Chat Transcript for Dr. Amy H. Kao
February 13, 2008
Moderator
Good afternoon. The Lupus Foundation of America is pleased to welcome Dr. Amy H. Kao.
Dr. Kao is currently assistant professor of medicine at the University of Pittsburgh and rheumatologist with the Lupus Center of Excellence at the University of Pittsburgh Schools of the Health Sciences and University of Pittsburgh Medical Center (UPMC).
Dr. Kao graduated from the State University of New York Science Center at Brooklyn and completed her residency and fellowship at UPMC. Dr. Kao’s research interests include cardiovascular disease in lupus and rheumatoid arthritis, and as well as how cognitive impairment can impact the course and outcomes of patients with lupus. She currently is studying novel biomarkers that may help physicians predict disease activity in lupus patients.
We welcome Dr. Kao, and thank her for joining us this afternoon.
Dr. Kao
Before we get started, I’d like to say a few words. The heart is one of the many organs which can be affected by lupus from inflammation and/or the treatment of lupus. When we speak of "increased risk of heart disease" in lupus, we mean coronary heart disease from atherosclerosis, a process that occurs when fatty deposits and immune cells change the structure of the coronary arteries (blood vessels to the heart). These changes of the blood vessels can lead to heart attack from acute blockage of blood flow to the heart. Coronary heart disease is the leading cause of death for women in the United States. Strikingly, young women with lupus from the ages of 35-44 years have a 50-fold increased risk of having a heart attack compared to healthy women of similar age. Therefore, many researchers are studying the causes of this increase in risk and looking for potential therapies to reduce these risks.
Other parts of the heart can be involved in lupus, such as the pericardium (lining that surrounds the heart), valves, and heart muscles. Pericarditis is the inflammation of the pericardium, which is the most common heart involvement in lupus. Patients can experience sharp chest pain that may feel worse with taking deep breathes or lying down. Valvular heart disease can become symptomatic when the valves become leaky, which may result in shortness of breath. Myocarditis from the inflammation of the heart muscles is uncommon, which may cause irregular heart beat or heart failure.
Moderator
Thank you Dr. Kao. Without further delay, let's begin. The first question comes to us from South Carolina. What are the cardiovascular risks of lupus patients, and what interventions have been used to decrease these risks?
Dr. Kao
Patients with lupus are more likely to have traditional cardiovascular risk factors for heart disease compared to healthy individuals. These traditional cardiovascular risk factors include high blood pressure, high levels of bad cholesterols (triglycerides and low density lipoprotein or LDL cholesterols), and diabetes. These risk factors may be worsened by the inflammation from lupus and the medication use (corticosteroids) to treat lupus.
These traditional risk factors do not fully account for the increased risk of coronary heart disease in patients with lupus. There are “lupus factors,” such as chronic inflammation, antibodies that affect the blood vessels, cumulative damage from lupus, and corticosteroid use, which further increase the risk for coronary heart disease in patients with lupus.
The researchers are studying strategies to reduce these risks. The lupus patients can reduce the traditional risk factors by doing the followings: stop smoking, do aerobic exercise, maintain a normal weight, treat the high blood pressure, high blood sugar and high cholesterol levels. To reduce the “lupus factors,” your physicians will prescribe therapy to decrease the inflammation caused by lupus and be cautious about high dose and prolonged use of corticosteroids.
Moderator
I was diagnosed with SLE when I was 17 (liver problems and then joint problems). After treatment with steroids for about 6 months, it went into remission and I haven't had a flare up since (I'm now almost 25). I exercise regularly and try to eat healthy (although this is something I've only started doing consistently for the last 2 years). Should I still be worried about possible heart problems? Is there any test I should be asking my doctor to do even though I don't have any warning signs of heart disease? Heart disease does run in my family, and I vaguely remember having high cholesterol when I was little (but not any longer). Should I just relax and not worry until something happens (ex: a flare up, developing high blood pressure, etc.)? -- Syracuse, NY
Dr. Kao
Patients with SLE are at increased risk for cardiovascular disease such as heart attack and stroke. However, there is no established guideline to do preventive measures for cardiovascular disease in SLE. It makes sense to reduce traditional cardiovascular risk factors such as high cholesterol, high blood pressure, cigarette smoking, high blood glucose (sugar), and being overweight. It is very good that you have been exercising regularly and eating healthy. Even though you do not have any symptoms for heart disease, a routine fasting cholesterol panel may be a simple test to check for high cholesterol (especially bad cholesterols such as low-density lipoprotein/LDL cholesterol and triglycerides) levels since you have a history of high cholesterol levels and a family history of heart disease.
