Silent myocardial infarct as a main manifestation of systemic lupus erythematosus

Myocardial infarction has rarely been reported in patients with systemic lupus erythematosus but may develop late in the disease usually as a result of severe and accelerated atherosclerosis or coronary arteritis. A 32-year-old man with untreated and unrecognized systemic lupus erythematosus, in the absence of conventional coronary risk factors (except family predisposition) and definite extracardiac manifestations of systemic lupus erythematosus had a silent myocardial infarction early in the course of the disease. A coronary arteriogram revealed multiple stenosis of the left anterior descending artery and critical stenosis of the right coronary artery. It is our belief that lupus vasculitis is a likely contributing factor in the development of obstructive coronary disease in this patient.     

Coronary arteritis in systemic lupus erythematosus.

Acute myocardial infarction in systemic lupus erythematosus may be due to an atheromatous or arteritic process. Confirmation of the latter etiology has previously been made only at postmortem examination. A 45-year-old white woman with known systemic lupus erythematosus developed anginal pain and multiple episodes of acute myocardial infarction. During this period, there was serologic but no other clinical evidence of active systemic lupus erythematosus. Serial coronary angiographic studies were strongly suggestive of an arteritic process based upon (1) a saccular aneurysm with no obstructive lesions in a coronary artery supplying an area of recent transmural myocardial infarction and (2) the development of significant obstructive lesions in a previously normal coronary artery over a period of 18 days. This case illustrates the difficulties in distinguishing between atherosclerosis and arteritis using a single coronary angiographic study. The distinction is significant because of the different therapeutic interventions required.     

Myocardial perfusion abnormalities in asymptomatic patients with systemic lupus erythematosus

Accelerated coronary artery disease and myocardial infarction in young patients with systemic lupus erythematosus is well documented; however, the prevalence of coronary involvement is unknown. Accordingly, 26 patients with systemic lupus were selected irrespective of previous cardiac history to undergo exercise thallium-201 cardiac scintigraphy. Segmental perfusion abnormalities were present in 10 of the 26 studies (38.5 percent). Five patients had reversible defects suggesting ischemia, four patients had persistent defects consistent with scar, and one patient had both reversible and persistent defects in two areas. There was no correlation between positive thallium results and duration of disease, amount of corticosteroid treatment, major organ system involvement or age. Only a history of pericarditis appeared to be associated with positive thallium-201 results (p less than 0.05). It is concluded that segmental myocardial perfusion abnormalities are common in patients with systemic lupus erythematosus. Whether this reflects large-vessel coronary disease or small-vessel abnormalities remains to be determined.     

Coronary artery disease in systemic lupus erythematosus: A review of the literature

CONTEXT: Coronary artery occlusive disease is a common though underappreciated complication of systemic lupus erythematosus (SLE), typically a disease of young women. A case of a premenopausal patient with SLE and an acute myocardial infarction is presented, and the etiology and management of coronary artery disease in SLE reviewed. OBJECTIVES: To review the incidence, risk factors, pathology and treatment of coronary artery disease in systemic lupus erythematosus. DATA SOURCES: MEDLINE search of articles in English-language journals from 1980 to 2000. The index words "systemic lupus erythematosus" and the following co-indexing terms were used: "coronary artery disease," "atherosclerosis," "vasculitis," "anticardiolipin antibodies," "antiphospholipid syndrome." SELECTION SYNTHESIS AND ABSTRACTION: Papers identified were reviewed and abstracted by the authors with a presentation of a summary. RESULTS: The prevalence of coronary artery disease among women with SLE between the ages of 35 and 44 years is at least 50-fold greater than among age-matched control subjects. Of these, coronary atherosclerosis accounts for the vast majority of cases; vasculitis of the coronary arteries and other causes generally believed to be more typical of SLE are comparatively rare. CONCLUSIONS: The evidence suggests that SLE is a significant risk factor for coronary atherosclerosis independent of the classic risk factors of hypertension, tobacco use, and hyperlipidemia.     

Acute myocardial infarction associated with systemic lupus erythematosus documented by coronary arteriograms

A 19-year-old man with untreated systemic lupus erythematosus had an acute myocardial infarction. A coronary arteriogram five hours after the onset of symptoms revealed total occlusion of the left anterior descending coronary artery. Reperfusion was achieved by coronary thrombolytic therapy with urokinase. Four weeks later, a coronary arteriogram showed only minimal luminal irregularities at the original site of occlusion, where significant reduction in diameter could be induced by ergonovine maleate. This case suggests that coronary arterial involvement in systemic lupus erythematosus may be related to coronary arterial spasm.     

