PUBLISHED 02/21/22 BY BARBARA BRODY
People with lupus have an increased risk of heart disease — but understanding this link is a great first step in lowering it.
Having inflammatory types of rheumatic disease means that your risk of having a heart attack, stroke, or other serious cardiovascular issue is far higher than average. That’s certainly not great news, but take heart: You have the power to lower your risk and protect your ticker and blood vessels — and it starts with patient education.
In honor of American Heart Month this February, we’re taking a closer look at how lupus, gout, and axSpA affect your heart — and what you can do to keep your heart healthy. You can also check out A Patient’s Guide to Understanding Rheumatoid Arthritis and Heart Disease for more information on this topic.
Lupus is one of the trickiest autoimmune diseases to diagnose because it can impact so many different parts of the body. For the same reason, even people who are already living with lupus need to understand that their symptoms may not tell the full story. While it’s natural to focus on what’s bothering you right now — such as a rash, fatigue, or achy joints — lupus has the potential to cause system-wide damage, including to your heart and blood vessels.
Cardiovascular disease, unfortunately, is exceptionally common among people with lupus. Studies have found that lupus patients are at least twice as likely as members of the general population to develop it.
In general, heart disease risk increases as you get older, but for people with lupus the increased risk starts young. Lupus patients of all ages have a seven- to nine-fold increased heart attack risk compared to the general population, but women age 35 to 44 with lupus are 50 times more likely than women without lupus to have a heart attack.
These stats may seem alarming, but consider them motivation to learn more so you can take steps to protect yourself.
Types of Cardiovascular Problems in Lupus
About 50 percent of lupus patients develop some type of heart problem. The most common ones are:
Pericarditis
The membrane around the heart becomes swollen, which causes fluid to leak out around the heart. About 25 percent of people with systemic lupus erythematosus (SLE), the most common kind of lupus, develop pericarditis.
Endocarditis
This refers to the buildup of growths on the surface of heart valves. It’s more common in lupus patients who have antiphospholipid antibodies (more on this below), and it’s a major risk factor for infection and stroke. About 15 percent of SLE patients experience this problem.
Myocarditis
This is an inflammation of the heart muscle itself. It often causes a rapid heartbeat and enlargement of the heart.
People with lupus may also develop rhythm disorders (arrhythmias), a rapid accumulation of fatty plaque in their arteries (accelerated atherosclerosis), and blood clots that could lead to a stroke, heart attack, or pulmonary embolism (which most often occurs when a blood clot from the deep veins in the legs travels to the lungs).
Why Lupus May Harm Your Heart
Although research is ongoing, there are several reasons lupus and cardiovascular diseases often overlap.
Inflammation
The inflammatory, autoimmune nature of lupus can wreak havoc throughout the body, including in your blood vessels and the tissues in and around your heart. “The level of systemic inflammation in lupus can be quite high, and this can cause more atherosclerosis [fatty plaques] to develop,” says rheumatologist Theodore R. Fields, MD, Professor of Clinical medicine at Weill-Cornell Medical College and Attending Physician at Hospital for Special Surgery.
Lupus-related inflammation can also make these fatty plaques more likely to break off (rupture), form a clot, and travel to the head or heart (causing a stroke or heart attack).
Blood clotting
About half of all lupus patients have antiphospholipid antibodies, which attack a specific part of cell membranes. There are a few different types of these antibodies, including lupus anticoagulant and anticardiolipin antibodies.
Antiphospholipid antibodies inflame blood vessels and make your blood more likely to clot inappropriately. While not all blood clots are equally dangerous, some can lead to a potentially fatal pulmonary embolism, stroke, or heart attack.
Hypertension and/or High Cholesterol
About half of all lupus patients have high blood pressure, which forces your heart to work harder, contributes to hardening of the arteries (atherosclerosis), and raises the risk of stroke. Many people with lupus also have too much LDL (“bad” cholesterol as well as triglycerides, both of which can clog arteries.
Meanwhile, HDL cholesterol — the kind that’s typically described as “good” — might not act the way that it should: Some lupus patients have “dysfunctional” HDL, which causes more inflammation and further contributes to the buildup of fatty plaque in the arteries.
Medication
The biggest offenders are steroids like prednisone and methylprednisolone (Medrol), which are often used to control lupus flares. Flares themselves can be bad for your heart; it’s not unusual to develop pericarditis in the midst of a flare. However, the steroids used to control very active disease may also be problematic.
“Prednisone is frequently used in lupus as an anti-inflammatory steroid. There is some data suggesting that higher doses of prednisone can increase the risk of coronary disease,” says Dr. Fields. These drugs can raise your blood pressure, cholesterol, and blood sugar.
That said, time and intensity matter: The longer you’re on these drugs and the higher the dose, the greater the risk to your cardiovascular system. Low doses of steroids for a short period of time aren’t nearly as problematic as far as your heart is concerned.
