Systemic Lupus Erythematosus
Özet
Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that affects multiple organ systems, increasing morbidity and mortality. Cardiovascular disease (CVD) is a major cause of mortality in SLE, with more than 50% of patients experiencing some form of cardiac involvement. This includes pericarditis, valvular disease, myocarditis, conduction abnormalities, and coronary artery disease (CAD). Pericarditis is the most common cardiac manifestation, occurring in up to 50% of patients, often at disease onset or relapse. Valvular involvement, identified in approximately 40–50% of patients through echocardiographic assessment, is a significant cardiac manifestation of SLE, with Libman-Sacks endocarditis being one of its most characteristic features. Myocarditis, present in 9–57% of cases, can cause arrhythmias and heart failure. Conduction abnormalities, including sinus tachycardia and QT prolongation, are common, with neonatal lupus potentially causing congenital heart block. CAD is a leading cause of late mortality, with SLE patients having a significantly higher risk of myocardial infarction due to accelerated atherosclerosis, inflammation, and traditional risk factors. Early diagnosis and treatment are crucial to reducing cardiovascular complications in SLE patients. Given the high risk of CVD, regular cardiovascular screening is recommended for SLE patients to improve outcomes.
Sistemik lupus eritematozus (SLE), birden fazla organ sistemi etkileyen, morbidite ve mortaliteyi artıran kronik otoimmün bir hastalıktır. Kardiyovasküler hastalık (KVH), SLE'de mortalitenin başlıca nedenidir ve hastaların %50'sinden fazlasında kardiyak tutulum görülmektedir. Perikardit, kapak hastalığı, miyokardit, iletim anormallikleri ve koroner arter hastalığı (KAH) başlıca tutulumlardandır. Perikardit, lupus hastalarında %50'ye varan oranda saptanabilen en yaygın kardiyak tutulumudur ve genellikle hastalığın başlangıcında veya alevlenme sırasında gözlenebilmektedir. Hastaların yaklaşık %40-50'sinde ekokardiyografik değerlendirme ile tespit edilen kapak tutulumu, SLE'nin önemli bir kardiyak belirtisidir ve bunlardan Libman-Sacks endokarditi en karakteristik olanıdır. Vakaların %9-57'sinde gözlenebilen miyokardit, aritmilere ve kalp yetmezliğine neden olabilmektedir. Sinüs taşikardisi ve QT uzaması başta olmak üzere iletim anormallikleri yaygındır. Özellikle neonatal lupus, konjenital kalp bloğuna neden olabilmesi açısından dikkat gerektirmektedir. KAH, geç mortalitenin önde gelen nedenlerinden biridir ve SLE hastalarında hızlanmış ateroskleroz, inflamasyon ve artmış geleneksel risk faktörleri nedeniyle miyokard enfarktüsü riski önemli ölçüde daha yüksektir. Erken tanı ve tedavi, SLE hastalarında kardiyovasküler komplikasyonları azaltmak için çok önemlidir. Yüksek KVH riski göz önüne alındığında, sonuçları iyileştirmek için SLE hastalarına düzenli kardiyovasküler tarama önerilmektedir.
Referanslar
Petri M. Epidemiology of systemic lupus erythematosus. Best Pract Res Clin Rheumatol. 2002;16(5):847-58.
Cojocaru M, Cojocaru IM, Silosi I, Vrabie CD. Manifestations of systemic lupus erythematosus. Maedica (Bucur). 2011;6(4):330-6.
Fava A, Petri M. Systemic lupus erythematosus: Diagnosis and clinical management. J Autoimmun. 2019;96:1-13.
Smith PP, Gordon C. Systemic lupus erythematosus: clinical presentations. Autoimmun Rev. 2010;10(1):43-5.
Fors Nieves CE, Izmirly PM. Mortality in Systemic Lupus Erythematosus: an Updated Review. Curr Rheumatol Rep. 2016;18(4):21.