Heart disease in systemic lupus erythematosus: diagnosis and management

Most patients suffering from systemic lupus erythematosus develop secondary heart disease at some time during the course of the primary illness. The most common forms of this type of heart disease are acute fibrinous pericarditis and hypertension. By means of echocardiography, an increased incidence of pericardial effusion has been demonstrated. Although commonly noted at autopsy, myocarditis is often clinically silent. However, endomyocardial biopsy may confirm its presence during life. Libman-Sacks endocarditis, although encountered in 40 to 50% of hearts at autopsy, is rarely diagnosed during life. When significant valve dysfunction such as aortic insufficiency or mitral regurgitation develops during the course of systemic lupus erythematosus, then Libman-Sacks endocarditis should be strongly suspected. Cardiac arrhythmias, first degree AV block, and acquired complete heart block may develop either de novo or in association with lupus pericarditis, myocarditis, vasculitis, etc. Complete congenital heart block has been reported in newborns of mothers with systemic lupus erythematosus, particularly those who have an antibody to a soluble tissue ribonucleoprotein antigen called RO(SS-A). Coronary arteritis and premature coronary atherosclerosis manifesting in either angina pectoris or myocardial infarction in young adults, particularly women suffering from systemic lupus erythematosus, have received attention recently. The development of hypertension and hyperlipidemia while such patients are receiving prolonged corticosteroid therapy has been incriminated as the significant risk factor in premature coronary atherosclerosis. Longstanding hypertension and congestive heart failure have unfavorable prognoses. This report is based on a cumulative review of 50 patients with acute and chronic systemic lupus erythematosus seen at our institution and in private practice during the last 10 years.     

Myocardial infarction secondary to premature coronary artery disease as the initial major manifestation of systemic lupus erythematosus

A 32-year-old woman admitted to the emergency department was diagnosed with acute anterior myocardial infarction, treated with thrombolytics and referred for angiography on the basis of her age. The patient was then referred for angioplasty with the diagnosis of an atherosclerotic lesion in the left anterior descending (LAD) coronary artery. Successful treatment of the lesion by primary stenting ensued. Laboratory findings revealed a state of hypercoagulability as well as some collagen fibre disease. The final diagnosis, confirmed by a rheumatologist, was systemic lupus erythematosus (SLE) with premature atherosclerosis of the LAD in addition to hypercoagulability. A Medline search of the literature revealed limited previous reports of myocardial infarction due to premature coronary artery disease as the first manifestation in SLE.     

CORONARY ARTERY VASCULITIS AND MYOCARDIAL INFARCTION ASSOCIATED WITH ANTIPHOSPHOLIPID ANTIBODIES IN A PREGNANT WOMAN

A 28-year-old, 16 week primigravida presented with an acute anteroseptal myocardial infarction and a past history of recurrent venous thromboembolism and primary infertility. Although she lacked other clinical features of systemic lupus erythematosus, she had a circulating lupus' anticoagulant, anticardiolipin antibodies, a weakly positive anti-nuclear antibody and thrombocytopenia. She died suddenly despite corticosteroid therapy and autopsy revealed coronary arteritis and thrombosis.     

Myocardial infarction in young patients (< or =35 years of age) with systemic lupus erythematosus: a case report and clinical analysis of the literature

The present study aims to report a-20-year old girl with systemic lupus erythematosus (SLE) who developed myocardial infarction (MI) and also aims to review acute myocardial infarction (AMI) in young SLE cases (< or =35 years) reported in the literature. We conducted a comprehensive review of the English literature from 1975 to 2006 to analyse data on MI in SLE patients who had developed AMI either at 35 or earlier. In 32 English articles, we identified 49 SLE patients, plus our case, with AMI. They consist of 41 female and nine male patients, their mean age being 24 +/- 6.4 years (range of 5-35). Disease duration varied between 0 and 13 years. The lag time between the onset of the SLE manifestations and development of AMI was 7.7 +/- 5.4 year (range of 1 month to 20.5 years). We divided the patients into three subgroups according to their coronary involvement type (Group I: normal coronary artery or coronary thrombosis (n = 16); Group II: coronary aneurysm/arteritis (n = 12); Group III: coronary atherosclerosis (n = 22)). The lag time between the onset of the SLE manifestations and development of MI in the subgroups showed variations: Group I < Group II < Group III. Both prevalence of renal involvement and steroid therapy were higher in patients with coronary atherosclerosis than were in Group I. There were one or more risk factors for atherosclerosis in 39 SLE patients. AMI in young SLE patients may be seen, albeit rare. We suggest that clinicians should have a low threshold for cardiac evaluation in patients with SLE. Also, traditional risk factors could be managed through preventive measures.     

Intra-vascular ultrasound findings of diffuse coronary atherosclerotic change in systemic lupus erythematosus with secondary antiphospholipid syndrome.

Systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APS) are autoimmune inflammatory diseases associated with juvenile atherosclerosis and thrombosis, respectively. A 44-year-old woman who had SLE with secondary APS had been treated with corticosteroid therapy, however, her inflammatory marker had never been within a normal range in her clinical course, and finally acute myocardial infarction was developed. Intra-vascular ultrasound also revealed diffuse coronary atherosclerosis progression for her age, which might result from SLE and APS, including vascular inflammation.     

Immune complex deposition and coronary vasculitis in systemic lupus erythematosus. Report of two cases

Extramural coronary arteries were examined in two patients with systemic lupus erythematosus (SLE). Coronary vasculitis was found in both patients. One patient with clinically and serologically inactive SLE had died suddenly and was found to have a myocardial infarction secondary to the coronary vasculitis. Immunopathologic studies demonstrated immune reactants in the walls of inflamed and noninflamed arterial segments in a pattern consistent with immune complex aggregates. Immunologic injury secondary to immune complex deposition may be responsible for the development of coronary disease in patients with SLE. This has been demonstrated in experimental animals but not in humans. Although this is an uncommon complication of SLE, it represents a cause of sudden death and a potentially treatable lesion in this patient population. Its occurrence may be related to the deposition of immune aggregates in the walls of coronary vessels.     

Thrombolytic therapy for a patient with systemic lupus erythematosus and acute myocardial infarction

A young patient with systemic lupus erythematosus was admitted to our hospital because of acute myocardial infarction, and treated by thrombolysis. Coronary angiography revealed a significant stenosis of the left anterior descending artery, together with an intraluminal thrombus. Clotting studies demonstrated an anticoagulant factor suggestive of lupus erythematosus. We conclude that thrombolytic therapy can be useful in patients with systemic lupus erythematosus who present with acute myocardial infarction, although some caution is needed in treatment.     

Myocardial infraction as the first manifestation of systemic lupus erythematosus in a 22-year-old man

We report the case of a 22-year-old male survivor of myocardial infarction as the first symptom of systemic lupus erythematosus and antiphospholipid syndrome. The diagnosis of myocardial infarction was based on typical ECG and enzymatic chanches and subsequently confirmed by technetium 99 scintigraphy. However, coronary arteries appeared to be normal at angiography. The authors conclude that myocardial infarction in SLE could be caused by a combination of cardiac microvascular thrombosis and inflammation accompanying the antiphospholipid syndrome.     

Cardiac rupture following acute myocardial infarction in systemic lupus erythematosus: case report

A thirty-three year-old woman with systemic lupus erythematosus (SLE) suffered from acute myocardial infarction. Prednisolone 20 mg/day was used because the signs of SLE, such as fever and decreased serum C3, levels, became aggravated on the fifth hospital day of acute myocardial infarction. Fatal cardiac rupture occurred on the twenty-second hospital day. At autopsy, extensive myocardial infarction with coronary artery thrombi and diffuse coronary arteritis were revealed. The rare clinical picture of a fatal cardiac rupture in the later phase of acute myocardial infarction and the precise dosage of prednisolone for her SLE are described.     

A case of myocardial infarction in a young man with systemic lupus erythematosus]

Apparently the incidence of coronary artery disease in systemic lupus erythematosus (SLE) has been increasing. However, most of the cases had been treated with corticosteroids, and had atherosclerotic lesions in the coronary arterial tree. A 21-year-old man with latent and untreated SLE had an attack of acute myocardial infarction. Coronary arteriography showed eccentric stenotic lesion at the proximal segment of the right coronary artery. One week later, in the 2nd coronary arteriography, this stenotic lesion was not able to be recognized. We supposed that the coronary artery occlusion was due to thrombus formation, and was not related to atherosclerosis, arteritis and embolus. He had no coronary risk factors. Laboratory data showed lymphocytopenia, proteinuria, positive antinuclear antibody, and positive LE cell, and the case was diagnosed as SLE. Subsequent investigations showed the presence of antibodies to cardiolipin. It was suggested that anticardiolipin antibody and other thrombogenic factors were the causes of the coronary occlusive thrombosis in this patient with SLE.     

