Lupus and Cardiovascular Disease (CVD) – Top 10 Series

1. What is the risk of cardiovascular disease in lupus?

Cardiovascular Disease (CVD) commonly refers to issues involved in coronary heart disease, including heart attacks, cerebrovascular disease, or strokes. Lupus patients are more likely to have CVD than the general population, and CVD is one of the major causes of mortality among lupus patients.1-3

Furthermore, lupus disease activity and corticosteroids used to suppress the immune system may increase the chances of CVD risk factors such as high blood pressure, high cholesterol, or high body mass index.4 Another potential risk factor for CVD or blood clots in 30% to 40% of lupus patients is antiphospholipid antibodies (aPL).

2. Do you have a healthy diet?

A healthy diet can greatly decrease the risk of CVD by decreasing chances of risk factors such as hypertension, high cholesterol, and obesity. Certain medications commonly prescribed to lupus patients may also cause sudden gains and losses of weight. It is important to maintain a balanced diet and to take any necessary supplements.

Suggestions for a healthy diet include the following:

• Eating 3-5 portions of fruits and vegetables every day
• Eating whole grain, high fiber foods, which helps “bad” fats pass through the intestines
• Eating fish twice a week
• Limiting salt intake
• Limiting alcohol intake to no more than one drink per day for women, and two drinks per day for men
• A diet low in saturated fat, trans fat, and cholesterol.

3. Do you exercise regularly?

Exercise has been shown to decrease stress on inflamed joint – which are very common in lupus patients – while decreasing chances of heart disease. Some examples of low impact exercise that can be of benefit to lupus patients include Pilates and tai chi. These exercises help improve lupus patients’ range of motion, endurance, and strength while still employing low impact methods which do not produce much stress on the joints and body. If you experience pain while exercising, you may consider taking pain-relieving medications prescribed by your doctor.

Physical therapy can also help soothe your joint pains and strengthen your muscles. To control your weight, aim to exercise for around 30 minutes a day of moderate intensity aerobic exercise on most (4 to 5) days of the week. If your goal is to lose weight, your regimen should increase to 60-90 minutes a day of moderate intensity aerobic exercise on most (4-5) days of the week.

4. Do you have diabetes?

Diabetes is a disease in which the body does not produce enough of, or does not respond adequately to, the hormone insulin – a protein necessary for the body to use sugar. Sugar that is not absorbed deposits around the veins and arteries, which can cause poor circulation. Patients with lupus have a greater chance of developing diabetes.

The combination of lupus and diabetes can potentially lead to a predisposition to renal and retinal diseases that must be monitored regularly.5 For those with diabetes, it is very important to check your blood sugar level frequently, monitor your blood pressure, and watch your diet.

5. Do you have hypercholesterolemia (high blood cholesterol)?

There are three types of cholesterol that you should watch out for: LDL (“bad cholesterol”), triglycerides, and HDL (”good cholesterol”). Too much bad cholesterol and triglycerides in the blood build up along the artery walls. Over time, this buildup may cause the hardening and narrowing of your arteries (atherosclerosis), which results in a slowed blood flow to the heart, or complete blockage.

However, good cholesterol helps cholesterol from building up in the arteries. Studies have demonstrated accelerated atherosclerosis in lupus patients due to increased vascular damage by autoantibodies.6 Therefore, it is important to control your cholesterol levels by maintaining a healthy diet, a healthy weight, and regular physical activity.

6. Do you have hypertension (high blood pressure)?

Hypertension is a blood pressure greater than 140/90 mmHg during more than three separate measurements, while the overall goal is to keep your blood pressure below 120/80 mmHg. Blood pressure can sometimes be hard to control in lupus patients because of use of nonsteroidal anti-inflammatory drugs (NSAIDs) or prednisone which can elevate blood pressure. Furthermore, lupus-related kidney disease can also increase your blood pressure.

Those with high blood pressure constantly have a greater-than-normal force of blood pushing against the walls of their arteries. This increased force damages the blood vessel walls and may lead to kidney disease, hardening of the arteries, and other cardiovascular problems. In combination with the effects of having active lupus, chronic high blood pressure may greatly increase your risks of developing CVD.

