Q&A with Monica Richey - Preventive Cardiac Care and Lupus

Monica Richey, MSN, ANP-bc/GNP, is a Lupus Center nurse practitioner coordinator at the Hospital for Special Surgery

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 have chronic angina and I have had lupus for 27 years. I'm 58 now; will the angina put me at risk for coronary disease as I age? Naples, FL

Angina is a sign of heart (coronary) disease. What happens is that if there is not enough blood going into the heart muscle due to atherosclerosis (plaque build-up), the heart “complains” by causing pain/angina. You need to see a cardiologist and have a full work-up including, a stress test and an echo cardiogram. A simple EKG does not work because it only shows what the heart is doing at that exact minute. So please see you cardiologist soon

2. I have had a few 'episodes' where my entire left side goes numb, pain wraps under arm and across chest and feels like someone is sitting on my chest (heaviness). Does this have anything to do with lupus and a cardiac issue or can this be related to a muscular issue? San Antonio, TX

Yes it can be a muscular thing, but it sounds like you are having an angina attack, which is a cardiac issue. It can be related to lupus and or other risk factors. You need to have a full work-up (stress test/echo) as soon as you can get an appointment.  I don’t know how long or how often these episodes last, but my advice is if it happens again, go to your local ER and have them work it up. Cardiac or not it needs to be looked at.

3. I have SML, with kidney failure, and a year ago started having arrhythmias. My cardiologist prescribed potassium because I was losing this mineral through my urine. Is this also the beginning of heart failure? Mexico

No, it is not a sign of heart failure, loss of potassium has to do with kidney disease. If the kidney disease is not well controlled that can lead to heart failure due to the excess of fluid accumulating in your body. The excess fluid can cause the heart to “stretch”. If this happens the heart won’t work well as it has lost the capability to contract, and it increased in size. Lack of potassium can lead to cardiac arrhythmias as well.

4. I have lupus and have Peripheral Vascular Disease in my legs does that mean I may get it in my heart or in my chest area?  Bermuda

Hi there, the answer is maybe. PVD (peripheral vascular disease) has 2 different presentations. It can affect the arteries or the veins in your legs, or both. When it affects the arteries (also called PAD) it can lead to heart disease as well. If one artery is being affected, then any artery can be affected. The other presentation is when it affects your veins – most people know it as varicose veins. This is when blood does not move up well and causes the veins to dilate. In that case it increases you risk of having a blood clot. Blood clots can travel to your heart and lungs and cause heart attacks or stroke. If you don’t know what is you PVD type, as your physician for clarification. Ask if you need any kind of blood thinner to help with blood flow (such as aspirin).

Also PVD and lupus can be two completely unrelated issues. What to do: make sure your PVD is treated and controlled and also that your lupus is treated and well controlled.  That way you are covered in both.

5. I'm wondering if lupus can be the cause of exercise induced pulmonary hypertension and if so, can this lead to Pulmonary Hypertension. Is the progression of PH worse for lupus sufferers? Australia

The answer is maybe. Yet, exercise induced hypertension can also happen in people who don’t have lupus. Research has not yet concluded if exercise induced pulmonary hypertension can progress to pulmonary hypertension. In a few cases that can happen. The fact that you also have lupus increased your chances of developing it in the future. What to do? Make sure you are closely monitor by you pulmonologist and start medication management as soon as necessary.

6. I have frequent irregular heartbeats yet my cardiologists say there is nothing wrong with my heart. Ruskin, FL

Arrhythmias sometimes happen even for people without lupus. It can be caused by stress too much caffeine, etc. It can happen without any kind of heart problems as well.

That said, since you have lupus it is important to know (you and your physician) how often it happens and what kind of arrhythmia (irregular heart beat) you have. If it happens frequently enough (e.g daily, and many times) it may interfere with the workings of the heart. If you have shortness of breath or dizziness when these episodes happen, then it becomes a problem. Make sure you have a full work-up such as a stress test/echo and also a holter monitor. That way your cardiologist can see when and what type of irregular heart beat you have. Remember also to keep a detailed “diary” of these occurrences, noting, day, time, activities and any symptoms that are associated with these episodes.

EKG’s are not the best way to detect arrhythmias.

7. Does lupus interfere with the heart electrical system? Winter Garden, FL

Lupus can cause many different problems with the heart, including the issues with electrical system. It is hard to tell in this particular instance what the cause may be. Sometimes it is something completely un-related to lupus. It also needs to be treated as an independent problem. You need to treat this problem as well as your lupus; just treating lupus will not resolve this issue.

8. How does a person with lupus get their disease under control so they do not get heart disease? I am on Plaquenil, tried Methotrexate with no success. Had success on Benlysta until I found out that my insurance will not cover it. I had a severe heart attack last December 2012, with triple bypass. Now diagnosed with Heart Disease along with my lupus.  So how are we lupus patients supposed to keep our disease under control? Harrisburg, PA

I can definitely understand your frustration. I am surprised Benlysta did not pick up the bill; they have a good patient advocacy program. You could ask you physician to appeal to your insurance company as well. There are many other medications that you and your physician can try in order to control your lupus: azathioprine, mycophenolate, Rituximab are some that come to mind. Please don’t lose hope.

