeed, one study found a greater than seven-fold increase in the risk of nonfatal myocardial infarction and stroke in a cohort of 263 patients with SLE, after controlling for traditional risk factors based on the Framingham Heart Study.[5]

Numerous SLE-related factors have also been implicated in accelerated atherosclerosis ( Table 3 ). Increasing age at SLE diagnosis has been associated with increasing risk of both subclinical and clinical atherosclerosis;[1,6] of note, the case patient was diagnosed with SLE relatively late in life at the age of 41 years. Other SLE-related factors implicated in premature atherosclerosis include disease duration, cumulative inflammatory disease activity, and damage.[4,6,7] The case patient's progressive burden of disease activity and damage are indicated by her serial SLE disease activity and damage index scores ( Table 1 ). Some studies report an association between antiphospholipid antibodies and accelerated atherosclerosis,[8,9] whereas others do not.[4,10] Whether antiphospholipid antibodies truly predispose patients to atherosclerosis, or promote symptomatic CAD due to primary thrombosis, is unclear.

Various serum correlates of atherosclerosis have also been studied in patients with SLE, including cytokines, adhesion molecules, autoantibodies, and lipoproteins.[1,2] The case patient had markedly elevated lipoprotein(a) levels, which have been associated with symptomatic atherosclerosis in a small SLE cohort;[8] however, it is premature to recommend routine monitoring of lipoprotein(a) in all patients with SLE. In addition, the case patient also had an elevated erythrocyte sedimentation rate and an elevated serum C-reactive protein (CRP) concentration at her second study visit, which might be reflective of her ongoing, active SLE. Elevated CRP is an independent risk factor for cardiovascular disease in healthy young men and women.[1] Although some studies of patients with SLE have found independent associations between elevated CRP and both vascular events[9] and subclinical atherosclerosis,[11] this finding has not been consistently observed.[4,12] Point measurements of these inflammatory markers are useful for monitoring SLE disease activity, but their utility in monitoring atherosclerotic risk remains uncertain.

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