duane
I heard that women with lupus have a higher risk for heart disease than the general population. What is the reason for this increased risk?
Dr. Kao
We do not completely understand the reason for this increased risk. We know that patients with lupus have increase in traditional cardiovascular risk factors as I mentioned above. In addition, we are still studying to understand the "lupus factors" which may include chronic inflammation and treatment of lupus such as corticosteroids.
Moderator
Hi, I was diagnosed with SLE in 1998, and recently had heart valve replacement surgery because of a "leaky" aortic valve. Is this a common certain for people with lupus. -- Winterville, NC
Dr. Kao
Valvular heart disease is common in patients with lupus. The presence or change in valvular disease is not related to SLE disease activity, therapy, or duration of having SLE. However, presence of antiphospholipid antibodies has been reported to be associated with valvular disease. Libman-Sacks (nonbacterial) endocarditis with valvular vegetations has been associated with antiphospholipid antibodies in some studies. The patients usually do not have any symptoms. However, the affected valves can become damaged and put patients at risk for developing bacterial endocarditis when patients undergo procedures at high risk for transient bacteremia (bacteria in the blood), such as dental or gum surgery. The routine practice is to use antibiotics with these types of procedures. Other complications related to valvular disease include ischemic stroke and peripheral embolism from the valvular vegetations.
Moderator
Dr. Kao Mia Dr. Kao Moderator Dr. Kao JDudak Dr. Kao Moderator Dr. Kao Moderator Dr. Kao Mia Dr. Kao Moderator Dr. Kao starr Dr. Kao Moderator Dr. Kao Lalo Consorte Dr. Kao Moderator Dr. Kao Moderator Dr. Kao For more educational material, please feel free to the LFA Health Educator at 202-349-1159 or LupusInfo@lupus.org. Bea Dr. Kao Moderator Dr. Kao Moderator Dr. Kao Moderator Feel free to continue this discussion in our message boards, located here http://www.lupus.org/messageboards. Please join us Wednesday, March 12 at 3 p.m. Eastern for our guest Dr. James Tumlin, who will discuss Kidneys & Lupus. Check out the LFA’s blog, located here http://lfa-inc.blogspot.com/. Help spread the word about our lupus chats. See you next time.
I am a 61 year old male with Class IV nephritis, diagnosed 7-2004. I take statins with very good results. BP is 110/70 and my father history enlarged heart. Weight is in acceptable range. Which tests are appropriate -- EKG, stress, etc.? And what is your opinion on a heart scan? I believe it is a MRI scan. -- Lakewood, CO
Exercise stress thallium study will be a reasonable test. It is a nuclear perfusion study in conjunction with a stress test. The amount of radiation receives from thallium is less than that from a chest x-ray. Pictures of the heart are taken with a special camera that picks up the radioactivity of the thallium. Regions of the heart not receiving good blood flow from blockage in the arteries of the heart can be identified. Stress echocardiogram is another option that can detect changes in the heart muscle movement (contractions) during exercise compared to at rest. Abnormal movement or contractility of the heart muscle during exercise may indicate coronary heart disease.
Is there a correlation between lupus Antiphospholipid syndrome and individuals with lupus with known heart disease?
Patients with APS have developed thromboembolic events or miscarriages. These patients are at increased risk for developing coronary heart disease.