9. I've suffered a few mini strokes with in the last year. What makes a lupus sufferer even more susceptible to strokes? Besides the obvious, having high blood pressure, high cholesterol and in my particular case, steroid induced type II diabetes. Van Nuys CA

It seems like, besides lupus, you have a very important risk factor for strokes, which is diabetes. In your case, the strokes could have been caused by either. Lupus itself is an independent risk factor for atherosclerosis. The inflammation can cause plaque formation in the arteries and decrease/stop the blood flow to the heart or brain, in this case causing the strokes. If you have antiphospholid syndrome, then your risk is even higher. Steroids are also a big culprit in the story. It can lead to high blood pressure, elevated cholesterol level and diabetes type II.  Mini strokes are unfortunately a common occurrence within the lupus population. Now, that said, what can you do? Make sure your blood pressure, cholesterol anddiabetes are well controlled. The second and very important thing is to maintain you steroids levels at a minimum or none at all (even better, if possible). Then remember to eat healthy and also maintain a healthy weight. Talk to you physician to see if you would benefit from taking a blood thinner such as aspirin, that can help prevent strokes from happening again.

10. What are the most effective meds for pregnancy if you already have preexisting hypertension? Raleigh, NC

There are very few medications for hypertension that you are allowed to use during pregnancy. The most commonly used are usually Beta blockers such as labetolol, metoprolol or calcium channel blockers such as nifedipine. To keep your lupus controlled, the only ones allowed are Plaquenil, azathioprine and prednisone.

11. Is there any treatment for rapid heartbeat other than embolization associated with lupus when there are no other heart issues? Coconut Creek, FL

It depends; sometimes doctors will start you on a beta-blocker type of medication (e.g. metoprolol, atenolol, etc) that tends to regulate arrhythmias. Unfortunately, sometimes the arrhythmias are serious enough, or are not responding to the medications. In that case embolization or radioablation are the recommended procedures.

12. Can the same inflammatory cells call to both the heart and lungs and cause similar damage? Also, can it cause inflammation of the veins as well? Would this link the heart, lung and vascular issues we suffer? Roswell, GA

Lupus knows no borders. In lupus your body is making antibodies against your own organs and it can definitely affect and cause damage in every organ (heart, lungs, kidneys, brains) and/or “structure in your body” e.g. arteries, veins, capillaries. If the inflammation affects the arteries/veins within your heart it will lead to heart disease, peripheral vascular/artery disease as well.  It can also cause different issues with your lungs, such as interstitial lung disease, pulmonary hypertension, etc.

Controlling your lupus is the best way to avoid these other complications.

13. I have developed hypo-functioning adrenal glands after being on prednisone for over 15 years because of lupus. I have been on as high a dose as 60mg by mouth to as low as 7mg. Currently, I am holding steady at 7.5mg. I also take hydroxychloroquine 200mg twice a day. I have not been able to decrease the prednisone any lower because my blood pressure starts to plummet and or I flare-up. Will being on the hydroxychloroquine prevent extensive plaque build-up? Oviedo, FL

It is likely that you will always need prednisone because your adrenal glands are not functioning well. Plaquenil is proven to have beneficial effects on your cholesterol levels; improves platelets function and decreased plaque formation

14. I was sent for a regular chest x-ray for complaints of sharp chest pain when taking deep breaths, coughing, bending and laughing. The x-ray is normal but I am still having symptoms. What do you recommend? I also have mitral valve prolapse. I am pretty active, run 3-6 miles 2-3 times a week, swim, canoe paddle. When I hit about 3 mi. in running or 10 meters swimming, 15 min. paddling I start coughing or am short of breath. If I keep pushing it sometimes it subsides. Is it lupus & if so what can I do?

It seems like you are experiencing something called pleuritis, which is an inflammation of the lining of the lungs. It will not show on x-rays. Usually you need a CT scan of your chest. Pleuritis can cause pain when taking deep breaths and is a very common symptom of lupus. Your shortness of breath can be related to you mitral valve prolapsed, which causes your heart to not pump blood effectively, if very severe. Please ask you doctors for a full cardiology work up, including an exercise stress test and echo– cardiogram. You will need an echo every 12 months. (for your mitral valve prolapse)

For the pleuritis (if that is the case), usually anti-inflammatories help. 

Lupus headaches can occur, but are very hard to diagnose (as lupus related headaches). The SELENA-SLEADAI is a lupus disease activity report and it does include headaches as a disease manifestation category.

Headaches can also be an independent issue and can also be related to cardiac issues such as your MVP. In any case, for you headaches, have a full work-up done by a neurologist

15. I am a lupus patient who was diagnosed with supraventricular tachycardia (SVT). Is this related to lupus in any way? Or is it another issue entirely? Thank you! AZ

That is very hard to say, it is a 50/50 equal split. We know that lupus can cause a diverse array of cardiac issues, but sometimes heath care providers tend to blame everything on lupus. Even the best work-ups sometimes will not show what the cause is. The best thing to do is first (very important), to get the SVT under control. Then make sure your lupus is well controlled.