To control your blood pressure, stick to the following guidelines:

• Eat foods that are low in sodium (salt), calories, and fat.
• Eat more fresh fruits, vegetables, and low-fat dairy products.
• Lose weight if you are overweight or obese, and increase your physical activity.

7. Are you overweight or obese?

A good way to determine whether you are overweight is by calculating your Body Mass Index (BMI) – a measure of body fat calculated from your height and weight. Normal BMI is 18-24. Someone who is overweight has a BMI greater than 25, and someone who is obese has a BMI greater than 30. Obesity is typically an indicator of other CVD risk factors, such as high cholesterol, high blood pressure, and a sedentary life style; however, it can independently cause atherosclerosis and congestive heart failure.

Gaining weight increases the volume and muscle wall stress on the compartments of the heart. This extra strain on the heart may lead to severe coronary atherosclerosis, pulmonary embolism (blockage in the lungs), and most commonly, cardiac arrhythmias.7

Unfortunately, some medications prescribed to lupus patients also may result in unwanted weight gain that may be hard to control. Because of this added risk, it is important that you pay extra attention to your weight and other CVD risk factors. If you are overweight or obese, consider making lifestyle changes such as an increase in physical activity and nutrition counseling. Remember, the more belly fat, the higher the risk of heart attack!

8. Do you smoke?

Smoking is associated with arterial stiffening in those with or without lupus. Smoking also increases the chances of developing lupus and results in higher disease activity in lupus patients.8 Therefore, inflammatory exposure from smoking and from lupus both contribute to accelerated development of CVD.8

All lupus patients are encouraged to avoid smoking. If you are a smoker, consider participating in smoking cessation-counseling programs or taking medications that aim to help you quit, since smoking cessation has been shown to reduce CVD-related death rates.

9. Do you know the signs of a heart attack or stroke?

Symptoms of a possible heart attack include:

• Chest pain or discomfort that can last more than a few minutes
• Pain or discomfort in one or both arms, the back, neck, jaw/teeth, or stomach
• Shortness of breath; nausea, vomiting, lightheadedness, fainting, or intense sweating

Symptoms of a possible stroke include:

• Sudden numbness or weakness on one side of your body (face, arm, or leg)
• Trouble speaking or understanding (slurred speech, confusion, inability to speak)
• Trouble with seeing in one or both eyes (blurred, blackened, decreased vision, or double vision)
• Trouble with walking
• Sudden, severe, “out of the blue” headache

If you have any of these symptoms, go to the emergency room immediately.

10. What should I do to minimize my cardiovascular disease risk?

The above questions and answers may help you better understand and decrease the risk of cardiovascular disease (CVD). However, you should always speak with your doctor about your CVD risks and potential preventive medications or lifestyle changes.

Learn more about the Lupus and APS Center of Excellence.

Updated: 9/15/2023

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References

1. 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; 44:233.
2. Leeuw K, Blaauw J, Smit AJ, Kallenberg CG and BijI, M. Vascular responsiveness in the microcirculation of patients with systemic lupus erythematosus is not impaired. Lupus 2008; 17:1010-1017.
3. Erkan D. Lupus and Thrombosis. J Rheumatology 2006; 33;1715-1717.
4. O’Neill SG, Pego-Reigosa JM, Hingorani AD, et al. Use of a strategy based on calculated risk scores in managing cardiovascular risk factors in a large British cohort of patients with systemic lupus erythematosus. Rheumatology 2009; 48:573–575
5. Cortes, S, Chambers, S, Jeronimo, A, Isenberg, D. Diabetes mellitus complicating systemic lupus erythematosus – analysis of the UCL lupus cohort and review of the literature. Lupus 2008;17:977-980.
6. Thomas GN, Tam LS, et al. Accelerated atherosclerosis in patients with systemic lupus erythematosus: a review of the causes and possible prevention. HKMJ 2002; 1.
7. Eckel RH, for the Nutrition Committee. Obesity and Heart Disease: A Statement for Healthcare Professionals From the Nutrition Committee, American Heart Association. Circulation 1997;l96:3248-3250.
8. Scalzi LV, Bhatt S, Gilkeson RC, Shaffer ML. The relationship between race, cigarette smoking and carotid intimal medial thickness in systemic lupus erythematosus. Lupus 2009; 18:1289–1297.

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