ATLANTA -- New research reveals that, in the U.S., Black patients with lupus have a threefold higher risk of stroke and a 24-fold higher risk of ischemic heart disease. The study also found several lupus-specific symptoms that predict stroke and IHD in these patients. Details of the study was presented at ACR Convergence, the American College Rheumatology's annual meeting (ABSTRACT #0433).
Systemic lupus erythematosus, also called lupus or SLE, is a chronic disease that causes systemic inflammation affecting multiple organs, such as the skin, joints, kidneys, the tissue lining the lungs (pleura), heart (pericardium) and brain. Many patients experience fatigue, weight loss and fever. The disease is more common among Black, Asian, and Native American people and tends to be worse in these groups.
Black people with lupus have a 19-fold higher occurrence of cardiovascular disease compared to other groups and have a disproportionately higher number of stroke-related events around the time of lupus diagnosis. Researchers wanted to know more about the specific risks and predictors of stroke and ischemic heart disease in Black people with lupus.
"The risk for developing cardiovascular disease is up to 52 times higher in patients with lupus, compared to patients without lupus. Black populations have three times higher risk to develop lupus, develop it at a significantly younger age and have more severe disease. However, most prior lupus and cardiovascular disease (CVD) studies were conducted in predominantly white cohorts, limiting the generalizability of the findings," says the study's co-author, Shivani Garg, MD, MS, Assistant Professor of Medicine at the University of Wisconsin School of Medicine and Public Health. "It's important to quantify the risk, predictors and timing of stroke and ischemic heart disease in Black people with lupus in order to guide early CVD diagnosis and preventive interventions in this at-risk population." The study highlights the need for aggressive heart disease preventive care to reduce these racial disparities and improve lupus outcomes, particularly in recently diagnosed patients, she adds.
The researchers collected data from the Georgia Lupus Registry of lupus patients from Atlanta. They identified patients from 2002 to 2004 who met four or more of the ACR's SLE criteria or three criteria with a final lupus diagnosis by their own rheumatologist. They matched the patients to the Georgia Hospital Discharge Database and National Death Index from 2000 to 2013. Stroke and ischemic heart disease-related hospitalizations and deaths were based on hospital admission and death medical codes. Transient ischemic attacks were included in the stroke data, and myocardial infarction (heart attack) and angina were included in ischemic heart disease data. The researchers also examined symptoms that predicted strokes and ischemic heart disease. Of the 336 lupus patients included in the final study, 87% were female, 75% were Black, and the mean age at diagnosis was 40.
They found 38 stroke-related and 25 ischemic heart disease -related health events or deaths that occurred from two years before to 14 years after a lupus diagnosis. In the 11% of patients who had strokes, the mean age at first stroke was 48, and 78% of the strokes occurred in females. Ninety percent of the strokes occurred in Black patients. The peak number of strokes happened in the second year after lupus diagnosis. The study also showed that 8% of the patients had ischemic heart disease, and their mean age at diagnosis was 52. All the ischemic heart disease cases occurred in females, 96% occurred in Black patients and the peak number of cases occurred in the 14th year after diagnosis with lupus. All in all, the data showed that Black patients with lupus have a threefold higher stroke risk and a 24-fold higher ischemic heart disease risk than other groups.
What about potential predictors of stroke or ischemic heart disease? Discoid rash at the time of lupus diagnosis predicted a five-fold higher risk of stroke, while renal disorder at the time of lupus diagnosis predicted a two-fold higher stroke risk. Neither discoid rash nor renal disorder predicted ischemic heart disease, however. Strong predictors of ischemic heart disease were neurologic disorders (prior psychosis or seizure) and immunologic disorders (anti-DNA, anti-Sm, or antiphospholipid antibodies), but these did not predict strokes.
These findings highlight significant racial disparities in both stroke and ischemic heart disease among patients with lupus, says Dr. Garg.
"Our study increases awareness of higher risk, the timing of accelerated risk and disease presentations that contribute to higher risk of stroke and ischemic heart disease among Black patients with lupus. Such knowledge can help patients and providers look for and diagnose CVD events earlier and discuss starting preventive care to reduce their risk," says Dr. Garg. "Timely interventions could help reduce cardiovascular disparities in lupus and reduce CVD-related morbidity and mortality in young lupus patients, who are at relatively higher risk of premature CVD."