Update on vascular disease in systemic lupus erythematosus

PURPOSE OF REVIEW: Young women with systemic lupus erythematosus have strikingly high rates of coronary heart disease. Current knowledge indicates that atherosclerosis is an active inflammatory and immune-mediated process. Therefore, the chronic inflammation and immune dysregulation characteristic of systemic lupus erythematosus undoubtedly contribute to the accelerated vascular disease seen in these patients. Carefully considering what is known about atherogenesis in the general population will provide clues to unraveling the complexity of why systemic lupus erythematosus and atherosclerosis are linked so frequently. RECENT FINDINGS: Inflammation is involved in all aspects of atherogenesis from the initial endothelial "response to injury," to foam cell formation leading to the atherosclerotic lesion, to the rupture of the "vulnerable" fibrous cap, resulting in the acute coronary syndrome and potentially in death. The authors review how factors commonly seen in systemic lupus erythematosus or inherent to the underlying disease mechanism may contribute to each of the stages of atherogenesis. SUMMARY: Our focus on the causes of vascular disease in systemic lupus erythematosus must now include nontraditional risk factors such as immune and inflammatory mediators. With the advent of noninvasive screening tools for atherosclerosis, we are better equipped to measure subclinical vascular disease and associated risk factors, including immune and inflammatory mediators. When considering strategies for preventing premature cardiovascular disease in systemic lupus erythematosus, modifying immune and inflammatory risk factors will likely become a major component of the program in addition to modifying the current traditional risk factors.     

Myocardial involvement in systemic lupus erythematosus detected by magnetic resonance imaging

Myocardial involvement in systemic lupus erythematosus is commonlyfound at autopsy but seldom recognized clinically or by routinecardiological investigations. As the magnetic resonance relaxationparameter, Tl, is altered by changes in tissue cellularity,we carried out magnetic resonance imaging in 10 patients withsystemic lupus erythematosus. Five had active systemic lupuserythematosus when assessed using the lupus activity criteriacount. The mean ( ±SD) Tl was 319 ±12 in normal volunteersand 321 ± 10 in a second control group with hypertrophiccardiomyopathy. In the group with systemic lupus erythematosus,there was a higher mean value of 336 ms/vith a wider scatterof individual results (SD±22 ms). In the subgroup ofpatients with active disease, Tl was significantly higher (349± 24) than in either of the two control groups. In addition, there was an inverse correlation between serumcomplement and myocardial Tl in patients with systemic lupuserythematosus. Myocardial abnormalities in systemic lupus erythematosuswere demonstrated by magnetic resonance imaging even where othernon-invasive cardiac investigations were negative. We concludethat Tl calculated from magnetic resonance imaging is oftenabnormal in systemic lupus erythematosus and probably indicatesmyocardial involvement.     

Unusual coronary artery aneurysm and acute myocardial infarction in a middle-aged man with systemic lupus erythematosus

A 55-year-old man developed acute myocardial infarction (AMI) related to a large coronary artery aneurysm and a distal coronary stenotic lesion after steroid therapy for systemic lupus erythematosus (SLE). Only 13 SLE patients with AMI caused by coronary artery aneurysms have been reported, 11 of whom were young or middle-aged women and the 2 remaining were young men. This is the first report of a middle-aged man with multiple coronary lesions.     

Ischemie heart disease in systemic lupus erythematosus in the young patient: Report of six cases

To clarify the clinical spectrum of coronary arterial abnormalities in systemic lupus erythematosus, the data were reviewed on six patients who had a diagnosis of lupus at ages 15 to 29 years and who had ischemie heart disease before age 35. Two patients had coronary arteritis diagnosed on postmortem examination. In a third patient alterations in coronary arterial anatomy occurred with angiographic improvement temporally related to the initiation of steroid therapy. The other three patients had severe diffuse atherosclerotic coronary disease that was identified in two at postmortem examination. In the third patient the course of the disease strongly suggested coronary atherosclerosis, and eventually coronary bypass grafting was performed for relief of angina, In summary, clinically important extramural coronary arteritis and atherosclerosis both occur, although rarely, in young patients with lupus. Coronary artery disease may occur with or without coexisting active extracardiac lupus manifestations. Short-term steroid therapy and follow-up angiography for those with angina and in whom coronary arteritis is suspected warrant consideration. When stable coronary arterial anatomy is demonstrated on follow-up angiography, management is determined by the patient's symptoms Irrespective of the prior history of lupus and, if indicated, cardiac surgery for symptomatic relief can be safely performed.     

Vascular imaging: changing the face of cardiovascular research

Patients with systemic lupus erythematosus (SLE) are at significant risk for premature cardiovascular disease, now a leading cause of death in this population. Most previous studies have used an overt clinical event to identify cardiovascular disease, likely underestimating the actual prevalence in these patients. Although the rates of myocardial infarction in SLE are high, the actual number of coronary events is low, precluding large clinical trials using a coronary event as the sole outcome. The ability to measure atherosclerosis, a known determinant of coronary heart disease, provides investigators with a desirable surrogate for the clinical cardiac event. With the advent of sensitive imaging techniques to identify subclinical atherosclerosis, we are now better equipped to determine the true prevalence and mechanisms of vascular disease in SLE. In this review, we will discuss several vascular imaging techniques and the current trend away from measuring flow-limiting vessel stenosis toward measuring earlier structural and functional aspects of the vascular system.