The Expert Series: Lupus and Heart Health

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Host  0:03  
Welcome to The Expert Series brought to you by the Lupus Foundation of America. Our topic today is lupus and heart health. Heart attacks and cardiovascular disease are now the leading causes of death and people with lupus. Many factors contribute to cardiovascular disease, and lifestyle choices can improve one's heart health. In today's episode, we will discuss the importance of understanding the risk of cardiovascular disease, some of the warning signs and causes of concern and the ways patients can take action to lead longer, healthier lives. I am thrilled to introduce Dr. Jim Oates, Director of the Division of Rheumatology at the Medical University of South Carolina, currently serving as the Associate Editor for the American Journal of Medical Sciences and Vice Chair for Research for the Department of Medicine at MUSC. Thank you Dr. Oates for joining us.

Dr. Oates  1:00  
Lupus is a chronic inflammatory condition that ramps up the immune system to react against various parts of the body and how this shows itself clinically, really varies from one patient to another. And as a background, your immune system in the setting of an infection normally activates itself to protect you. But when that infection goes away, the inflammation resolves. The problem in lupus is this kind of inflammation persists even in the absence of an infection. And a common cause of long-term chronic inflammation in lupus patients is cardiovascular disease. This is due to a narrowing in blood vessels to the heart or brain or other organs. And when this narrowing becomes a blockage, heart attacks, heart failure and strokes can occur. And these occur in lupus patients at a younger age and a greater number than the general population. Risk of heart disease is increased by about seven to nine times in lupus patients compared to those who are the same sex or age in the general population. So there are other things that lupus can do to the vascular system and one I mentioned earlier is heart failure. And this can happen even in younger patients with lupus and is often due to long-standing or poorly controlled high blood pressure. And oftentimes that's in the setting of kidney disease and lupus. However, it could be due to inflammation in the heart; this is more rare. That's caused by the lupus or inflammation in the heart from a viral infection. Another thing lupus can do is it can cause inflammation around the lining of the heart; it's called pericarditis. Patients may notice this is pain that is worse with lying down. And it lasts for 12 hours or more, and can resolve with anti-inflammatory treatment. So another thing that can happen with lupus and even outside the setting of lupus is that certain blood factors can predispose to blood clots, and these are called anti-phospholipid or anticardiolipin antibodies, and they can cause abnormal growths on heart valves and lead to valve dysfunction or leaky valves, but they can also lead to a sudden blood clot - either presenting as a heart attack or a stroke or clots in the veins in the leg that move to the lungs, so-called pulmonary emboli, and your doctor can test for these factors or any phospholipid antibodies to know your risk for this. 

Dr. Oates  3:35  
Heart disease in lupus patients is again is thought to be due to chronic inflammation that is not well controlled. Therefore, it's important to treat disease activity with long-acting steroid-sparing medications that control the disease. Taking medicines that reduce the chance of flares, such as hydroxychloroquine, or Plaquenil, are associated with less heart disease. Prednisone, which is very effective and works well in the short term to control inflammation, patients feel much better on it, but they should know that it can actually make heart disease worse if taken in the long term. In addition, risk factors that we traditionally think of with heart disease are also important and lupus, and these are kidney disease, high blood pressure, high cholesterol, diabetes, obesity, inactivity and smoking. And this point was nicely illustrated in a recent publication by our colleagues in Toronto, Urowitz and Gladman. And they looked at lupus patients who went into their clinic in two different cohorts - one between 1975 and 1987, and another between 1999 and 2011. They followed these patients long term. And the patients who were in the more recent cohort actually had a 60% lower incidence of heart attacks, angina, strokes, transient ischemic attacks or heart failure, and they noted that the patients in that more recent cohort had better control over lupus disease activity and better control over traditional risk factors for heart disease. So this really gives us hope that the risk of heart disease and lupus patients can be reduced if we control disease, more rigorously, reduce the use of prednisone and have better control over risk factors - that are the traditional risk factors we think of in lupus. 

Dr. Oates  5:28  
So this means that lupus patients themselves have more control of their own outcomes by making smart choices every day. So a diet that is low in processed foods, red meat and trans fats is the first step. And patients often ask me, "How do you do that?" And a good resource is going to the sites on the Mediterranean diet or the DASH diet. The latter diet is for those who have high blood pressure and is very similar to the Mediterranean diet. So either one is, is useful. These diets eliminate processed foods and are high in vegetables and fruits and good fats from fish and olive oil and nuts. And they have again, fishes the primary meat protein. If you smoke, you should stop now. Smoking kills close to half a million people every year. And that's true for lupus patients as well. Inactivity is the new smoking, and it's responsible for one in 10 deaths in the United States. Therefore, patients should engage in 150 minutes across a week of moderate exercise. And that's the kind of exercise where you increase your heart rate and your breathing when you're exercising, but you can sustain the exercise. So it's not like high intensity where you have to take a break because you're short of breath. But even 10 minutes a day makes a difference. Some good examples of this are walking or taking the stairs rather than driving or taking an elevator and those are good examples of ways to fit exercise into a busy day. If you have arthritis, and this limits your ability to do these kinds of activities, the National Resource Center on Lupus is a good resource for how to accomplish this. If your knees are a problem or your hips or your ankles, getting in a pool and swimming or walking is a wonderful way to get exercise while taking the weight off of those painful joints, and chair exercises are also possible. So work with your primary care provider to make sure your weight, your blood pressure, your blood sugar and your cholesterol are at safe levels. Work with your rheumatologist to control your lupus activity and minimize the use of prednisone. 

Dr. Oates  7:44  
I'd like to move into signs and symptoms of heart disease themselves when they present acutely. And while we want to prevent cardiovascular disease, it really pays to know the warning signs of an acute event. The most patients with lupus or women and heart disease is not always present in the classic fashion. But these are signs and symptoms to look out for. Symptoms of angina or heart attack might be pressure in the chest or tightness. Some people describe it as like having an elephant on your chest. And it may be associated with some shortness of breath, sweating or nausea. And this sensation may radiate to the jaw or the arm. And if this lasts longer than 15 minutes, you really should seek immediate attention. If this occurs with exercise, but goes away with rest, it's less urgent in terms of needing to go to the emergency room, but you really should let your primary care provider know as soon as this happens. Stroke symptoms may include problems with speech or weakness on one side of your body either in the face or the arm or the leg. And if this occurs, you should immediately go to the emergency room there's a four-hour window after a stroke occurs where you need to address it or permanent damage can occur. Finally, heart failure can present as swelling in the legs, and then shortness of breath, particularly when lying down. All this sounds pretty scary. But remember that prevention is the way to avoid these acute problems and medical providers can help with these risk factors as we discussed before, but only patients are in control the choices they make about what they eat, how much they exercise, and whether they choose to smoke cigarettes or not. These choices are as important as the pills that we take to prevent heart disease.

Host  9:31  
Thank you Dr. Oates for joining us today. We appreciate all the great information that you've shared about heart health with lupus. For those listening in, we invite you to check out additional segments of The Expert Series at lupus.org. If you'd like to learn more about living well with lupus, you can find additional resources on the National Resource Center on Lupus or you can call one of our Health Educators at 1-800-558-0121. Thank you and have a wonderful day.