"Cardiovascular Health & Lupus" Chat Transcript for Dr. Amy H. Kao
February 12, 2009Moderator
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.
Dr. Kao’s work has been funded by the American College of Rheumatology, the Arthritis Foundation of Western Pennsylvania, National Institutes of Health, and the Pittsburgh Foundation.
We welcome Dr. Kao, and thank her for joining us this afternoon.
Dr. Kao
I like to begin by providing a brief background. When we speak of "heart disease" in lupus, we mean coronary heart disease from atherosclerosis, a process that occurs when fatty deposits and immune cells (inflammation) 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 have as high as 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 cardiovascular risk and looking for ways to reduce these risks. Unfortunately, we do not yet have established guidelines on the prevention of “heart disease” in individuals with lupus.
Other parts of the heart can be involved in systemic 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. 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 less common, which may cause irregular heart beat or heart failure.
Moderator
Without further delay, let's begin. How does preventive cardiology help with lupus? I've heard that it's very helpful but I have not found such doctor in my area. -- El Paso, TX
Dr. Kao
Preventive cardiology includes evaluation of cardiac risk factors that include cholesterol levels, high blood pressure, diabetes, cigarette smoking, and family history of heart attack or stroke. Primary care physician can begin this assessment by ordering the fasting cholesterol blood work (lipid profile). Cardiologist in your area can then complete this assessment. The goal of preventive cardiology is to treat any preventable cardiac risk factors since having lupus increases the risk of having cardiovascular disease.
Moderator
If the heart is affected with people who have lupus should your physician be setting some tests up with a cardiologist? Do you wait until you have so kind of symptoms like chest pains or shortness of breath? -- Hermitage, PA
Dr. Kao
This is where preventive cardiology comes in. Although there are no established guidelines in preventing cardiovascular disease in individuals with lupus, it does not make sense to wait for cardiac symptoms to occur before doing any preventive measures. Primary care physician can begin this assessment by ordering the fasting cholesterol blood work (lipid profile). Cardiologist in your area can then complete this assessment. The goal of preventive cardiology is to treat any preventable cardiac risk factors since having lupus increases the risk of having cardiovascular disease.
Moderator
Do people with discoid lupus have as high of a risk for cardiovascular disease as those with SLE? -- Colleyville, TX
Dr. Kao
Individuals with only skin form of lupus usually do not have a higher risk for cardiovascular disease as those with systemic involvement. However, if the treatment of discoid lupus requires systemic steroids (e.g. oral steroids) frequently, steroid use may create cardiovascular risk factors including elevated blood sugar levels, cholesterols and blood pressure.
LupieLeBean
How does a person know when chest pains are due to lupus or something more serious to be concerned about?
Dr. Kao
There are many causes for chest pain. You can have sharp chest pain or pressure pain. The causes include angina, blood clot, or inflammation of the lining of the heart or lung. Therefore, it is important to contact your physician immediately.
VH
Is routine ECG important in lupus patients?
Dr. Kao
There are no established guidelines in terms of having baseline ECG to assess for cardiovascular disease.
Moderator
Is the treatment for someone with lupus who suffers an acute cardiac event the same as it would be for the general population, or do extra measures need to be taken? -- Sylvania, OH
Dr. Kao
Someone with lupus and had an acute cardiovascular event should obtain the basic treatment and secondary prevention as the general population. Furthermore, this lupus patient should also check for presence of antiphospholipid antibodies since these antibodies are associated with increased risk of thrombosis and anticoagulation therapy may be needed. The maintenance steroid dosage in the treatment of lupus should be minimized since steroid can promote atherosclerosis. However, if lupus is active and requires higher dose of steroid temporarily, treating the inflammation may reduce cardiovascular risk. The role of steroid in cardiovascular disease remains controversial.
