Q&A with Dr. Jim Oates - Cardiac Issues and Lupus

Dr. Jim Oates is an associate professor of medicine at the Medical University of South Carolina, Division of Rheumatology and Immunology.

Ask the Experts is a series of educational talks and presentations on a variety of topics designed to provide you with important information about living with lupus. To listen to and download the original presentation, and to see other topics, please visit www.lupus.org/ask.

1. I recently experienced an event that was determined to be a spinal cord infarct. I am relatively young with no organ involvement, and my lupus is very well controlled on Plaquenil and Benlysta. Although I do have one risk factor that increases my risk of cardiovascular events (high BMI), there were no other clinical indications that I could be at risk of such an event. I am now taking daily low-dose aspirin. I understand that it may be associated with immune-mediated vasculitis. I would like to know if I am at risk for, or may have, vasculitis, and what measures I can take to treat it and moderate its effects on my health.   Providence, RI

Thank you for your question. This is difficult to answer without knowing quite a bit more about your situation. Therefore, I will speak more generally only. However, there are different ways that someone with lupus could have spinal cord involvement like this. One is with inflammation in the blood vessels (vasculitis). This, when diagnosed, is treated with aggressive immunosuppression. The second area that should not be missed is blood clotting abnormalities related to antiphospholipid antibodies. Certainly, these should be checked if they have not already. With both of these presentations, patients are often treated with plasmapheresis acutely. The treatment for this is blood thinners like warfarin. Infection should be ruled out. Having said all of this, it would require a full consultation by a rheumatologist to delve into these possibilities and treat them.

2. I am a 42 year old woman with lupus. A few months after childbirth I had a transient ischemic attack (TIA). It was determined after a trans esophageal echo that I have a patent foramen ovale (PFO) with atrial aneurysm and that a small clot made its' way to my brain to cause the TIA. I have been on aspirin 325mg since this occurred in 2009. There is debate in the literature and amongst my physicians if I should have the PFO repaired. I also had mitral valve prolapse and often have rapid heart rate (sinus tachycardia.) I worry about a more severe stroke. I show positive anticardiolipins though the tests are inconsistent. I also have secondary Sjogren's. Providence, RI

Thank you for your question. Without knowing your full situation, it is difficult to give specific advice. However, I can make general comments.  I will leave the discussion about the repair of the PFO to the cardiologists. However, relating to the antiphospholipid antibodies, these need to be consistently positive to be considered significant. Infections can cause false positives. If two readings are positive more than 12 weeks apart, then they are positive. For the syndrome, one needs to have an event not attributable to other causes to warrant anticoagulation more than aspirin. The presence of the PFO and the small aneurysm clouds the picture. I would enquire as to whether it was felt that you also had Libman Sachs endocarditis on the mitral valve, which can be associated with anticardiolipins and can sometimes shower pieces to the brain. This would be treated more aggressively than aspirin if there is not a bleeding risk.

3. I have major problems when going to the dentist. My heart rate goes up extremely high when given anesthesia. Is this due to the lupus or the anesthesia itself? Lansdowne, PA

Not knowing the specifics, I will speak generally. Lupus patients can have fast heart rates due to rhythm problems. An EKG or holter monitor can often distinguish the types. However, if it only comes with anesthesia and not outside this context, it may be your response to the anesthesia independent of your lupus.

4. I constantly have chest pain and at times it really hurts, I have passed out in the street and this has been going on for 2yrs. I have had multiple tests and they find nothing, what could it be? Lansdowne, PA

Thank you for your question. This is hard, as the list is long. Not knowing your situation fully makes it difficult to comment about this in a way that is helpful. However, doctors typically rule out causes that are dangerous by evaluating heart blood flow, heart squeeze function, heart valve function, and right heart pressures as well as heart rhythm. Sometimes problems relate to one’s ability to regulate blood pressure. Sometimes, ambulatory heart monitors are used to capture the heart rhythm during the episodes of dizziness. However, not knowing your situation better, I cannot comment specifically.