Guzmán J, Cardiel MH, Arce-Salinas A, Alarcón-Segovia D. The contribution of resting heart rate and routine blood tests to the clinical assessment of disease activity in systemic lupus erythematosus. J Rheumatol. 1994;21(10):1845-8.
Ansari A, Larson PH, Bates HD. Cardiovascular manifestations of systemic lupus erythematosus: current perspective. Prog Cardiovasc Dis. 1985;27(6):421-34.
Kao AH, Manzi S. How to manage patients with cardiopulmonary disease? Best Pract Res Clin Rheumatol. 2002;16(2):211-27.
Hahn BH. Systemic lupus erythematosus and accelerated atherosclerosis. N Engl J Med. 2003;349(25):2379-80.
Alghareeb R, Hussain A, Maheshwari MV, Khalid N, Patel PD. Cardiovascular Complications in Systemic Lupus Erythematosus. Cureus. 2022;14(7):e26671.
Moder KG, Miller TD, Tazelaar HD. Cardiac involvement in systemic lupus erythematosus. Mayo Clin Proc. 1999;74(3):275-84.
Bidani AK, Roberts JL, Schwartz MM, Lewis EJ. Immunopathology of cardiac lesions in fatal systemic lupus erythematosus. Am J Med. 1980;69(6):849-58.
Quismorio FP, Jr. Immune complexes in the pericardial fluid in systemic lupus erythematosus. Arch Intern Med. 1980;140(1):112-4.
Lange RA, Hillis LD. Clinical practice. Acute pericarditis. N Engl J Med. 2004;351(21):2195-202.
Chen J, Tang Y, Zhu M, Xu A. Heart involvement in systemic lupus erythematosus: a systemic review and meta-analysis. Clin Rheumatol. 2016;35(10):2437-48.
Castier MB, Albuquerque EM, Menezes ME, Klumb E, Albanesi Filho FM. Cardiac tamponade in systemic lupus erythematosus. Report of four cases. Arq Bras Cardiol. 2000;75(5):446-8.
Gupta S, Jesrani G, Gaba S, Gupta M, Kumar S. Constrictive Pericarditis as an Initial Manifestation of Systemic Lupus Erythematosus. Cureus. 2020;12(10):e11256.
Vakamudi S, Ho N, Cremer PC. Pericardial Effusions: Causes, Diagnosis, and Management. Prog Cardiovasc Dis. 2017;59(4):380-8.
Morel N, Bonjour M, Le Guern V, Le Jeunne C, Mouthon L, Piette JC, et al. Colchicine: a simple and effective treatment for pericarditis in systemic lupus erythematosus? A report of 10 cases. Lupus. 2015;24(14):1479-85.
Kruzliak P, Novak M, Piler P, Kovacova G. Pericardial involvement in systemic lupus erythematosus: current diagnosis and therapy. Acta Cardiol. 2013;68(6):629-33.
Oliveira Pinheiro F, Seabra Rato M, Madureira P, Paiva M, Costa L. Recurrent Lupus Pericarditis Treated with Anakinra - a Case Report. ARP Rheumatol. 2022;1(4):334-5.
Jain D, Halushka MK. Cardiac pathology of systemic lupus erythematosus. J Clin Pathol. 2009;62(7):584-92.
Omdal R, Lunde P, Rasmussen K, Mellgren SI, Husby G. Transesophageal and transthoracic echocardiography and Doppler-examinations in systemic lupus erythematosus. Scand J Rheumatol. 2001;30(5):275-81.
Prasad M, Hermann J, Gabriel SE, Weyand CM, Mulvagh S, Mankad R, et al. Cardiorheumatology: cardiac involvement in systemic rheumatic disease. Nat Rev Cardiol. 2015;12(3):168-76.
Vivero F, Gonzalez-Echavarri C, Ruiz-Estevez B, Maderuelo I, Ruiz-Irastorza G. Prevalence and predictors of valvular heart disease in patients with systemic lupus erythematosus. Autoimmun Rev. 2016;15(12):1134-40.