I have SLE and antiphospholipid syndrome. I understand that APS, livedo reticularis are associated with heart disease. My rheumatologist said that if high cholesterol isn't controlled with diet, I should be treated like someone who's had a triple bypass. What are your thoughts? -- Mt Prospect, IL
Your rheumatologist is aware of the increased cardiovascular risk in patients with lupus. Antiphospholipid syndrome is an additional risk factor for heart disease. Therefore, your rheumatologist is treating your traditional cardiovascular risk factor by lowering your cholesterol levels to prevent the development of heart attack. Diet alone may not be enough to lower the cholesterol level. Cholesterol-lowering medications like “statin,” frequently used in patients with established heart disease (like those with triple bypass), can treat the high cholesterol levels.
My question is regarding the strategies to reduce risk, specifically with the prolonged use of corticosteroids. What other therapy options are there, and how effective are they?
To date, there are no official guidelines to reduce the cardiovascular risk factors. Some researchers may suggest treating lupus patients similar to those with diabetes. Corticosteroids use can reduce inflammation, which is a "lupus factor" for cardiovascular disease. However, long-term corticosteroid use may affect the cholesterol levels. We recommend using the lowest dose of corticosteroids necessary to treat lupus since it may be difficult to be off corticosteroid totally if the patients have been on long-term corticosteroids. Immunomodulator such as hydroxychloroquine and/or immunosuppressive agents may be used as steroid-sparing agents.
I have systemic lupus. I had a stroke two years before being diagnosed with SLE. I have a heart murmur. Does that add and dangers? -- Palm Coast, FL
You probably need evaluation of your heart murmur by echocardiogram to make sure that you do not have vegetations on your heart valves, which can embolize and cause stroke. In addition, you will need cardiovascular and clotting risk assessment by your doctors. The assessment may include blood tests for cholesterol and clotting problems, blood pressure measurement, and smoking cessation if you smoke. You can reduce your risk of stroke or heart attack by treating these cardiovascular risk factors.
Since women with lupus are very vulnerable to heart problems, do you think that the Cardiac Calcium Score Screenings would be a useful medical test for us to have completed? -- Fairview, TX
Coronary artery calcification screening is a noninvasive CT scanning test that can identify and measure “calcified” plaque in the coronary arteries (arteries of the heart). This screening test may be useful in individuals fro whom the results of this test would be expected to change or influence therapy. However, this test is not part of the standard of care. Research studies have found that coronary artery calcification is more frequent in patients with lupus than in healthy controls. However, we do not yet know if this calcification equates to development of heart attack in patients with lupus. The vulnerable or non-calcified plaques are the ones that lead to acute heart attack from plaque rupture.
Would you recommend women -- especially with lupus and a significant family history of heart disease -- have a yearly CT heart scan (something that was mentioned on the Today Show)? I can't remember the exact name of the scan.
I think you mean the CT scan to measure the coronary artery calcium. As I mentioned above, this test is not the current standard of care. Therefore, a yearly CT heart scan is not recommended until further studies have proven otherwise.
Does taking large doses of Ecotrin hurt or help my heart? I take around 2400 mg a day for pain. I'm not sure if that has the same effect as a baby aspirin would. -- Gaithersburg, MD
Aspirin use is recommended by the American Heart Association for patients who have had a heart attack, angina, stroke or mini-stroke, as long as the patients do not have conditions (such as aspirin allergy, bleeding disorders and peptic ulcer) that prevent aspirin use. Baby aspirin may be recommended in patients at high risk to prevent heart disease. The high dose of aspirin may put you at risk for gastrointestinal bleeding or tinnitus (ringing in your ears).
I am 46 years old, was diagnosed with lupus 10 years ago, with mitro valve prolapse. I don't have insurance. What risks do I face?
Mitral valve prolapse does not put you at increased risk for coronary heart disease. However, if your mitral valve develops vegetation and become leaky, you will need to take prophylactic antibiotics when you undergo procedures with increased risk for bacteremia (bacteria in the blood) such as dental procedures. To learn more about insurance resources, please contact the LFA Health Educator at 202-349-1159 or LupusInfo@lupus.org.
