15 Questions - Cardiovascular Issues with Lupus

1. What are some of the different ways that lupus can affect the heart?

For clarification, when I state “lupus” in this session, I am referring to Systemic Lupus Erythematosus (SLE) and not lupus localized in skin only (cutaneous lupus).

Lupus can affect various parts of the heart. Pericarditis or inflammation of the lining of the heart from lupus can lead to sharp chest pain and fluid around the heart, often worsened with deep breathing and certain body positions.  Rarely, lupus may involve the heart valves and heart muscle (myocardium).  More importantly, patients with systemic lupus erythematosus are at increased risk for coronary heart disease (resulting in blocked arteries) from increased cardiovascular risk factors including: chronic inflammation, dyslipidemia (high LDL/”bad” cholesterol but low HDL/”good” cholesterol levels), overweight, and physical inactivity.

2. What kinds of test can be done to determine if lupus is actually affecting the heart?  La Mirada, CA

Tests are typically ordered based on the individual’s symptoms.  If you report symptoms suggestive of coronary heart disease (shortness of breath on exertion, chest pain or pressure, and/or decrease in exercise tolerance), your physician may order electrocardiograms (EKGs), exercise stress tests (including “X-ray” imaging of the heart) and echocardiograms (ultrasound of the heart) to evaluate your heart function. If you have sharp chest pain that worsens when lying down and improves when leaning forward, you may have pericarditis and your physician may order an echocardiogram to evaluate for fluid around the heart.  Cardiac testing is not routinely ordered in asymptomatic individuals.

3. Would you encourage those with lupus to be evaluated by a preventive cardiologist?

Yes since the preventive cardiologists can evaluate the modifiable cardiovascular risk factors, such as hypertension (high blood pressure), dyslipidemia (high LDL/”bad” cholesterol but low HDL/”good” cholesterol levels), and overweight status. Primary care physicians can also manage these cardiovascular risk factors and work with individuals in smoking cessation.

4. I am wondering about the frequency of heart disease after kidney failure in SLE; i.e., is the lupus attacking the heart after a kidney transplant because it's just moving on to the next vulnerable organ?  San Diego, CA

Having kidney disease/kidney failure in SLE is a risk factor for coronary heart disease.  There are several explanations. First, lupus nephritis (kidney disease) is one of the more severe features of SLE and is associated with high level of system inflammation. Second, the protein leakage from this kidney disease can cause abnormal cholesterol profile and can also increase the clotting risk, sometimes leading to blocked arteries.  Furthermore, the treatment of lupus nephritis includes high dosage of steroids that can lead to weight gain, abnormal cholesterol profile and elevated blood sugar level.  However, these risk factors are not unique to patients with SLE.  Patients without lupus but with kidney disease/kidney failure and patients without lupus who had organ transplant are known to have increased risk for coronary heart disease. 

5. Can lupus elevate your cholesterol level?  Cartersville, GA

Systemic lupus can elevate the LDL (“bad”) cholesterol level and lower the HDL (“good”) cholesterol level by the disease itself. The treatment with systemic steroids that causes weight gain can also worsen the cholesterol profile.

6. In 1985 my wife was diagnosed with SLE.  In 2002 she was diagnosed with Pulmonary Arterial Hypertension (PAH).  Is PAH a common complication of lupus?  Can it be prevented? Alpharetta, GA

Pulmonary arterial hypertension (PAH) is not a common complication of systemic lupus.  It results in increased blood pressure in the vessels carrying blood flow to the lungs. Causes of PAH include interstitial lung disease (inflammation of the lung tissue) and pulmonary embolism (blood clots in lung blood vessels), which should be investigated. Obstructive sleep apnea (airway obstruction during sleep) can also cause PAH.  PAH is not preventable. However, it can be monitored.  There are treatments when the PAH becomes more symptomatic.

7. I often have Pleurisy and am afraid I will pass off chest pains for Pleurisy. What are the major differences?  Monte Vista, CO

Pleurisy tends to be sharp (jabbing) pain and worsens with taking deep breaths. The chest pain from coronary heart disease can be described as pressure, squeezing, and heartburn but usually not sharp. You may also experience shortness of breath and get winded easily. Furthermore, the chest pain from coronary heart disease tends to improve with rest and worsen with physical activity (exertion). However, if you experience chest pain that is different from your usual “Pleurisy” chest pain, you should inform your physician instead of trying to figure out yourself.

8. I have symptomatic Premature Ventricular Contractions (PVC's) that fortunately are controlled through medication. They came on suddenly and I am curious if they are a manifestation of my lupus.  I have read that there are studies that say that conduction disturbances can occur from rheumatologic conditions, although many cardiologists will say there is no correlation.  DeWitt, MI

Premature Ventricular Contraction is a common condition resulting in “extra” heart beats that can be seen in patients without lupus. If there is an electrical abnormality within the heart from lupus involvement, we may see heart block (slow heart beats) or less often, arrhythmias (sustained rapid heart beats).  This is not common but can be seen in neonatal lupus, meaning certain circulating antibodies (anti-SSA/Ro, anti-SSB/La) from the mother can pass to the fetus and may affect the electrical system of the fetus.  Patients with lupus or other rheumatologic conditions (for example, Sjögren syndrome) are more likely to have these antibodies.  Therefore, we routinely check for these antibodies as part of the pregnancy evaluation. Fetal heart monitoring beginning at week 16 is warranted if the mother has one of these antibodies.