Moyssakis I, Tektonidou MG, Vasilliou VA, Samarkos M, Votteas V, Moutsopoulos HM. Libman-Sacks endocarditis in systemic lupus erythematosus: prevalence, associations, and evolution. Am J Med. 2007;120(7):636-42.
Appelgren D, Dahle C, Knopf J, Bilyy R, Vovk V, Sundgren PC, et al. Active NET formation in Libman-Sacks endocarditis without antiphospholipid antibodies: A dramatic onset of systemic lupus erythematosus. Autoimmunity. 2018;51(6):310-8.
Chen H, Liang H, Gu T, Ren W, Miao Y, Wang G, et al. Libman-Sacks Endocarditis and Infective Endocarditis Vegetations Coexisting in a Patient With Antiphospholipid Syndrome. Circ J. 2022;86(11):1789.
Doherty NE, Siegel RJ. Cardiovascular manifestations of systemic lupus erythematosus. Am Heart J. 1985;110(6):1257-65.
Chang YS, Chang CC, Chen YH, Chen WS, Chen JH. Risk of infective endocarditis in patients with systemic lupus erythematosus in Taiwan: a nationwide population-based study. Lupus. 2017;26(11):1149-56.
Roldan CA, Qualls CR, Sopko KS, Sibbitt WL, Jr. Transthoracic versus transesophageal echocardiography for detection of Libman-Sacks endocarditis: a randomized controlled study. J Rheumatol. 2008;35(2):224-9.
Ménard GE. Establishing the diagnosis of Libman-Sacks endocarditis in systemic lupus erythematosus. J Gen Intern Med. 2008;23(6):883-6.
Roldan CA, Sibbitt WL, Jr., Greene ER, Qualls CR, Jung RE. Libman-Sacks endocarditis and associated cerebrovascular disease: The role of medical therapy. PLoS One. 2021;16(2):e0247052.
Roldan CA, Shively BK, Crawford MH. An echocardiographic study of valvular heart disease associated with systemic lupus erythematosus. N Engl J Med. 1996;335(19):1424-30.
Jensen-Urstad K, Svenungsson E, de Faire U, Silveira A, Witztum JL, Hamsten A, et al. Cardiac valvular abnormalities are frequent in systemic lupus erythematosus patients with manifest arterial disease. Lupus. 2002;11(11):744-52.
Sonsöz MR, Tekin RD, Gül A, Buğra Z, Atılgan D. Treatment of Libman-Sacks endocarditis by combination of warfarin and immunosuppressive therapy. Turk Kardiyol Dern Ars. 2019;47(8):687-90.
Wijetunga M, Rockson S. Myocarditis in systemic lupus erythematosus. Am J Med. 2002;113(5):419-23.
du Toit R, Karamchand S, Doubell AF, Reuter H, Herbst PG. Lupus myocarditis: review of current diagnostic modalities and their application in clinical practice. Rheumatology (Oxford). 2023;62(2):523-34.
Gartshteyn Y, Tamargo M, Fleischer S, Kapoor T, Li J, Askanase A, et al. Endomyocardial biopsies in the diagnosis of myocardial involvement in systemic lupus erythematosus. Lupus. 2020;29(2):199-204.
Salomone E, Tamburino C, Bruno G, Di Paola R, Silvestri F. The role of endomyocardial biopsy in the diagnosis of cardiac involvement in systemic lupus erythematosus. Heart Vessels. 1989;5(1):52-3.
Logar D, Kveder T, Rozman B, Dobovisek J. Possible association between anti-Ro antibodies and myocarditis or cardiac conduction defects in adults with systemic lupus erythematosus. Ann Rheum Dis. 1990;49(8):627-9.
Davies MJ, Ward DE. How can myocarditis be diagnosed and should it be treated? Br Heart J. 1992;68(4):346-7.