Other than the routine recommended heart disease preventions (weight, exercise, no smoking, children's aspirin, etc.) do you recommend taking multivitamins, DHA/omega supplements or any other additional vitamins? There is a lot of conflicting information out there about the alleged benefits of vitamins and other supplements and the effects on heart disease. – Baltimore, MD
Omega-3 fatty acid from fatty fish may benefit the heart. DHA or docosahexaenoic acid is one kind of omega-3 fatty acid. The ways that omega-3 fatty acids reduce cardiovascular risk are still being studied. It is true that information regarding the benefits of vitamins and supplements can be conflicting on their effects on heart disease since alleged benefits may be first observed in observational studies, which need to be confirmed with randomized clinical trials. For example, researchers conclude that there is no role for antioxidant supplements such as vitamin E and beta carotene in prevention of cardiovascular disease. However, it does not preclude food sources of antioxidants and vitamins that do not necessarily occur in the supplement form. A well-balanced heart-healthy diet, including fruits, vegetables and whole grains, is better than swallowing a bunch of vitamin and supplement pills.
My wife was diagnosed 4 years ago with SLE. 15 years ago, she had a Monostrut mitral valve implanted. In the last few years, she has developed tricuspid and aortic moderate insufficiency. Is it to be feared that her situation will worsen as time goes on?
Unfortunately, the presence or change in valvular disease in SLE is not related to SLE disease activity, therapy, or duration of having SLE. Therefore, we cannot predict if her situation will worsen.
What is the risk of cardiac involvement with SLE and lupus nephritis? – Mason, MI
Patients with lupus nephritis, like non-lupus patients with chronic kidney disease, are at increased risk of coronary heart disease. The reasons are several folds. First, patients with lupus nephritis usually have elevated blood pressure from injury to the kidney. Second, some patients with lupus nephritis can have significant loss of proteins in the urine, leading to high cholesterol levels. This loss of protein in the urine can also lose some important proteins that can prevent blood clot formation. Furthermore, the treatment of lupus nephritis using high dose of corticosteroid may worsen the cardiovascular risk by increasing the cholesterol and blood sugar levels but at the same time may reduce the cardiovascular risk by reducing the inflammation. These are some of the reasons for the increased risk in patients with lupus nephritis.
I see a cardiologist for an aortic insufficiency. Last time I saw him, I requested a full heart check-up which he said was unnecessary. I told him that people with lupus have a high degree of heart disease and he seemed surprised to hear this. I would like to give him some literature. Do you know where I can obtain some? -- Falls Church, VA
Here is the link to the Lupus Foundation of America article on lupus and heart disease (PDF), published in Lupus Now magazine.
Do you think that taking an inmunosuppressant like Neoral (cyclospororine) increases the risk of heart problems? I am also a kidney transplant patient.
Immunosuppressants can reduce inflammation in patients with lupus, which can reduce the cardiovascular risk. Cyclosporine may affect the cholesterol level and kidney function as part of the side effect profile, which can be monitored closely. Cholesterol-lowering medications can treat the high cholesterol levels. As a transplant patient, you should have routine assessment and management of cardiovascular risk factors as I mentioned earlier.
I am in heart block, pacemaker, CHF, clots, MI, SLE. I have CP and increase pressure in chest doing anything. What could it be? I can't breath. It’s been getting worse for over a year. -- Richmond, VA
You should discuss with your cardiologist for further evaluation. You may need a cardiac catherization (injection of contrast material/dye to check for blockage of blood vessels to your heart).
In addition to heart murmurs, I now have irregular heart beats. Also, with minimal activity, my face becomes blood red and I sweat profusely. My heart races. Also, I had a major stroke in 2003 and several mini-strokes since then. Can SLE cause these problems? -- New Salisbury, IN
Patient with SLE are at increased risk for heart attack and stroke. You will likely need cardiac evaluation that include cardiovascular risk factor assessments and stress thallium/echocardiogram since you are at high risk with a history of stroke and your current symptoms.
That is all the time we have for today’s chat. Thank you to Dr. Amy H. Kao for joining us.
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