Kidney Disease or Type 2 Diabetes
Lupus often damages the kidneys, causing a problem called lupus nephritis. While that’s problematic enough on its own — you need your kidneys to filter out waste from your body — it’s also bad for your heart.
When your kidneys aren’t working properly, the heart has to pump more blood to them. In fact, heart disease is the most common cause of death for kidney disease patients who require dialysis (not necessarily because of lupus).
Lupus is also linked to a higher risk of type 2 diabetes, which is a significant risk factor for cardiovascular disease.
How to Lower Your Heart Disease Risk
Step one: Talk to your rheumatologist or a cardiologist and make sure one of them is keeping close tabs on your cardiovascular health. Other key steps:
Start with a risk assessment
Basics like blood pressure, cholesterol, and blood sugar should be measured regularly in patients with lupus, says Joshua F. Baker, MD, Associate Professor of Rheumatology and Epidemiology at the University of Pennsylvania and the Corporal Michael J. Crescenz VA Medical Center. Your doctor should use the findings from these tests — along with other information about risk factors, such as your weight and whether or not you smoke — to make some predictions about your personal heart disease risk.
“If a patient with lupus appears to be high risk based on one of these tools [such as the Framingham Risk Score], then they don’t need any additional testing, but they may need treatment” to mitigate their risk of heart disease, he adds. That might mean taking a statin (cholesterol-lowering drug), low-dose aspirin, and/or blood pressure medication.
When in doubt, go for extra testing
“Lupus patients who don’t appear to be high risk may also benefit from a closer look,” says Dr. Baker. “Some, but not all, patients may benefit from things like coronary calcium scoring or other testing but this has not yet become standard of care.”
If you’re unsure about your level of risk or are having any heart-related symptoms, ask your doctor if you should get additional testing. That might include an electrocardiogram (EKG), stress test, angiogram, CT scan (for coronary calcium scoring), or MRI.
Take your medications as prescribed
As with other inflammatory conditions, high disease activity in lupus often correlates with a higher risk of cardiovascular disease. Working closely with your doctor and taking your medications as directed should help.
“There is reason to believe that medications, such as hydroxychloroquine, methotrexate, or mycophenolate mofetil, each of which are used for different presentations of lupus, can decrease heart risk by decreasing inflammation in the system,” says Dr. Fields.
Tackle traditional heart disease risk factors
While you can’t change the fact that you have lupus, there are several cardiovascular disease risk factors that you can control. “[Patients] can avoid smoking, try to get themselves to their ideal weight, watch their cholesterol through diet (and medication when indicated), and develop an aerobic exercise program if they are able,” says Dr. Fields.
While you’re at it, aim to eat plenty of fruits and vegetables, enjoy fish twice week, and limit your intake of salt, alcohol, and saturated fat. If you’re having trouble exercising because of joint discomfort, consider seeing a physical therapist who has experience working with people with lupus.
The bottom line: This is the perfect time to take steps to manage your lupus and reduce your risk of cardiovascular problems — your heart will thank you!
SOURCES
American Kidney Fund. Heart disease & chronic kidney disease (CKD). kidneyfund.org/kidney-disea....
Brigham and Women’s Hospital. Lupus and the Heart. brighamandwomens.org/medici....
Costenbader, K, et al. Coronary heart disease in systemic lupus erythematosus. UpToDate. uptodate.com/contents/coron....
Hospital for Special Surgery. Getting Exercise and Keeping Physically Fit While Living with Lupus. hss.edu/conditions_getting-....
Hospital for Special Surgery. Top 10 Series: Lupus and Heart Conditions. hss.edu/conditions_top-ten-....
Interview with Joshua F. Baker, MD, associate professor of rheumatology and epidemiology at the University of Pennsylvania and the Corporal Michael J. Crescenz VA Medical Center.
Interview with Theodore R. Fields, MD, rheumatologist and professor of clinical medicine at Weill-Cornell Medical College.
John Hopkins Medicine. Antiphospholipid Antibodies. hopkinslupus.org/lupus-info....
John Hopkins Medicine. How Does Lupus Affect the Cardiovascular System. hopkinslupus.org/lupus-info....
National Institute of Diabetes and Digestive and Kidney Diseases. Lupus and Kidney Disease (Lupus Nephritis). niddk.nih.gov/health-inform....
Schoenfeld SR, et al. The epidemiology of atherosclerotic cardiovascular disease among patients with SLE: A systematic review. Seminars in Arthritis and Rheumatism. 2013. doi: doi.org/10.1016/j.semarthri....
Soltész P, et al. Cardiac manifestations in antiphospholipid syndrome. Autoimmunity Reviews. 2007. doi: doi.org/10.1016/j.autrev.20....