About ACR Convergence
ACR Convergence, the ACR's annual meeting, is where rheumatology meets to collaborate, celebrate, congregate, and learn. Join ACR for an all-encompassing experience designed for the entire rheumatology community. ACR Convergence is not just another meeting - it's where inspiration and opportunity unite to create an unmatched educational experience. For more information about the meeting, visit https://www.rheumatology.org/Annual-Meeting, or join the conversation on Twitter by following the official hashtag (#ACR20).
About the American College of Rheumatology
The American College of Rheumatology (ACR) is an international medical society representing over 7,700 rheumatologists and rheumatology health professionals with a mission to empower rheumatology professionals to excel in their specialty. In doing so, the ACR offers education, research, advocacy and practice management support to help its members continue their innovative work and provide quality patient care. Rheumatologists are experts in the diagnosis, management and treatment of more than 100 different types of arthritis and rheumatic diseases.
Racial Disparities and New SLE-Specific Predictors of Stroke and Ischemic Heart Disease in Patients with Lupus
In the US, cardiovascular disease (CVD) is the leading cause of disparities in life expectancy between black and white populations. We recently reported a 19-fold higher occurrence of CVD in blacks with SLE compared to non-blacks and noted disproportionately high stroke-related events around the time of SLE diagnosis. This study measured the risk and predictors of stroke and ischemic heart disease (IHD) in a predominantly black, population-based, incident cohort.
The Georgia Lupus Registry (GLR) is a population-based registry of SLE patients from Atlanta, Georgia. Incident patients in 2002-04 met ?4 ACR SLE criteria or 3 criteria with a final diagnosis of SLE by their board-certified rheumatologist. Patients were matched to the Georgia Hospital Discharge Database and National Death Index from 2000-13. Stroke- and IHD-related hospitalizations and deaths were classified by the first three admission or cause of death codes. Stroke also included transient ischemic attack, and IHD included myocardial infarction and angina. Predictors of strokes and IHD were examined using Cox proportional hazards models.
Among 336 incident SLE patients, 87% were female, 75% were black patient with a mean age at SLE diagnosis of 40 ± 17 years. There were 38 stroke-related and 25 IHD-related events or deaths, from the period 2 years before through 14 years after SLE diagnosis.
In the 11% with strokes, the mean age at first stroke was 48 years, with 78% occurring in females and 90% in blacks. The peak number of strokes occurred during the 2nd year after SLE diagnosis. We noted 8% had IHD, the mean age at first IHD was 52 years, with all occurring in females and 96% in blacks. The peak number of IHD occurred in the 14th year after SLE diagnosis.
Blacks had a 3-fold higher risk for stroke (HR 3.4, 95% CI 1.2-10, p 0.03) and a 24-fold higher risk for IHD (HR 24, 95% CI 3-206, p 0.004) (Table 1 & 2). Discoid rash at SLE diagnosis predicted a 5-fold (HR 4.6, 95% CI 1.7-13, p 0.003) and renal disorder predicted a 2-fold higher risk for stroke (HR 2.4, 95% CI 1.1-2.5, p 0.04) (Table 1). Neither impacted IHD (Table 2). Neurologic (HR 4.0, 95% CI 1.3-13, p 0.02) and immunologic disorder (HR 4.7, 95% CI 1.3-18, p 0.02) (Table 2) were strong predictors of IHD but not stroke.
Race stratified Cox proportional hazard models showed significantly accelerated stroke and IHD events in black compared to non-black patients (p ? 0.001) (Figure 1A & B).
We found a 3-fold higher risk of stroke and 24-fold higher risk of IHD in blacks with SLE. We found different SLE-specific predictors of stroke and IHD: discoid rash and renal disorder predicted stroke, and neurologic and immunologic disorder strongly predicted IHD. This study provides unique insights on significantly different SLE-disease related predictors, timing and racial disparities in stroke compared to IHD in SLE. Hence, we highlight the need to consider different preventive strategies for stroke and IHD in SLE.