TOPIC SERIES: CVD PREVENTION IN RHEUMATIC DISEASE

Cardiovascular disease (CVD) prevention counseling programs may successfully decrease the prevalence of established CVD risk factors in patients with systemic lupus erythematosus (SLE), according to research published in Arthritis Care & Research.

Doruk Erkan, MD, MPH, of the Barbara Volker Center for Women and Rheumatic Diseases at the Hospital for Special Surgery and Weill Cornell Medicine in New York, and colleagues conducted a retrospective analysis of prospectively collected data from participants in the CVD Prevention Counseling Program at the Hospital for Special Surgery. Dr Erkan and colleagues aimed to assess the effectiveness of the program in decreasing the prevalence of CVD risk factors in patients with SLE.

Participation in the free, 3-year CVD-Prevention Counseling Program was based on patients’ clinical diagnosis of SLE. Additional patients who met 3 or more of the American College of Rheumatology (ACR) SLE Classification Criteria were also invited to participate in the program.


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Participants attended a 2-phase baseline visit. During the first phase, blood pressure, glucose, fasting cholesterol panel, and body mass index (BMI) were evaluated. Smoking status, diet, exercise, antiphospholipid antibody (aPL)-profile, and medications were also assessed by clinicians.

During the second phase, patients participated in a detailed discussion of risk factors based on their lifestyle, as well as CVD and thrombosis prevention strategies. Each patient received tailored lifestyle recommendations, a written summary of the meeting, and in the case of patients with a BMI ≥25, a referral to a dietitian for as-needed visits.

High Yield Data Summary

  • Significant improvements after 3 years of participation in the counseling program were noted only among patients with SLE considered “high risk” for CVD 

Finally, all patients completed an anonymous survey on CVD risk awareness and their general diet and exercise habits.

During 3 years of follow-up, patients were screened every 3-6 months (determined by their CVD risk at baseline) for CVD risk factor reassessment. Additional education was undertaken by a nurse practitioner and physician. 

Patients regularly received newsletters, pamphlets, and brochures about CVD risk factors and prevention strategies.

Between March 2009 and December 2014, 121 patients (aged 41.4±13.7 years, 89% female, 48% white) completed 696 visits (mean 4.7±3.7; range: 1-13). At the beginning of the study, 64% of patients were considered overweight or obese (mean BMI, 28.4). Results of the CVD awareness survey indicated that 42% of patients were not aware of their CVD risk; 36% had limited knowledge, and 22% considered themselves risk-aware.

During 3-year follow-up, no significant changes were identified in the percentage of patients with abnormal blood pressure (mean baseline systolic blood pressure 118±15.9 mmHg; mean baseline, diastolic blood pressure 73±9.9 mmHg).

An analysis of patients with abnormal baseline blood pressure showed a significant decrease in both the number of patients with abnormal blood pressure (odds ratio [OR]: 0.94; 95% confidence interval [CI], 0.92-0.96) and in mean systolic blood pressure (-6.12±2.16 mmHg).

No significant changes were identified in patients’ mean blood glucose, although the percentage of patients with abnormal blood glucose increased significantly over the follow-up period (OR: 1.11; 95% CI, 1.08-1.15). In the same vein, BMI did not change significantly, even among patients with abnormal BMI at baseline.

Only mean high density lipoprotein (HDL) cholesterol showed any significant improvement; in an analysis of 94 patients with baseline abnormal cholesterol profiles (mean total cholesterol 183±36 mg/dl; low density lipoprotein (LDL) 107±30 mg/dl; HDL 51±20 mg/dl, triglycerides 129±68 mg/dl), a significant improvement in the number of patients within that subgroup (OR: 0.90; 95% CI, 0.92-0.96).

Significantly, the percentage of patients categorized as having a “poor diet” decreased during the follow-up, while the number of patients who regularly consumed fruits, vegetables, whole-grains, and fish increased, with the number of patients having poor diet habits decreasing over time (OR: 0.93; 95% CI, 0.91-0.95). 

No significant change was found in the percentage of patients who engaged in 60-90 minutes a day of moderate physical activity.

Summary and Clinical Applicability

CVD risk factors are common among patients with SLE. Despite this, many patients are not appropriately counseled or screened—and many do not perceive a diagnosis of SLE to be a risk factor for CVD.

While benefits do exist for CVD prevention programs, the researchers noted that significant improvements (particularly in blood pressure, blood glucose, and cholesterol levels) were seen only in patients with abnormal baseline values who could be considered “high risk.”

“The European League Against Rheumatism already recommends increasing the CVD risk score by a factor of 1.5 in patients with rheumatoid arthritis; a similar approach might be considered for lupus,” wrote Dr Erkan and colleagues. “Although we believe that CVD prevention counseling should be incorporated into routine lupus care, long-term follow-up of larger SLE cohorts will determine if the counseling decreases the incidence of CVD.”

Limitations and Disclosures

  • Half of the participants did not complete the full 3-year program.
  • There was no way to separate those who were referred to counseling (voluntary participation), so patients may not be representative of the whole SLE population.
  • Potential confounders including SLE disease activity and premenopausal status was not recorded
  • Some data (diet habits, physical activity) was self-reported

Disclosures: The researchers report no conflicts of interest.

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Reference

  1. Yelnik CM, Richey M, Haiduc V, Everett S, Zhang M, Erkan D. Cardiovascular disease prevention counseling program for systemic lupus erythematosus patients. Arthrit Care Res. 2016 Oct 11. doi: 10.1002/acr.23128 [Epub ahead of print]

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