Moderator
How can we get health professionals to measure homocysteine levels in lupus patients to screen for this under-recognized risk factor for cardiovascular disease? Particularly those on methotrexate, which tends to raise homocysteine levels? With treatment for hyperhomocysteinemia being so cheap and over the counter, it seems a prudent and cost effective way to reduce CV risk. -- Littleton, CO
Dr. Kao
Several large randomized controlled studies did not show treatment that lower homocysteine levels in the individuals with hyperhomocysteinemia helps with cardiovascular disease. However, these types of studies have not been done in lupus patients. We routinely prescribe folate (folic acid) for patients on methotrexate therapy to reduce its side effects. Folic acid may lower the homocysteine level but we do not yet know if it will reduce CV risk. Please discuss with your cardiologist.
Dee
Are there any types of heart medications that may be used to treat heart problems in SLE that should be avoided by patients with SLE?
Dr. Kao
There are no heart medications that patients with SLE should avoid taking. Certain medications to treat high cholesterol levels may have more side effects, such as muscle cramps, in patients with SLE. You can ask your cardiologist and rheumatologist to discuss with each other and to verify the heart medications first.
LupieLeBean
When I asked my rheumatologist when I should be concerned about organ involvement with lupus, she said that after taking medication for a year, you see what pain is left and then evaluate it. I react to all medications and therefore don't take any. I fear the damage that could be happening to my heart as well as other organs, especially when I have severe chest pain and am at a loss as to what to do.
Dr. Kao
Having lupus puts you at increased risk for coronary heart disease. Untreated lupus leads to chronic inflammation, which not only can promote heart disease but can also lead to damage in other organ. Acute inflammation in tissues may lead to irreversible organ damage. Therefore, it is important to take the medications or find the one you can tolerate to keep lupus under control. You may consider seeing a cardiologist for evaluation of your severe chest pain and preventive care.
Moderator
I had been on Lipitor long term and had severe problems with muscle cramps etc. Other meds (Crestor etc.) had the same effect. What are some other things – like fish oil, and cinnamon -- that work? And in what typical dose would you use if you have high cholesterol? -- Corpus Christi, TX
Dr. Kao
The lipid-lowering agents (statins) you listed work very well in treating the high cholesterol. Other medications, such as niacin and ezetimibe, can be used if you cannot use these statins due to their side effects. You should discuss with your cardiologist. Your cardiologist can work with you in adjusting the dosage depending on your cholesterol level and tolerability. Fish oil can be used in conjunction.
Toosie
Can kidney disease affect your heart, lungs, and other organs? In Nov., a nephrologist, whom I saw for the first time, diagnosed me with stage 3 chronic kidney disease. The same day I asked my rheumatologist why my diffusing lung capacity was 69% of expected and he said "You have restrictive lung disease."
Dr. Kao
Patients with kidney disease, regardless of having lupus, have a higher risk for coronary heart disease. These patients may have additional cardiovascular risk factors, such as high blood pressure and abnormal cholesterol levels. Therefore, it is advisable to have preventive cardiology evaluation. Lupus can affect other organs. Therefore, you can consider seeing a pulmonologist for further evaluation of your lung disease.
Moderator
My 15 year old daughter has had lupus for 6 years. She recently completed the APPLE study for pediatric lupus patients. Are there any updates on the research regarding pediatric patients & Lipitor? Also, are there special tests she should be having on a regular basis to make sure she has good heart health? -- Dale City, CA
Dr. Kao
Atherosclerosis Prevention in Pediatric Lupus Erythematosus (APPLE) study has just completed the recruitment. We do not know the results yet. Currently, similar to adult lupus patients, there are no established guidelines in cardiovascular prevention in pediatric lupus patients. Healthy diet and regular exercise may promote good heart health.
Moderator
I have SLE and RA; my diagnosis was made on my 50th Birthday in 2006. Does being a male affect my risk of heart disease in lieu of being diagnosed late in life? -- St. Paul, MN
Dr. Kao
There is not as much data in male patients since these diseases more commonly affect women. However, having chronic inflammation from lupus and rheumatoid arthritis likely puts you at a higher risk for heart disease even if the diagnosis is made later in life.
Steve
How does lupus increase cholesterol levels? Is the increase in cardiovascular disease in lupus patients due to increased cholesterol levels or increase tendency of inflammation?