Meridor K, Shoenfeld Y, Tayer-Shifman O, Levy Y. Lupus acute cardiomyopathy is highly responsive to intravenous immunoglobulin treatment: Case series and literature review. Medicine (Baltimore). 2021;100(18):e25591.
Al-Nokhatha SA, Khogali HI, Al Shehhi MA, Jassim IT. Myocarditis as a lupus challenge: two case reports. J Med Case Rep. 2019;13(1):343.
Law WG, Thong BY, Lian TY, Kong KO, Chng HH. Acute lupus myocarditis: clinical features and outcome of an oriental case series. Lupus. 2005;14(10):827-31.
Gawałko M, Balsam P, Lodziński P, Grabowski M, Krzowski B, Opolski G, et al. Cardiac Arrhythmias in Autoimmune Diseases. Circ J. 2020;84(5):685-94.
Lazzerini PE, Laghi-Pasini F, Boutjdir M, Capecchi PL. Anti-Ro/SSA Antibodies and the Autoimmune Long-QT Syndrome. Front Med (Lausanne). 2021;8:730161.
Chen CY, Wang FL, Lin CC. Chronic hydroxychloroquine use associated with QT prolongation and refractory ventricular arrhythmia. Clin Toxicol (Phila). 2006;44(2):173-5.
Teixeira RA, Borba EF, Bonfá E, Martinelli Filho M. Arrhythmias in systemic lupus erythematosus. Rev Bras Reumatol. 2010;50(1):81-9.
Myung G, Forbess LJ, Ishimori ML, Chugh S, Wallace D, Weisman MH. Prevalence of resting-ECG abnormalities in systemic lupus erythematosus: a single-center experience. Clin Rheumatol. 2017;36(6):1311-6.
Tselios K, Gladman DD, Harvey P, Su J, Urowitz MB. Severe brady-arrhythmias in systemic lupus erythematosus: prevalence, etiology and associated factors. Lupus. 2018;27(9):1415-23.
Friedman DM, Rupel A, Buyon JP. Epidemiology, etiology, detection, and treatment of autoantibody-associated congenital heart block in neonatal lupus. Curr Rheumatol Rep. 2007;9(2):101-8.
Bharati S, Swerdlow MA, Vitullo D, Chiemmongkoltip P, Lev M. Neonatal lupus with congenital atrioventricular block and myocarditis. Pacing Clin Electrophysiol. 1987;10(5):1058-70.
Buyon JP, Hiebert R, Copel J, Craft J, Friedman D, Katholi M, et al. Autoimmune-associated congenital heart block: demographics, mortality, morbidity and recurrence rates obtained from a national neonatal lupus registry. J Am Coll Cardiol. 1998;31(7):1658-66.
Miner JJ, Kim AH. Cardiac manifestations of systemic lupus erythematosus. Rheum Dis Clin North Am. 2014;40(1):51-60.
Jayaprasad N, Johnson F, Venugopal K. Congenital complete heart block and maternal connective tissue disease. Int J Cardiol. 2006;112(2):153-8.
Doria A, Iaccarino L, Sarzi-Puttini P, Atzeni F, Turriel M, Petri M. Cardiac involvement in systemic lupus erythematosus. Lupus. 2005;14(9):683-6.
Von Feldt JM, Scalzi LV, Cucchiara AJ, Morthala S, Kealey C, Flagg SD, et al. Homocysteine levels and disease duration independently correlate with coronary artery calcification in patients with systemic lupus erythematosus. Arthritis Rheum. 2006;54(7):2220-7.
Asanuma Y, Oeser A, Shintani AK, Turner E, Olsen N, Fazio S, et al. Premature coronary-artery atherosclerosis in systemic lupus erythematosus. N Engl J Med. 2003;349(25):2407-15.
Manzi S, Meilahn EN, Rairie JE, Conte CG, Medsger TA, Jr., Jansen-McWilliams L, et al. Age-specific incidence rates of myocardial infarction and angina in women with systemic lupus erythematosus: comparison with the Framingham Study. Am J Epidemiol. 1997;145(5):408-15.
