Lupus Update with Dr. Katz - Cardiovascular Problems & Lupus
Cardiovascular Problems and Lupus
There are several types of problems involving the heart and lungs either directly or indirectly linked to lupus.
Problems related to lupus include pericarditis, which is inflammation of the lining of the heart-not the heart itself. Pericarditis causes chest pain made worse by taking a deep breath. It is demonstrated best on an echocardiogram as the fluid around the heart can be seen on this tool. Pericarditis is usually treated with steroids (prednisone). Lupus can involve the heart itself, something called myocarditis, but rarely.
Pleurisy is common in lupus. Patients experience chest pain worsened by deep breathing. There is inflammation of the lining of the lungs. Fluid accumulates outside the lung. Occasionally that fluid is tapped with a needle by a doctor to see if the fluid shows a lot of white blood cells consistent with lupus. Steroids are the usual treatment for pleurisy.
Lupus patients can have non-cardiac chest pain. Sometimes the pain is muscular and not directly related to lupus. Then the chest wall may be tender and all the cardiac and lung tests are normal. Some of the tests include blood studies such as troponin, which is elevated in acute heart attacks, chest x-ray, chest Cat scan, an electrocardiogram, an echocardiogram, and sometimes a thallium exercise stress test, especially if chest pain is of unclear etiology and/or is produced by exertion.
The heart may be involved due to hypertension related to lupus, such as with lupus kidney disease. Coronary artery disease is more common in lupus. Lupus patients area more susceptible to the narrowing of their coronary heart blood vessels due to an accumulation of atherosclerotic plaque. Once the cholesterol plaque is inside the blood vessels, if some of that plaque breaks off, platelets from the blood can fill in the hole with a clot that obstructs blood flow to the heart, leading to a heart attack. The slow accumulation of cholesterol plaque in the coronary arteries can block blood flow to the heart. That can cause chest pain with exertion, which can be diagnosed with an abnormal thallium exercise stress test. An abnormal stress test can lead to performing a coronary angiogram and a stent may be placed in one or more coronary arteries to relieve the blockage and increase blood flow to the heart.
For patients with chronic kidney disease, the normal recommended limits of blood pressure are 130/80. Otherwise, blood pressure generally should be less than 140/90. Cholesterol should be low. The bad cholesterol or LDL cholesterol, needs to be less than 130, but in patients with any sign of coronary artery disease, the LDL should be less than 100 or even less than 70 in those who have had significant heart problems due to atherosclerosis. Triglycerides also should be low. Triglycerides come from carbohydrates, which are converted into a storage form called triglycerides. Cholesterol comes from animal fat, but also other products such as egg yolks and cheese. Those with lower body weight generally have fewer problems with hypertension, hyperlipidemia and diabetes.
Diabetes is a risk factor for coronary artery disease, with or without lupus. Prednisone can raise blood sugar and sometimes blood lipids.
If a patient with lupus is having chest pain, first a determination needs to be made whether the chest pain is cardiac in origin, due to pericarditis or pleurisy as part of active lupus or to non-cardiac causes. Treatment for active lupus includes steroids and immunosuppressive drugs, such as methotrexate, azathioprine, and mycophenolate, and mycophnolate mofetil (CellCept) and Benlysta. Measures may need to be initiated to lower cholesterol, triglycerides, blood pressure, and blood sugar.
Robert S. Katz, M.D.