Cardiovascular Disease (CVD) Prevention in Lupus Patients

Introduction

This summary is based on a presentation from Dr. Virginia Haiduc and Lupus Center Nurse Practitioner Monica Richey focusing on cardiovascular disease (CVD) prevention for patients with lupus. The purpose of the presentation was threefold:

1. To raise awareness of the impact of heart disease for patients with lupus. 
2. To discuss the risk factors and strategies that can help patients with lupus live a heart-healthy lifestyle. 
3. To describe the CVD Prevention Counseling Program, which is jointly supported by the Hospital for Special Surgery Lupus Center and the NY Community Trust.

Dr. Haiduc introduced the presentation by defining what is meant by CVD. She then described some of the important non-modifiable (unchangeable) CVD risk factors of which individuals with lupus should be aware. Next, Lupus Center Nurse Practitioner Monica Richey addressed the CVD risk factors that can be modified or changed, and some of the prevention strategies involved.

What is Cardiovascular Disease (CVD?)

Dr. Haiduc explained that CVD occurs in both the heart and blood vessels, where two common forms of CVD are heart attack and stroke. Heart attacks are caused by blockage of the arteries that feed the heart. Strokes are caused by a break or blockage of the arteries that feed the brain. Overall, CVD is the leading cause of death for both women and men in United States and has been shown to be prevalent among patients with lupus.

Lupus and CVD

Dr. Haiduc next shared to the group some key facts that are associated with lupus and CVD.

• Women with lupus ages 18–44 are hospitalized with heart attacks or strokes almost nine times more often than the general population.(1)
• People with lupus are 17 times more likely to have CVD than the general population.(2)
• Heart attacks occur 10 times higher in lupus patients than in the general population (2) and 52 times higher in young women with lupus compared to young women without lupus.(3)

CVD Risk Factors in Those with Lupus

As the above statistics dramatically illustrate, having lupus can put individuals at a higher risk of developing CVD. The next section of the presentation focused primarily on risk factors: What are risk factors? What important factors should patients with lupus be aware of?

Risk factors are factors that can increase a person’s chances of developing a disease. The more risk factors one has, the higher one’s chances of getting a disease.

Dr. Haiduc explained that there are two types of risk factors: non-modifiable and modifiable. Non-modifiable risk factors are factors that cannot be changed, while modifiable risk factors are factors that can be changed or treated.

Some non-modifiable risk factors for CVD include age, gender, race, and family history of CVD. As you can see, these are components of one’s life that cannot be changed or prevented: 

• Age: The risk of CVD doubles every 10 years after age 55.
• Gender: Overall, men have a greater risk of heart attacks than women early in life. Women, on the other hand, are protected by estrogen and are at greater risk of heart attacks after menopause.
• Race: CVD is more common among African Americans and Hispanic Americans.
• Family history of CVD: It is important to tell your doctor if your father or brother (when under the age of 55) or mother or sister (when under the age of 65) was diagnosed with CVD.

There are many factors, however, that patients with lupus can change and should be aware of to decrease their risk for CVD.

Next, Lupus Center Nurse Practitioner Monica Richey spoke in great detail about the variety of modifiable risk factors of CVD that individuals with lupus should be aware of, as well as some important steps to eliminate and treat these “changeable” situations.

Some modifiable risk factors for CVD include the following:

• Hypertension (High Blood Pressure): Blood pressure is the force of the blood pushing against the artery walls. Someone with high blood pressure has constant pressure going into the heart at a rate higher than 140/90 mmHg. The overall goal is to keep your blood pressure below 120/80 mmHg.
   
• Diabetes (High Blood Sugar): Diabetes is a disease in which the body does not produce enough insulin or the cells ignore the insulin. Insulin is a hormone necessary for the body to use sugar. Sugar that is not absorbed deposits around the veins and arteries, which can cause poor circulation. Diabetes can be detected through a blood test.
  
  For those with diabetes it is very important to check your blood sugar frequently, monitor your blood pressure and watch your cholesterol. For those without diabetes, sugar levels should be between 70 and 80 but no higher than 100mg/dl.
• Hypercholesterolemia (High blood cholesterol): There are three types of cholesterol that you should watch for: overall cholesterol (which should be below 200mg/dl), LDL (Bad Cholesterol) and HDL (Good Cholesterol). Bad cholesterol should be below 130 mg/dl for moderate CVD risk patients & below 100 mg/dl for high CVD risk patients. Good cholesterol should be above 40 mg/dl for men & above 50mg/dl for women. Triglycerides should be below 150mg/dl. Patients are considered high risk CVD patients if they already have; coronary artery disease, cerebrovascular disease, peripheral arterial disease, end-stage or chronic kidney disease, abdominal aortic aneurysm, and/or diabetes. 
• Metabolic Syndrome: Metabolic syndrome is a collection of risk factors that occur together to increase one’s risk of heart disease. These risk factors include: high blood pressure, high blood sugar, high cholesterol levels, and belly fat. So if you have more then one of these conditions, please be aware of your risk and speak to your doctor! 
• Overweight/Obesity: People who are overweight or obese are at a higher risk for developing CVD. A good way to determine if you meet the criteria for being overweight or obese is by testing your Body Mass Index (BMI). BMI is a measure of body fat (calculated from a person's weight and height). Normal BMI is 18-24. For someone overweight, BMI is greater than 25 and for someone who is obese, BMI is greater than 30.
  