5. My wife was diagnosed with lupus a few years ago and has recently been experiencing a rapid heart rate. Her rheumatologist has run several tests and she has even been checked out and tested by a cardiologist who determined that there was nothing medically wrong with her heart, and sent her on her way even though her resting HR sometimes sits at 120. They had to stop the tests prematurely because it was approaching 200. This leads us to believe that her lupus is most likely causing this somehow.  Any info you have on tachycardia and lupus would be great. Canada

There was a study done out of Chicago that looked at factors associated with a fast heart rate in lupus that is not atrial fibrillation or ventricular tachycardia. It was a small number of patients, but there were a few associations including disease activity and poor physical function. This does not mean that these things cause the high heart rate, but there is an association. See: Utset, T. O., Ward, A. B., Thompson, T. L. and Green, S. L. (2013), Significance of Chronic Tachycardia in lupus. Arthritis Care Res, 65: 827–831. doi: 10.1002/acr.21902

6. I had a stroke last summer (with no side effects). I have an aneurism on my aortic valve. I am going to need a valve replacement. When I have a flare, I am concerned about taking steroids. What effects do steroids have on the heart and blood pressure? Barre, VT

This brings up the issue of steroids in general. If doses higher than 6 mg are given, they should be used as sparingly as possible. However, sometimes the potential for organ damage from flares makes this necessary. They can lead to hypertension, abnormal cholesterol, and weight gain among other side effects, so the risk needs to be outweighed by the benefit of preventing organ damage. This is a very individual decision, so I cannot comment specifically about your situation.

7. I have lupus and was wondering if having had pericarditis as well as a diagnosis of mitral valve prolapse put me at an increased risk for heart disease. Also, I have had issues caused by medication that have made my blood pressure very low (80s/50s), weight loss and being underweight, hypoglycemia, and ATCH deficiency. I know it was mentioned that high blood pressure, diabetes, and being overweight can lead to heart disease, but what if you experience the opposite spectrum of symptoms? Castle Rock, CO

As long as you are not malnourished and have normal electrolytes, I am unaware of an increase in cardiovascular disease or heart disease in those without additional traditional risk factors. Having said that, if you’re being underweight is due to chronic lupus disease activity, it is possible that this could increase your risk independent of these other risk factors you mention. This argues for tight disease control if possible.

8. I have had 3 echocardiograms done and all have shown rising pulmonary arterial pressure (PA). In 9/13, I had a right and left heart catheter. The PAP was 27 as opposed to 46 on echocardiograms. I have thickening heart valves, clean coronary arteries, a small pericardial effusion and PACs. My blood pressure runs very low. Is there always such a discrepancy between tests like this and if the next echocardiograms shows a high PAP, what do you recommend for lupus patients? Right now, I am dealing with gastro paresis that is severe and getting ready to undergo and Esophagogastroduodenoscopy (EGD) in 2 weeks. I am on no meds for lupus right now until we see what that test shows. Then, if I can, I will resume the Plaquenil. I have been on that since 2009 and before taking it had normal PAPs, no pleural thickening or interstitial lung disease, no proteinuria and no gastro paresis. Port St. Lucie, FL

If you have been diagnosed with lupus and do not have contraindications to taking it, most rheumatologists would agree that Plaquenil is a good drug for preventing flares and may prevent cardiovascular events and blood clots. The gold standard for measuring pressures to define pulmonary hypertension is the right heart cath. The echo is a good screening tool but is often different from the right heart cath.

9. Having lupus for 22 years I have been suffering with TIA's this last past year. I have also been diagnosed with PFO which they suspected was the cause of the original TIA. Being on Coumadin for over 4 months suffered yet another TIA with an INR of 2.5. Blood tests normal and SED rate is normal. What would cause this TIA to occur? Would/Could it be lupus related? Bozrah, CT

Please refer to the answer to question 2.

