Evaluation and Treatment of Acute Myocardial Infarction Complicating Systemic Lupus Erythematosus

doi:10.1378/chest.101.2.420

Chest

Volume 101, Issue 2, February 1992, Pages 420-424

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Coronary artery disease has emerged as an important cause of death in young patients with SLE. We report three cases of acute myocardial infarction in young lupus patients who underwent emergent coronary angiography. One patient had a large coronary aneurysm and died five months later from myocarditis. The other two patients underwent coronary angioplasty. The difficulty in distinguishing coronary arteritis from premature atherosclerosis and its relevance to methods of treatment is discussed.

Section snippets

CASE 1

A male patient was diagnosed with SLE at 17 years of age and required steroid therapy for glomerulonephritis. At the age of 18 years, he was treated with steroids and azathioprine for pericarditis and neutropenia. Then at age 21 years he suffered a left hemispheric stroke attributed to CNS vasculitis and was treated with high-dose steroids.

At age 25 years, he was admitted to our hospital with left hip pain secondary to avascular necrosis and worsened right hemiparesis. He had alopecia, but no

DISCUSSION

Coronary artery disease has a number of possible pathogenic mechanisms. Occlusive arteritis as a cause of acute myocardial infarction in young SLE patients has been documented by autopsy in several case reports.4, 5, 6 Pathologic arterial findings include neutrophilic and lymphocytic infiltrates with fibrinoid necrosis and evidence of immune complex deposition. Inflammation and necrosis of the arterial media may lead to aneurysm formation as seen in case 1. Eight SLE patients with coronary

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Cardiac Involvement in Systemic Lupus Erythematosus
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Citation Excerpt :
Ischemia due to vasculitis is more frequent in young people with active disease, often of short duration. Moreover, in these patients the detection of vasculitic abnormalities in other organs is not uncommon; however, the absence of these last features does not rule out coronary arteritis (Wilson et al., 1992). Ischemia due to atherosclerosis, although occurring earlier in SLE patients than in the normal population, affects more frequently older SLE patients, with long-standing disease, long period of corticosteroid intake, and, usually, quiescent disease at the time of the cardiovascular event.
Systemic lupus erythematosus (SLE) is a chronic autoimmune disease of unknown etiology, characterized by the production of autoantibodies by autoreactive B cells, which are capable of inducing inflammatory changes in various organs and systems by several mechanisms. In patients with SLE, all the cardiac structures can be involved. Pericarditis is the most common cardiac abnormality, but lesions of the valves, myocardium, and coronary vessels may also occur. Nowadays, cardiac manifestations can be frequently recognized by echocardiography and other noninvasive tests, such as cardiac computed tomography or cardiac magnetic resonance imaging. Echocardiography is a nonexpensive, sensitive, and specific technique in detecting cardiac abnormalities, particularly mild pericarditis, valvular lesions, and myocardial dysfunction. Premature atherosclerosis is the most frequent cause of coronary artery disease in SLE patients. Efforts should be made to control traditional risk factors as well as all other factors, which could contribute to atherosclerotic plaque development.
Cardiovascular systemic lupus erythematosus
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2004, Systemic Lupus Erythematosus, Fourth Edition
Cardiac Involvement in Systemic Lupus Erythematosus
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Citation Excerpt :
Ischemia due to vasculitis is more frequent in young people with active disease, often of short duration. Moreover, in these patients the detection of vasculitic abnormalities in other organs is not uncommon; however, the absence of these last features does not rule out coronary arteritis (Wilson et al., 1992). Ischemia due to atherosclerosis, although occurring earlier in SLE patients than in the normal population, affects more frequently older SLE patients, with long-standing disease and a longer period of corticosteroid intake.
Systemic lupus erythematosus (SLE) is a chronic inflammatory disease with a still undefined etiology, characterized by the production of autoantibodies and autoreactive T cells which can trigger an inflammatory process in various organ systems. Among these, the most affected ones are skin, musculoskeletal, hematopoietic and nervous system, kidney, lung, blood vessels, and heart. All the cardiac structures can be involved: pericardium, endocardium and valves, myocardium, coronary arteries, and conduction tissue. Pericarditis is one of the most characteristic manifestations of the disease and is included in the American Rheumatism association (ARA)/American College of Rheumatism (ACR) classification criteria for SLE. The prevalences of valvular verrucae and thickening observed in transthoracic and transesophageal echocardiography are reported in the chapter. There are two major pathogenetic hypothesis. The primum movens could be represented by a thrombus. According to this hypothesis, antiphospholipid antibodies (aPL) and anti-endothelium antibodies could bind to endothelial cells, which lead to their activation and, in turn, platelet aggregation and thrombus formation. Alternatively, the primum movens could be immune complex deposition between the endothelium and the basal membrane, followed by the inﬁltration of inﬂammatory cells.
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Chest

Clinical InvestigationsEvaluation and Treatment of Acute Myocardial Infarction Complicating Systemic Lupus Erythematosus

Section snippets

CASE 1

DISCUSSION

Am Heart J

Am J Cardiol

Ann Thorac Surg

Chest

Am J Med

Chest

Duration and death in systemic lupus erythematosis: an analysis of 249 cases

JAMA

Mortality in lupus nephritis

Arthritis Rheum

Mortality in systemic lupus erythematosis: the bimodal pattern revisited

Quart J Med

Immune complex deposition and coronary vasculitis in systemic lupus erythematosis: report of two cases

Am J Med

Cardiac complications in children with systemic lupus erythematosis

Pediatrics

[Myocardial infarction due to thrombi in coronary aneurysms in a young woman with systemic lupus erythematosis]

J Cardiogr

Clinical Investigations
Evaluation and Treatment of Acute Myocardial Infarction Complicating Systemic Lupus Erythematosus