  Patients with BMI above 30 should receive nutrition counseling. Waist circumference is measured at the hip bone. Women should be less than 88cm (34.6in) and men less than 102cm (40.2in).
  
  The more belly fat, the higher the risk of heart attack!

Cardiovascular Disease Prevention

The presenters next focused on CVD prevention in patients. They both underscored the importance of knowing your risk factors and how (when possible) to minimize or prevent these from occurring.

With all of these health concerns in mind, Ms. Richey stressed that there is a lot we can do to lessen our risks of CVD. Some examples include the following:

• Eat a healthy diet
  • Fruits and vegetables - 3 to 5 portions a day:
  • Whole grain, high fiber foods - brings all of the “bad” fat through when passing through the intestines. 
  • Fish at least twice a week
  • Alcohol intake no more than one drink per day for women and two drinks per day for men
  • Limited salt intake
  • Omega 3-fish oils 
  • Diet low in saturated fat, trans fat, and cholesterol (Limited amounts of fried food, red meat, whole milk and butter, etc.)
• Portion control is very important
  • One half (50%) of your plate should contain vegetables
  • One quarter (25%) of your plate should contain some source of protein, e.g., chicken, fish, meat, etc.
  • One quarter (25%) of your plate should contain some source of carbohydrates, e.g., pasta, baked potato, etc. 
• Physical Activity: Exercise has been shown to decrease stress on inflamed joints and to reduce heart disease. If you have a known or suspected heart disease, however, be sure to contact your doctor before starting an exercise program!
  If your goal is to control your weight rather than lose weight, then you should aim to exercise for around 30 minutes a day on most, preferably all, days of the week, with moderate intensity aerobic exercise. If your goal is to lose weight, then your exercise regimen should increase to around 60-90 minutes per day on most, preferably all, days of the week for moderate intensity exercise.
  All of these examples can be beneficial for your health, but it is important to remember to always talk to your doctor before starting something new, and also about the medication options that may be beneficial for your cardiovascular health
• Join a Smoking Cessation Program if You Are a Smoker: Lupus patients are urged to stop smoking. Smoking cessation has been shown to reduce death rates related to CVD. Talk to your doctor if you are ready or you are thinking about quitting smoking, as there are programs that can help!

Symptoms of Heart Attack and Stroke

Ms. Richey concluded the presentation by briefly discussing some key indicators that patients should be aware of regarding heart attack and stroke.

Medications that can be used for cardiovascular disease prevention were beyond the scope of this presentation; patients are encouraged to discuss the potentially useful medications with their primary care physicians or rheumatologists.

Be aware of the symptoms of a possible heart attack:

• Chest pain or discomfort: intense or mild pain (pressure, fullness, squeezing) that can last more than a few minutes
• Pain or discomfort beyond your chest: in one or both arms, in the back, neck, jaw/teeth, or stomach.
• Shortness of breath: with or without chest discomfort.
• Other signs: nausea (feeling sick to your stomach), vomiting, lightheadedness, fainting, or intense sweating.

If you have any of these symptoms, go to the ER right away.

Symptoms of stroke include the following:

• Sudden numbness or weakness on one side of your body (face, arm, or leg): if you try to raise both your arms over your head and one arm begins to fall, you may be having a stroke. 
• Trouble with speaking or understanding: slurred speech, confusion, inability to speak.
• Trouble with seeing in one or both eyes: blurred, blackened, or decreased vision; double vision.
• Trouble with walking: dizziness, loss of balance, or coordination
• Headache: sudden, severe, “out of the blue” headache.

If you have any of these symptoms, go to the ER right away.

References:

1. Ward MM, Premature morbidity from cardiovascular and cerebrovascular diseases in women with systemic lupus erythematosus, Arthritis Rheum 1999; 42:338

2. Esdaile JM, Abrahamowicz M, Grodzicky T et al., Traditional Framingham risk factors fail to fully account for accelerated atherosclerosis in systemic lupus erythematosus, Arthritis Rheum 2001; 44:2331

3. Manzi S, Meilahn EN, Rairie JE 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; 145:408

Learn more about the HSS SLE Workshop, a free support and education group held monthly for people with lupus and their families and friends.

Posted: 6/2/2010

Summary written by Christie Carlstrom, SLE Workshop Coordinator and Social Work Intern at HSS.

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