10. My mom had lupus & pulmonary fibrosis with a rapid heart rate & had a heart attack & died. I have lupus with it attacking my bile ducts/biliary cirrhosis & COPD with rapid heart rate controlled with Bystolic med.  My question is how do I know my heart will be ok? I also have Raynaud’s & arthritis. Sometimes at night my heart flutters for no reason & it’s kind of scary! Texarkana, AR

Without looking at your chart and talking with your doctor, it is difficult to say specifically. I can speak in generalities, however. Certainly, treating all of the traditional risk factors for heart attack is in order. Controlling your lupus disease activity is important. Specific to heart rhythm abnormalities, you should let your doctor know if the fluttering is associated with symptoms of dizziness or shortness of breath. If they are frequent or cause symptoms, it is reasonable to do an ambulatory heart monitor to see what kind of fast rhythm you have to determine if it is one that requires intervention. A frequent cause of heart problems in lupus patients is uncontrolled high blood pressure, so if your blood pressure is not at goal, this should be addressed.

11. My blood pressure is always on the low side. Am I more prone to having a stroke? I'm 52 years old and have been on Plaquenil for lupus for almost 20 years. Sandy Hook, CT

I can speak in generalities only, as I don’t know your specific situation. However, high blood pressure is a definite risk factor for stroke. Typically, low blood pressure is only a problem when someone has recently had a stroke or has a known blockage of one of the arteries to the brain. Otherwise, low blood pressure that does not cause symptoms should not be a problem.

12. I have lupus; my question pertains to my sinus tachycardia. My heart races constantly (both POTS and vasovagal), however I have low blood pressure so my cardiologist will not give me beta blockers. I am extremely fatigued and skinny. I have also had 2 myocardial infractions. I am only 33 years old; can anything be done about my racing heart and my resulting fatigue? Los Angeles, CA

I am afraid that your case is better answered by a cardiologist that treats problems like this and knows you better. Speaking generally about heart attacks at your age, I would make sure that you do not have a blood clotting abnormality related to antiphospholipid antibodies or an inherited blood clotting disorder. In general, POT symptoms can be worsened by anemia that can be seen in lupus patients. Your cardiologist can work with you determine the appropriateness of a rehabilitation program using exercises in a seated position (rowing machine or recumbent bicycle), as prolonged time lying down can worsen POT similar to what happens in astronauts. Hydration is extremely important as well.

13. I’m a 28 year old diagnosed with lupus (3 years). Shortly after I was diagnosed with tachycardia with a resting heart rate of 140. I currently take Tenormin. Will my tachycardia ever go away or get better? Or will it lead to a more serious heart problem? What is my outlook? Wauchula, FL

This depends on the cause of the fast heart rate. I would refer to comments made about this to questions 2, 5, 12, and 13.

14. Over the past few weeks, I have noticed especially at night my heart rate is increasing to 120-130. When I take my pulse it is irregular maybe AF.  It seems to feel regular in my chest but not my pulse. I am not taking any new medications, I recently have had bronchitis but that was a few weeks ago. I also get very light headed when this increase in heart rate happens. Vestal, NY

As with the other questions, I can speak only in generalities rather than specific to your problem. I would talk to your doctor about this if you have not already. Afib that is prolonged and converts to a normal rhythm can be an issue in and of itself. The management varies depending on other factors. Afib can be caused by many things, but heart ischemia is one. In general, one should evaluate traditional risk factors for heart attacks and make sure all of these are controlled and take Plaquenil (hydroxychloroquine) if it is not contraindicated.

15. Part of my lupus symptoms are moderate anticardiolipin, antiphospholipid. I take 81 mg aspirin every day. I am now experiencing high blood pressure and have started taking 5 mg of Amlodipine Besylate. Is there a connection between the clotting and high blood pressure? Also how does this relate to stroke factors? Any information would be great. Port Republic, NJ

I can speak generally about blood clotting and blood pressure. While they don’t tend to cause one another, each is an independent risk factor for vascular events such as stroke and heart attack. Therefore, controlling high blood pressure to a goal of < 140/90 is important. In the absence of known blood clots, taking an aspirin and Plaquenil (hydroxychloroquine) is a reasonable treatment for lupus patients with antiphospholipid antibodies that are high on two occasions 12 weeks or more apart. However, studies conflict on whether this regimen works. This needs to be weighed against the risk of a gastrointestinal bleed from the aspirin and other risk factors for cardiovascular events such as hyperlipidemia.