Dr. Kao
Lupus can cause abnormal cholesterol levels by itself and also from the medications used to treat lupus, such as steroids. Increased/abnormal cholesterol levels and inflammation are part of the "lupus factors" in cardiovascular disease. Some other "lupus factors" included antibodies that can affect the blood vessels and cumulative damage from lupus.
It is advisable that SLE patients should have primary care physicians to maintain general health care (including treating colds and providing age-appropriate cancer screening). It is no mandatory to be seen by a cardiologist since many primary care physician can initiate some preventive cardiology by checking and managing high blood pressure and abnormal cholesterol levels.
Moderator
I work out twice a week in the gym, doing fitness and aerobic/steps workouts. Do you have more tips for my cardiovascular health? -- Amsterdam, Netherlands
Dr. Kao
This is great that you are doing moderate intensity exercises. Other tips for improving cardiovascular health include: NO cigarette smoking, eat food with omega 3 (fatty fish or fish oil supplement), and make sure that blood pressure and cholesterol levels are within normal range.
Moderator
My father had several heart attacks at age 55 and died at age 71 (having lung cancer) of a heart attack. I was diagnosed with SLE with rheumatic and skin issues last year at age 34. Should I be worried? -- Amsterdam, Netherlands
Dr. Kao
Instead of being worried, you can take a proactive role. You can discuss with your doctors that you like to see a cardiologist for preventive cardiology assessment since you have increased cardiovascular risk with family history of heart attack and having lupus.
Moderator
A few days after the birth of my son, I was hospitalized for myocarditis and a pulmonary embolism. When myocarditis heals, does it leave any damage to the heart or put me at any increased risk of heart involvement in the future from SLE? Should I be taking any special precautions to protect my heart since having myocarditis? -- Jacksonville, FL
Dr. Kao
Myocarditis is inflammation of the heart muscles. Some may recover their cardiac function and some may have residual cardiomyopathy, meaning that the cardiac function is reduced. Having myocarditis does not mean that you’ll have higher risk of developing heart attack. However, if your pulmonary embolism is related to the presence of antiphospholipid antibodies and not just from the pregnancy, then you will be at increased risk for cardiovascular event from being hypercoagulable (increase tendency to clot). You should discuss this further with your rheumatologist and cardiologist.
Moderator
I have pericardial effusion which fluctuates from mild to moderate; echoes have shown some compromise in the past but none last time. Terrible pains in the chest area where my heart is woke me up once and lasted 8 minutes, scaring me. The cardiologist on call told me not to worry -- it was probably inflammation of area around heart sac. I also have positive anticardiolipin antibodies. I take Premarin (estrogen) and really need it as I am surgically menopausal. What can I do to protect myself from heart attack or stroke? I am on Plaquenil and live healthy. -- Bend, OR
Dr. Kao
Pericarditis may put you at risk for cardiac arrhythmias (irregular heart rate) from the inflammation causing irritation to the heart. Typically, we are concerned about increased risk of thrombosis with the presence of anticardiolipin antibodies (antiphospholipid antibodies) and estrogen use since estrogen therapy can be prothrombotic. Please discuss the risks and potential benefits with your cardiologist.
Moderator
The final question for today's chat comes to us from Provo, Utah. A couple of years after I was diagnosed I developed a heart murmur. Twenty years later I had open heart surgery to repair the mitral valve. Is it possible that this valve was damaged due to Lupus? I also have experienced arrhythmia a couple of times. My cardiologist shocked my heart and it returned to normal rhythm. Is that also related to Lupus or some other problem?
Dr. Kao
Patients with lupus who have antiphospholipid antibodies may develop valvular disease, caused by vegetations on the heart valve. Patients with valvular disease are more likely to develop arrhythmias or irregular heart beat. Please discuss with your cardiologist.
If you have any questions regarding lupus and heart disease, please feel free to discuss with your rheumatologist.
Moderator
That is all the time we have for today’s chat. Thank you to Dr. Amy H. Kao for joining us.
Please join us Wednesday, March 11 at 3 p.m. Eastern for our guest Dr. Brad Rovin, who will discuss Kidney Involvement & Lupus.
Help spread the word about our lupus chats. See you next time.
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