From the National Magazine

Lupus in Love

Dr Feza Erkeller-Yuksel
Barnet & Chase Farm Hospital NHS Trust, London

Lupus patients know that lupus likes the skin, the joints, the lungs, the kidneys and the blood however, what some patients and even some doctors may not be aware of is that most importantly lupus loves the heart.

Since most lupus patients are young or middle aged woman we do not usually investigate whether they have any evidence of coronary heart disease unless there are any obvious signs or symptoms. However, in the last decade we have seen more and more reports about increased frequency of heart disease and strokes in lupus patients. In my opinion not enough was done to prevent our patients going down the same route. Doctors who treat lupus patients always have had anecdotal experience of coronary heart disease and strokes in very young patients. We usually related strokes with other manifestations of lupus, and thought of the heart attacks and anginas as 'bad coincidences'.

Today I think coronary heart disease is one of the most important features of lupus because it is a leading cause of mortality and morbidity. One could initially come up with a theory to say that lupus patients now survive kidney disease and infections better than before and therefore they reach an older age, which is why they suffer from increased heart disease. Contradictory to this there are a number of studies to show that lupus patients are likely to develop coronary heart disease at a younger age than the rest of the population. Different studies show that risk of coronary heart disease related events are 5-10 times more frequent in lupus patients and this is usually independent of the usual risk factors of heart disease. Lupus itself is the strongest link. Some lupus patients have the other usual heart disease risk factors as well.

I have been seeing lupus patients for at least seventeen years and until recently I was more interested in patients day-to-day problems rather than looking ahead. I returned from a meeting in Sweden two years ago determined to see what risk factor our lupus patients had, concentrating on those factors we could treat or prevent so that we could reduce their chances of sustaining a heart attack. I planned a local audit for this purpose and Dr H Sinclair from neighbouring North Middlesex Hospital enrolled her lupus patients as well. A total of 90 patients were screened and the average age group was 50. Result of our audit showed that 41% of our patients were being treated for high blood pressure and as a result of this treatment average blood pressure was normal. As far as other risk factors looked at, 19% were smokers, 11% were receiving treatment for under-active thyroid, and 2% were diabetic. Eight percent of our group was already diagnosed with coronary heart disease, 26% knew about family history of high cholesterol, 10% had family history of strokes and another 10% had anticardiolipin antibodies in their blood. Sixty three percent of our patients were either current or previous steroid users.

Although nearly 50% of our patients had high cholesterol levels, only 18% were receiving treatment for this.

This small audit also reminded us that there are some actions we can take to reduce risk of cardiovascular disease in our patients like encouraging them to stop smoking, reducing cholesterol levels in their blood with tablets, inquiring about chest pain and so forth. We will be more vigilant in investigating any coronary related problems. Patients may be able to help themselves by eating a healthy diet and exercising as much as their illness a1lows.

There is still no consensus about a cut off point of abnormal cholesterol leve1 and when and who should be treated with tablets. Some colleagues in the US treat almost all patients with lupus to prevent heart disease even if they have normal cholesterol levels. Dr A. Rahman and Prof D. Isenberg have conducted a recent study to see what lupus specialists across the world do about this problem. The majority of the 3l lupus specialists who have responded to their questionnaire would check fasting lipids routinely every 1-2 years and advocate a lipid lowering diet and/or treatment if the levels are high. Cardiac investigations are generally performed if there is any need rather than a routine test. On the other hand some researchers strongly advise routine tests.

I have not chosen this topic to worry lupus patients but simply wanted to arm them with the knowledge so that they may be able to better look after themselves. The topic is still much discussed amongst lupus specialists and I am sure most lupus patients like to know about new developments. I certainly like to keep in touch with my local LUPUS UK Group and inform them of the results from our clinic. I think it is in everyone's interest to look for risk factors of cardiovascular disease and to take all possible precautions in order to avoid heart attacks and strokes.

I can summarise the whole thing with a single sentence - Don't let lupus get close to your heart.

Thank you, Dr Yuksel for this informative article. Clearly, by being informed, lupus patients can help lessen the risk of cardiovascular disease.

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