Predictors of major adverse cardiovascular events and all-cause death in populations of systemic lupus erythematosus without established cardiac disease

Abstract

BACKGROUND: Systemic lupus erythematosus (SLE) is an inflammatory disease modulated by pro-inflammatory cytokines, and is associated with significant cardiovascular morbidity and mortality. The aim of this study was to characterize independent clinical and echocardiographic (TTE) predictors of major adverse cardiovascular events (MACE) and all-cause death in populations with SLE without established cardiac disease. METHODS: Consecutive patients with SLE admitted to our institution over a 10-year period were examined. Patients with known cardiac disease were excluded. The clinical course of these patients was followed for up for a total of 60 months the composite outcome of allcause death and MACE. Myocardial strain analysis was performed by two independent cardiologists using vendor independent software (TomTec Arena v4.6). All statistical analysis was performed using SPSS v22. RESULTS: A total of 169 patients with SLE (41+/-16 years, 85% female) met the inclusion criteria, of which 22 patients (13%) met the primary endpoint over the follow-up period. Independent clinical predictors of the primary endpoint included the combination of a standard modifiable (SMuRF; smoking, diabetes, hypertension, hypercholesterolemia) and non-traditional risk factors (NTRF; obesity, obstructive sleep apnea, chronic kidney disease) (p=0.001), use of disease modifying therapy (p=0.04) and a high Charlson comorbidity index (p=0.001). Significant TTE predictors of the primary endpoint included impaired left ventricular global longitudinal strain (LV-GLS <-17%; n=51, p=0.007) and subclinical biventricular impairment (n=36, p=0.001), but not isolated impairment in right ventricular free wall strain (RV-FWS <-23%; n=63, p=0.66). LV-GLS strongly correlated with high anti-dsDNA titres (>1000 IU/ml; p=0.006). CONCLUSION: SLE populations with subclinical biventricular systolic impairment, a high Charlson comorbidity index and presence of combined SMuRFs and NTRFs are predisposed to higher cardiovascular morbidity and mortality. These higher risk populations should be identified early for aggressive follow-up and treatment.