SLE and cardiovascular manifestations

http://cardiologysearch.blogspot.in/



 Cardiac disease is common among patients
with systemic lupus erythematosus (SLE) as

 pericardial,
 myocardial,
 valvular and
 coronary artery involvement


 Pericardial involvement is the
 Pericardial effusion

 pericarditis

 second most common echocardiographic lesion in
SLE, and

 most frequent cause of symptomatic cardiac
disease.

 Conduction defects,

 Represent a sequel of active or past
pericarditis and/or myocarditis

 noted in 34 to 70 % of patients with SLE.

 First-degree heart block may be seen and is
often transient

 Congenital heart block may be part of the
neonatal lupus syndrome.

 The resting heart rate may correlate with
disease activity.

 Study 14 of 15 patients with a resting heart
rate above 90 beats/min had active disease


 Mitral valve involvement is most common;

 Mild to moderate regurgitant murmur may be
heard but most patients remain
asymptomatic

 Mitral valve prolapse in 25 percent of cases.

 Verrucous endocarditis — Libman-Sacks
(verrucous) endocarditis

 MYOCARDITIS

 uncommon,

 asymptomatic manifestation of SLE

 prevalence of 8 to 25 % in different studies


 Acute myocarditis

 infiltration of the myocardium with
mononuclear cells.

 Resolution of the inflammation leads to
fibrosis that may be manifested clinically as
dilated cardiomyopathy.


1. Coronary artery involvement is the most recent
cardiovascular manifestation to be recognized in
SLE
2. seen in 2 – 16 % of patients with SLE
3. can lead to acute myocardial infarction in
young women.
 In some cases, thrombi rather than coronary disease is
responsible for the ischemia .
 Coronary artery vasculitis is rare.


Other coronary artery manifestations -

 Coronary arteritis,

 Aneurysms,

 Vasospasm

 Embolic phenomenon

Presentation

 Angina,

 Myocardial infarction,

 Sudden death

 Responsible for 0.3 % deaths.


Pathogenesis


Risk
Factors


 Most striking feature of CAD in SLE is the
 predilection for young premenopausal women.

 Manzi and colleagues
 lupus women aged 35 to 44 years were over 50
times more likely to have an MI as compared to
controls.


 modifiable risk factor for occlusive vascular
disease in both general and lupus populations.

 Elevated homocysteine levels have been
reported in 15% of lupus patients

 Associated with
 cardiovascular events
 subclinical atherosclerosis


 43 yr old female

 A known case of SLE

 ANA positive

 On steroids


 OBESITY
 SYSTEMIC HYPERTENSION
 ANEMIA
 Acid peptic disease
 Hypothyroidism
 Nephropathy
 Hemorrhoids

 Old IWMI

 CAG-2003
 Mild CAD
 Mild LAD and RCA disease


 Acute coronary syndrome

 AWMI – delayed presentation

 Not Thrombolised

 Patient managed and stabilized

 Taken for CAG

 Right dominant system

 Two vessel disease

 Significant proximal LAD disease

 Critical mid RCA disease

 Major diagonal disease

 Hypokinetic IVS, apical segments.
Anterolateral segments

 Mild LV dysfunction

 EF -65 %

 Grade I – diastolic dysfunction


 Advised

 CABG SURGERY with grafts to
 Distal LAD
 Major diagonal
 Distal RCA
OR
PCI to LAD and RCA - IF considered high risk
for CABG

 Discussed with CT surgeons and anesthetists

 Due to Presence of
 high risk profile
 Symptomatic status – class III symptoms
 Nephropathy – high creatinine values, cr -2.7 mg%

 Patient taken for PCI


 Drug eluting stent placed in

 LAD -SUPRALIMUS CORE STENT
 RCA - ENDEAVOR STENT

 Patient was started on antiplatelets


 Patient developed GI –bleeding

 Coffee ground vomitting

 Profound hypotension

 Patient became unconscious


 Blood transfusion

 Fluid replacement

 Inotrops – dopamine.
Adrenaline infusion started

 Patient ABG - desaturation

 Patient connected to mechanical ventilator

 Antiplatelets stopped- inspite of DES

 Continuous Pantoprazole infusion started


 Active bleeding stopped - after 3 days

 Hemodynamic stability attained

 CLOPIDOGREL antiplatelet- started after 3
days

 Aspirin also restarted by 5 days


 Patient improved in 5 days

 Shifted to ward and discharged


 Blood disorder
 NSAIDS – used for different symptoms in SLE
▪ Increase bleeding
 Corticosteroids – produce peptic ulcer

 Thrombocytopenia – increase bleeding
▪ Autoimmune
▪ Drug induced
 Antiphospholipid antibody – increase thrombosis
▪ Increase chance of stent thrombosis

Bleeding Stent thrombosis

Anti platelets


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SLE and cardiovascular manifestations

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