Dr. Maureen McMahon Presents "“Heart Disease and Preventive Measures” at Lupus LA's Annual Patient Education Conference

Atherosclerosis in Systemic Lupus Erythematosus Maureen McMahon, MD, MCR Assistant Professor of Medicine David Geffen School of Medicine UCLA

Overall Survival in Lupus has Improved Gabriel, S. et al., Arthritis Rheum 1999;42:46-50. 1950-1979 1980-1992

Late Deaths in SLE are due to Heart Disease (Atherosclerosis) Abu-Shakra M, et al. J Rheum. 1995;22:1265–1270. [Evidence Level B]

There is an Increased Risk for Atherosclerosis (ATH) in SLE CVA = cerebrovascular accident. Esdaile JM, et al. Arthritis Rheum . 2001;44:2331–2337 [Evidence Level B]; Karrar A, et al. Semin Arthritis Rheum . 2001;30:436–443 [Evidence Level C]; Manzi S, et al. Am J Epidemiol . 1997;145:408–415 [Evidence Level B]; Manzi S, et al. Arthritis Rheum . 1999;42:51–60. [Evidence Level B]

Prevalence of ATH Plaque Among Control Subjects and Patients With SLE, According to Decade of Life Roman MJ, et. al. N Engl J Med . 2003;349:2399–2406. [Evidence Level B]  4th 5th 6th  7th Decade of Age P = .009 P = .01 P = .001 P = .08

Why do SLE patients have an increased risk of Heart Disease?

Patients with SLE Do Have Traditional Cardiac Risk Factors Petri et al. Medicine 1992

Traditional Risk Factors Do Contribute to ATH in SLE % of patients with plaque, age adjusted p=0.05 p=0.0001 p=0.07 Maksimowicz-McKinnon et al. J Rheum 2006

SLE Disease Activity Influences Standard Lipid Levels Posadas-Romero et al. Arthritis Rheum . 2004;50:160-165 .

Influence of treatment on lipid levels in SLE ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Prevalence and Risk Factors of Carotid Plaque in SLE ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Traditional Framingham Risk Factors Do Not Fully Explain Risk of ATH in SLE ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Esdaile JM, et al. Arthritis Rheum . 2001;44:2331–2337. [Evidence Level B]

Hypothesis ,[object Object],Ansell et al. Circulation 2003 Could “Pro-Inflammatory HDL be a factor in SLE??

LDL: the “Bad Cholesterol” LDL Mackness MI et al. Biochem J 1993. Lipids Online 2004 (Baylor) Blood Vessel White Blood Cells: Monocytes White Blood Cell: Macrophage HDL are anti-inflammatory Foam Cell HDL Remove “Bad Cholesterol” HDL Prevent Oxidation of LDL Oxidized LDL PLAQUE

Pro-Inflammatory HDL Assay DCFH (chemical that turns green when oxidized) LDL Fluorescent Signal Patient HDL (normal) -- + Patient HDL (pro-inflammatory) ,[object Object],[object Object],[object Object]

Populations of Women studied ,[object Object],[object Object],[object Object],[object Object]

45% of SLE patients have pro-inflammatory HDL

Pro-inflammatory HDL may be associated with heart disease 4 patients with a history of heart attack were included (all patients had SLE): All 4 had pro-inflammatory HDL!

Populations of Women studied ,[object Object],[object Object],[object Object],All subjects had blood drawn to measure HDL function All subjects had a carotid artery ultrasound to look for thickening of the arteries, or “plaque”

86% of SLE patients with ATH have piHDL * Chi-squared or Fisher’s Exact

Presence of piHDL Greatly Increases Risk for Carotid Plaque in SLE ,[object Object],[object Object]

Summary ,[object Object],[object Object],[object Object],Pro-Inflammatory HDL are significantly associated with plaque on carotid ultrasound in women with SLE but not in healthy controls. Pro-Inflammatory HDL may be one marker that can be used to predict which patients are at risk for ATH

Future Research Directions ,[object Object],[object Object]

What Can Lupus Patients Do to Decrease Their Risk of Heart Disease?

Ways to Improve ATH Risk Factors Without Medications ,[object Object],[object Object],[object Object],[object Object]

Control High Blood Pressure ,[object Object],[object Object],[object Object],[object Object],[object Object]

hp2010.nhlbihin.net/atpiii/ calculator .asp

Status of Statins in Rheumatic Diseases ,[object Object],[object Object],[object Object],McCarey et al. Lancet . 2004;363:2015-2021

Statins in SLE ,[object Object],[object Object],[object Object],[object Object],[object Object],Petri et al., Arthritis Rheum 2006; 54: suppl 1246

Summary of Statins in Rheumatology Practice ,[object Object],[object Object],[object Object],[object Object]

Antimalarial Drugs and Heart disease in SLE ,[object Object],[object Object],[object Object],Rahman P, et al. J Rheum . 1999;26:325–330. [Evidence Level B]

Hydroxychloroquine in SLE ,[object Object],[object Object],[object Object],Fessler BJ et al. , Arth Rheum 05; Ho KT et al. , Rheumatol 2005; Rahman et al., J Rheum 1999.; Roman et al NEJM 2003

Conclusions ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

If you or a friend are interested in participating in the carotid ultrasound /piHDL study: ,[object Object],[object Object],[object Object]

Acknowledgements UCLA Rheumatology Bevra Hahn, M.D. Christina Charles, M.D. Jennifer Grossman, M.D. John FitzGerald, M.D., Ph.D. Weiling Chen, M.S. UCLA Cardiology Alan Fogelman, M.D. Mohamad Navab, Ph.D. Cedars-Sinai Medical Center Daniel Wallace, M.D. Michael Weisman, M.D. UCLA Radiology Nagesh Ragavendra, M.D. Funding Organizations Lupus Research Institute Alliance for Lupus Research The Arthritis Foundation

Dr. Maureen McMahon Presents "“Heart Disease and Preventive Measures” at Lupus LA's Annual Patient Education Conference

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Dr. Maureen McMahon Presents "“Heart Disease and Preventive Measures” at Lupus LA's Annual Patient Education Conference