Cardiac Events In People With Lupus

A new study shines light on the treatment of cardiac events – one of the most common complications of lupus – in people with CLE.

Researchers have known for decades that people with systemic lupus erythematosus (SLE,) the form of lupus that affects organ systems throughout the body, were at higher risk of cardiovascular disease. 50% of people with lupus will experience some form of heart or circulatory system complication in the course of their chronic disease, about a 13-15% higher risk over 10 years compared to the general population. 

Cardiovascular (CVD) complications in the heart, lungs, and brain are one of the most common complications of lupus. Typically, CVD symptoms are treated with lifestyle changes (exercise, diet , avoiding alcohol and tobacco , among other therapies) and with medications. NSAIDs such as aspirin (which also has a blood thinning component,) and other lupus medications reduce inflammation and, in the process, reduce all symptoms of lupus – including cardiovascular. Warfarin, a powerful blood thinner, may be used in some cases. There are also medications that regulate heart rhythm or inhibit enzymes that would normally control the heart rhythm. In certain cases, a pacemaker might be installed to zap the heart back into the correct rhythm.

Lupus affects the cardiovascular system in many different ways. It can directly impact the heart, lungs, blood vessels, and even the mechanisms that the body uses to regulate its metabolism, bloodflow, and blood pressure. Here are some of the heart-related symptoms of lupus that can result.

Pericarditis

Pericarditis is one of the most common heart-related symptoms of lupus. Lupus causes pericarditis when it inflames the walls of the heart, which have two layers that hold fluid between them. When it works properly, the pericardium protects the heart and large blood vessels and acts as a lubricant to protect the hard-working organ from damaging itself. When inflamed, pericardial effusion can build up in between these layers, swelling the pericardium with too much fluid. This puts pressure on the heart as the tightened layer makes it more difficult for the heart to expand, contract, and pump correctly. This overabundance of fluid can also become a target for infection, which can damage the heart muscle and other tissues further.

Myocarditis and Valve Abnormalities

Lupus can also attack the heart muscle and the attached blood vessels directly, causing inflammation in the muscle tissues of the heart (myocarditis) and damage to the heart valves. Damage to the heart muscle interferes with heart contraction. The heart will often enlarge to attempt to compensate, but it will get to a point where it cannot pump blood effectively. The rhythm of the heart can also be affected, leading to an irregular (and inefficient) beat, an uncoordinated beat, or a sped-up heart that is vulnerable to other issues. Other complications of lupus, including kidney symptoms from lupus nephritis and hypertension can make myocarditis worse. 

Meanwhile, damage to the heart valves leaves abnormalities that can restrict bloodflow into or out of the heart, or an improper seal that allows blood to ‘leak’ back into the blood vessels it came from, causing the heart to pump less efficiently. Abnormal heart valves can develop growths which might break off and cause clots or blockages elsewhere in the circulatory system such as the brain or lungs.

Atherosclerosis

Atherosclerosis is one of the leading causes of heart attack and stroke and is directly caused by lupus damage. Atherosclerosis is accelerated in people with lupus for several reasons:

1: In lupus, the immune system damages and weakens the walls of the arteries. This stresses arteries and makes them ‘rougher’, which creates places where plaques can form more easily. These plaques can grow and block blood vessels, cutting off oxygen supply to vital organs. 

2: Kidney disease caused by lupus can damage the circulatory system as toxins and excess water and salts are not removed as effectively. This stresses the entire system, making it easier for atherosclerosis to form.

3: Steroidal medications, often used to control lupus and reduce flares, causes increased atherosclerosis formation. It encourages fluid and sodium retention, leading to high blood pressure and increased strain on the system. It also triggers the body to thicken and stiffen the walls of arteries and the heart’s ventricles, making them less flexible and able to expand and contract as-needed.

These CVD symptoms can happen to anyone with lupus, including lupus that is more focused on the skin or kidneys.

Cutaneous Lupus and Cardiovascular Symptoms

However, a new study revealed that people with skin manifestations of lupus, also known as cutaneous lupus erythematosus (CLE), with or without a diagnosis of SLE, also had high rates of cardiovascular disease. These people were also, the research notes, significantly undertreated and undiagnosed for these complications. 

This implies that many people with primarily skin-related symptoms might have their more inner system symptoms ignored or overlooked, and doctors should look more closely for additional symptoms of lupus such as high blood pressure (hypertension) and higher risk of heart attack and stroke.

This 2023 study by the University of Pennsylvania assessed the medical records of 370 people with CLE. They found that 67.3% of the patients (249 people) had above-average levels of low-density lipoproteins (LDL, also known, colloquially, as ‘bad cholesterol,’). They also assessed the rates of smoking, diabetes, hypertension, and other related conditions (such as prediabetes and hyperlipidemia). 

Disturbingly, while 71.9% of the patients in the study had hypertension, most (74.4%) were not being treated effectively or at all.

A Lupus Warrior’s Takeaway

On one level, the study’s result is not surprising – people with lupus are well known to have more risk factors, environmental and otherwise, for heart disease.  People with lupus also often face medical misdiagnosis and, due to many factors, frequently experience having their symptoms ignored or downplayed until they become severe. The fact that the undertreatment of one of the most common complications is extended to people with an existing diagnosis of lupus is concerning. Hopefully, this study sheds light on this problem will push medical professionals – and teachers – to catch the cardiovascular symptoms of lupus and treat it.

Lifestyle Changes, Obstacles, and Lupus

It is also important to remember that lifestyle change can actually be very difficult for a patient to accomplish.

The pain and fatigue of lupus can sometimes make heart-healthy lifestyles difficult, sometimes nearly impossible, to implement. Skin sensitivity to sunlight (and UV light in general) can make it difficult to find a safe time to go outside. Immunosuppression from lupus and its medications may make going out to a public place or a gym very risky – read more about how to stay safe when immunosuppressed here. And, of course, that assumes that the neighborhood itself is safe or conducive to walking or exercising in! You can read more about these social determinants of health here. 

Mouth and stomach symptoms can make it difficult to eat heart-healthy or anti-inflammatory food. Said food, which often requires a person to acquire and cook with fresh, whole ingredients, might not be accessible for that person due to its price or their location in a food desert or rural area. Without support from their community, friends, and doctors, it is very hard to overcome these obstacles. 

However, this new study brings additional awareness to the risks that people with CLE face, and may improve treatment by medical professionals, both personally and medically.