Symmons DP, Gabriel SE. Epidemiology of CVD in rheumatic disease, with a focus on RA and SLE. Nat Rev Rheumatol. 2011;7(7):399-408.
Bruce IN. 'Not only...but also': factors that contribute to accelerated atherosclerosis and premature coronary heart disease in systemic lupus erythematosus. Rheumatology (Oxford). 2005;44(12):1492-502.
Frostegård J. Systemic lupus erythematosus and cardiovascular disease. J Intern Med. 2023;293(1):48-62.
Hermansen ML, Lindhardsen J, Torp-Pedersen C, Faurschou M, Jacobsen S. The risk of cardiovascular morbidity and cardiovascular mortality in systemic lupus erythematosus and lupus nephritis: a Danish nationwide population-based cohort study. Rheumatology (Oxford). 2017;56(5):709-15.
McMahon M, Seto R, Skaggs BJ. Cardiovascular disease in systemic lupus erythematosus. Rheumatol Immunol Res. 2021;2(3):157-72.
Sherer Y, Zinger H, Shoenfeld Y. Atherosclerosis in systemic lupus erythematosus. Autoimmunity. 2010;43(1):98-102.
Reiss AB, Jacob B, Ahmed S, Carsons SE, DeLeon J. Understanding Accelerated Atherosclerosis in Systemic Lupus Erythematosus: Toward Better Treatment and Prevention. Inflammation. 2021;44(5):1663-82.
Doria A, Shoenfeld Y, Wu R, Gambari PF, Puato M, Ghirardello A, et al. Risk factors for subclinical atherosclerosis in a prospective cohort of patients with systemic lupus erythematosus. Ann Rheum Dis. 2003;62(11):1071-7.
Mosca M, Tani C, Carli L, Bombardieri S. Glucocorticoids in systemic lupus erythematosus. Clin Exp Rheumatol. 2011;29(5 Suppl 68):S126-9.
Petri M, Lakatta C, Magder L, Goldman D. Effect of prednisone and hydroxychloroquine on coronary artery disease risk factors in systemic lupus erythematosus: a longitudinal data analysis. Am J Med. 1994;96(3):254-9.
Karp I, Abrahamowicz M, Fortin PR, Pilote L, Neville C, Pineau CA, et al. Recent corticosteroid use and recent disease activity: independent determinants of coronary heart disease risk factors in systemic lupus erythematosus? Arthritis Rheum. 2008;59(2):169-75.
Nord JE, Shah PK, Rinaldi RZ, Weisman MH. Hydroxychloroquine cardiotoxicity in systemic lupus erythematosus: a report of 2 cases and review of the literature. Semin Arthritis Rheum. 2004;33(5):336-51.
Dima A, Jurcut C, Chasset F, Felten R, Arnaud L. Hydroxychloroquine in systemic lupus erythematosus: overview of current knowledge. Ther Adv Musculoskelet Dis. 2022;14:1759720x211073001.
O'Laughlin JP, Mehta PH, Wong BC. Life Threatening Severe QTc Prolongation in Patient with Systemic Lupus Erythematosus due to Hydroxychloroquine. Case Rep Cardiol. 2016;2016:4626279.
Cai T, Zhao J, Yang Y, Jiang Y, Zhang JA. Hydroxychloroquine use reduces mortality risk in systemic lupus erythematosus: A systematic review and meta-analysis of cohort studies. Lupus. 2022;31(14):1714-25.
Fanouriakis A, Kostopoulou M, Alunno A, Aringer M, Bajema I, Boletis JN, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736-45.
Giannelou M, Mavragani CP. Cardiovascular disease in systemic lupus erythematosus: A comprehensive update. J Autoimmun. 2017;82:1-12.
Knight JS, Kaplan MJ. Cardiovascular disease in lupus: insights and updates. Curr Opin Rheumatol. 2013;25(5):597-605.
