Chat Transcript for Dr. Susan Manzi,
February 27, 2007
Moderator
Good afternoon. The Lupus Foundation of America is pleased to welcome Dr. Susan Manzi. Dr. Manzi is currently Associate Professor of Medicine, Associate Professor of Epidemiology, Associate Professor of Dermatology, and a member of the Cardiovascular Institute of the UPMC Health System. She also co-founded the Lupus Center of Excellence at the University of Pittsburgh Schools of the Health Sciences and the University of Pittsburgh Medical Center.
Dr. Manzi graduated magna cum laude from the University of Notre Dame. She received her MD from the University of Pittsburgh, School of Medicine. A major emphasis of Dr. Manzi’s research is pathogenesis and associated risk factors of premature cardiovascular disease in young women with systemic lupus erythematosus (SLE).
Dr. Manzi serves on the Medical-Scientific Advisory Board for the Lupus Foundation of America. We welcome Dr. Susan Manzi, and thank her for joining us this afternoon.
Moderator
This question comes from PA. I have been just diagnosed with a weakened heart via. a heart catheterization. What do we mean when we say heart disease?
Dr. Manzi
The heart can be affected in many ways in lupus patients. The most common problem is inflammation around the lining of the heart. This is called pericarditis. Pericarditis causes chest pain with deep breathing that is worse when lying flat, relieved with sitting forward. Sometimes you may have shortness of breath and fever. Often the diagnosis is confirmed by an ultrasound of the heart (echocardiogram), which can show fluid around the heart. There may also be abnormal findings on an EKG, or CAT scan of the chest. Sometimes these tests may all be normal, but the history and physical exam suggest pericarditis. The best treatment is anti-inflammatory medications such as NSAIDs or prednisone. In some cases other immunosuppressive medications may be needed. In rare cases, the fluid around the heart may become so large that it must be drained. Fortunately this is rare and many patients do well with medications. Lupus patients may also have problems with their heart rhythm. The most common is a low heart rate that may require a pacemaker. Inflammation of the heart muscle may cause heart failure. This has been called cardiomyopathy, which means a heart muscle problem. The most common reason for this is uncontrolled high blood pressure, which puts a strain on the heart or coronary artery disease. The heart valves can be abnormal in lupus. A heart valve problem can be found by hearing a heart murmur on examination or by finding abnormalities on an echocardiogram. Most patients have no symptoms and no special treatment is required, except short courses of antibiotics prior to dental procedures in some cases. In rare cases, the valve problem may cause shortness of breath, and heart failure and a valve replacement is needed.
Finally, an often over looked problem is coronary artery disease. This is caused by plaque build up in the coronary arteries and can lead to heart attacks. Some patients may have angina (chest pressure with exertion or exercise that goes away with rest). Others may have shortness of breath, jaw pain, left arm pain and they may present with a heart attack. Because many patients with lupus are young women … they don’t recognize these symptoms as being coronary artery disease. They may think that they are too young for this, but not in lupus. It can occur prematurely.
Moderator
Our next question comes from Florida. What is the age that most women are when heart and blood vessel disease first occur?
Dr. Manzi
This is the most concerning part of the problem. Although heart disease is the leading cause of death for women in the United States, it usually does not occur until after women go through the change of life (menopause). This is usually around the age of 55 or 60. In lupus, women between the ages of 35-45 years have a 50 times greater chance of having a heart attack than women without lupus. Overall the risk of coronary disease is about 10 times more likely in women with lupus at all ages.
Moderator
This next question is from NY. To what degree does inflammation play a role in the development of cardiovascular disease in patients with lupus, and what causes coronary heart disease in lupus?
Dr. Manzi
Inflammation likely plays a role. We don’t know for sure what causes heart disease in lupus, but it is probably a combination of traditional risk factors and factors related specifically to lupus. Traditional risk factors such as high blood pressure, high cholesterol, obesity seem to occur more frequently in patients with lupus. These risk factors will increase your chances of getting coronary heart disease. However, the high risk of heart disease that we see in lupus cannot be fully explained by high cholesterol etc. There appears to be factors related to the inflammation and immune system abnormalities in lupus patients that increase the risk. It is also possible that the medications we use to treat lupus may not help. For example, if you are taking high doses of prednisone, it may lead to weight gain, diabetes, high blood pressure and prednisone may also increase cholesterol levels. It is possible that as we develop more effective treatments for lupus that can decrease inflammation, we will also be able to control the coronary heart disease.
Moderator
Michelle from Maryland asks. Do anti-dsDNA antibodies directly attack the heart? Are there other lupus specific risk factors that increase the risk of heart disease?
Dr. Manzi
Antibodies to dsDNA are associated with kidney disease in lupus. We don’t know if they play a role in heart disease. Patients with chronic kidney disease and those on dialysis have a higher risk of heart disease. We know that patients with antibodies to phospholipids (anti-cardiolipin antibodies, lupus anticoagulant) are clearly at increased risk for blood clots and stroke. It is less clear whether these antibodies are related to coronary heart disease. We do not have any evidence that other antibodies like those to SSA play a role in coronary disease.
Moderator
Our next question comes from Texas. What steps should lupus patients take in order to identify heart disease at its earliest stages?