9. How do Antiphospholipid antibodies effect possible cardiovascular problems. And what is the best way to prevent cardiovascular problems from happening.  Pittsburgh, PA

Antiphospholipid antibodies can be associated with thrombosis (abnormal spontaneous blood clotting). However, many patients can have positive antiphospholipid antibodies without ever developing any thrombotic (abnormal clotting) events. Therefore, the thrombotic risk in patients with antiphospholipid antibodies is different and can vary based on other cardiovascular risk factors such as cigarette smoking, kidney disease, estrogen-containing birth control pill usage, and abnormal cholesterol profile.  The best way to prevent cardiovascular disease is to minimize the modifiable risk factors and include heart-healthy exercise and diet.

10. My 10 year old otherwise healthy daughter has had systemic lupus for 4 years and is currently in good control on CellCept, plaquenil and off steroid for over two years. Is there an ideal target cholesterol level for children with lupus who have no other risk factors for heart disease except for having lupus and having anticardiolipin and lupus anticoagulant?  Is there a role for monitoring anticardiolipin over time or since she was positive at diagnosis is she always at greater risk of cardiovascular events?  Seattle, WA

There is no formal guideline for management of cardiovascular risk factors in patients (adults and children) with lupus at this time.  However, if the cholesterol levels are abnormal such as low HDL (“good” cholesterol) or high LDL (“bad” cholesterol), then dietary and exercise intervention is recommended first prior to usage of medications.  There is no role for repeat testing for anticardiolipin antibodies if they were tested positive.  Having antiphospholipid antibodies (e.g. anticardiolipin antibodies and lupus anticoagulant) may put patients at increased risk for thrombotic events but the risk varies among patients based on other thrombotic risk factors such as cigarette smoking. The goal is to reduce the modifiable cardiovascular and thrombotic risk factors. The protective effect of low-dose aspirin has not been proven against development of new thrombosis in patients with antiphospholipid antibodies in randomized controlled studies.

11. I have a mitral valve that leaks and the valve does not open as much as it should. At some point the valve will probably need to be replaced. Are problems with heart valves common in those with lupus?  Raleigh, NC

Valvular disease from Libman-Sack (non-bacterial or non-infectious) deposits on the valves is not commonly seen in lupus nowadays since the usage of steroids (prednisone) in 1950s. The valvular abnormalities resulting from Libman-Sacks deposits may predispose patients to bacterial endocarditis (serious heart valve infections). Therefore, preventative antibiotics should be used for dental or surgical procedures with an increased risk of transient bacterial leakage into the bloodstream.  

12. Can you explain what pericarditis is and what other drug besides prednisone are used in the treatment of pericarditis?  Merrick, NY

Pericarditis is inflammation of the lining around the heart (pericardium). Besides prednisone, nonsteroidal anti-inflammatory drugs such as ibuprofen have been used to treat pericarditis. However, if you have recurrent pericarditis, you will likely need immunosuppressive medications as steroid-sparing agent.

13. My partner has lupus and has recently begun treatment for hypertension.  Lisinopril caused coughing and her doctor wants to switch her to Propranolol.  Drug information states this drug can bring on SLE symptoms.  Can you speak to this issue?  Specifically should we avoid this medication or others like it?  Conifer, CO

Certain medications can cause drug-induced lupus, which has a different mechanism from the systemic lupus.  Unless your partner has other contraindications for using a beta-blocker (Propranolol) like asthma or poor finger circulation, there is no reason that she should avoid this medication. 

14. I have lived 18 years with SLE and have a high total cholesterol and LDL.  Are there any particular medications that are better for treating lipid problems in SLE?   Is there an anti-inflammatory effect of statins that also helps the disease process?  Chattanooga, TN

Statin medications (such as simvastatin, atorvastatin, rosuvastatin ) are good lipid-lowering medications to treat lipid problems. Lifestyle modifications with healthy diet and exercise along with the use of statin medications may even be better.  There is a potential anti-inflammatory effect of statin medications which have been shown to be beneficial in non-lupus patients but need to be studied in SLE.

15. The desire to maintain an adequate heart-healthy exercise program can be hard to sustain as a lupus patient, and especially when my condition flares and moving feels counter-intuitive to joint pain.  What types of exercise would you recommend as a typical heart-healthy exercise program for lupus patients with non-erosive lupus arthritis?  Phoenix, AZ

Low impact aerobic exercise, such as walking at moderate intensity (at the speed which your heart rate increases but you can still talk), is desirable for healthy heart.  However, it may be hard when you have arthritis flare or chronic joint pain.  Many times, I advise my patients to walk in the swimming pool back and forth as fast as they can without causing more joint pain. Buoyancy of the water reduces the weight stress to the joints of the legs. At the same time, walking against water creates resistance that also tones the muscles.  However, on the days with painful joints, you may like to limit your physical activity to Pilates, which stretches and tones the core muscles.