Dr. Manzi
For now, we recommend that anyone with symptoms of angina, chest pain or pressure, jaw pain, left arm pain or shortness of breath with any activity be evaluated for coronary disease. This may require special exercise testing, echocardiogram, thallium scan, etc. You should report to an emergency room or call your doctor if you have prolonged chest pain and shortness of breath. You must learn your own body signals. Some patients have tenderness of the chest wall and pain that changes with different positions. This may occur on a regular basis. This is less likely from your coronary arteries. If you develop new symptoms, discuss this with your doctor.
Moderator
Maryland has a question. I recently read that statins may not work as well in patients with lupus. What can I do to prevent heart disease?
Dr. Manzi
This is the most important question! We do not know whether statins (cholesterol-lowering drugs) will be as beneficial in lupus patients as they are in the general population. However, until there is strong evidence to show that they are not, we recommend that all lupus patients with elevated cholesterol be placed on a lowering agent if possible.
The first step to prevention awareness of the problem! Be your own health advocate. Not all doctors are aware of this problem! We recommend seeing a preventive cardiologist if there is one available near you. These doctors are trained to address all of the common risk factors for heart disease. At our Lupus Center in Pittsburgh, the preventive cardiologist is a part of the team of doctors that take care of our patients, along with the kidney specialists, rheumatologists, dermatologists, etc.
A few other important points for prevention include the following. Make sure you eat a well-balanced and heart healthy diet and be sure to exercise as best you can. This may mean low impact programs like walking, yoga, etc. Have your cholesterol checked and begin lipid lowering agents if your cholesterol level is elevated. Make sure your blood pressure is under good control, and keep your weight as close to ideal body weight as possible. If you have a family history of heart disease, this will increase your risk even further. You may benefit from a baby aspirin every day. We know that this has been shown to prevent strokes in women. Until we know for sure how prednisone affects your heart, we recommend using the lowest dose needed to control your disease. It is important that your lupus is under control.
Moderator
Texas asks another question. I am a RN, have lupus, CAD and have had two stents placed in the LAD. I continue to have chest pain and my doctor says I have 70-80% in other vessels. When the stents were placed, he had difficulty because of the hard plaque and couldn't inflate the balloon. It took quite an effort on his part. Are lupus patients helped by the usual treatments such as stents and bypass surgery for coronary heart disease?
Dr. Manzi
There are no special instructions for lupus patients who need these procedures. There is some evidence that lupus patients may be more likely to re-occlude (block) a coronary stent than those without lupus in the 6 months to 1 year following placement. It may be important to discuss anti-platelet therapy with your doctor after the procedure. Many patients with lupus undergo successful bypass surgery.
Moderator
Massachusetts asks the following question. Can you speak to the topic of cardiovascular problems associated with lupus as it may pertain to men? Is it different in men?
Dr. Manzi
This is an excellent question. We know less about coronary disease in men with lupus since most patients with lupus (about 90%) are women. However, from what we know, men share the same increased risk of coronary disease and should practice the same prevention measures that we discussed earlier. Keep in mind that men have a higher risk for heart disease than women from the start.
Lupee asks ...
Will low impact exercises help in the prevention of a stroke?
Dr. Manzi
Exercise has many advantages and it does not need to be high impact. Exercise can lower blood pressure, reduce stress, improve weight reduction, improve symptoms of depression, decrease pain and anxiety. All of these benefits will reduce your risk for heart disease and stroke. This may mean 10-15 minutes a day if that is all you are able to do. A little exercise is better than none at all. I like to have patients begin slowly and find a program that is easy to do.
Diet is also very important. It is probably even more important because you have lupus. We know that lupus increases the risk for heart disease and stroke. When you add to that obesity, high cholesterol, etc., you are drastically increasing your chances for stroke and heart attack. A low fat, low sodium (if you have blood pressure problems) diet is important. Minimizing sugar and maximizing vegetables, fish and meats low in fat is ideal. Eating well makes you feel better and also gives you an extra boost of energy for exercise.
Moderator
This final question is from VT. What does the future hold for lupus patients, and the prevention and treatment of coronary artery disease? And, can you also address the distinction between vascular and coronary disease?
Dr. Manzi
Vascular disease is a broad term used to describe problems in blood vessels that go beyond the coronary blood vessels or the blood vessels that supply the brain. Unfortunately in lupus all blood vessels are the target for disease. Lupus patients can get inflammation (vasculitis) and blood clots in the vessels of the eye (retina), the arms and legs, the lungs, etc. They can even get cholesterol build up and plaque in the legs and the main artery of the body called the aorta. Some patients require bypass surgery to open clogged vessels in the legs, just like the heart. Vascular disease in lupus is systemic (all organ systems).
A closing note: This is an exciting time for patients with lupus! Never before have more health care professionals, volunteer organizations and pharmaceutical companies taken a greater interest in improving the lives of patients with lupus. Organizations like the Lupus Foundation of America and programs like this website chat room empower you to take control of your disease like never before. More doctors are becoming aware of the problem and more aggressive prevention strategies are beginning to surface. We believe that with the novel therapies for lupus on the horizon…coronary disease and stroke will become much less of a problem. The future is bright!
Moderator
That is all the time we have for today’s chat. Thank you to Dr. Susan Manzi for joining us today.
Please join us Wednesday, March 7 at 3 p.m. EST for our guest Dr. Robin Brey from the University of Texas. Dr. Brey will discuss the central nervous system and lupus.
Connect with Us: