Cutaneous lupus erythematosus (CLE) is associated with an increased risk of cerebrovascular accidents, such as stroke and peripheral arterial disease, but not with ischemic heart disease or myocardial infarction, according to research presented in Arthritis Care & Research.
Vaidehi R. Chowdhary, MD, assistant professor of medicine in the Division of Rheumatology at the Mayo Clinic, and colleagues conducted a population-based cohort study of patients with CLE in Olmstead County, Minnesota, in an effort to estimate incidence and relative risk of and cerebrovascular accidents (stroke and transient ischemic attack), ischemic heart disease (coronary artery disease, myocardial infarction, and angina pectoris), heart failure, or peripheral arterial disease in this patient population.
High Yield Data Summary
- Patients with cutaneous lupus erythematosus are at an elevated risk for cerebrovascular accidents and peripheral arterial disease, but not ischemic heart disease.
The researchers age- and sex-matched 155 patients with CLE (mean age at diagnosis 44±16 years, 65% female, 77% white) to 155 controls. The cohort of CLE patients included 128 patients (73%) with chronic discoid lupus erythematosus (CDLE; 91 localized and 37 generalized), 23 patients (15%) with subacute cutaneous lupus erythematosus (SCLE; 6 annular and 17 psoriaform), 3 patients (2%) with lupus panniculitis, and 1 patient (1%) with bullous CLE. Therapies included 46 patients (30%) treated with hydroxychloroquine and 6 patients (4%) treated with prednisone.
Data showed that patients with CLE were more likely to be smokers compared with those without CLE (39.6% vs 20.6%, P =.001); however, patients with CLE had lower total cholesterol (P =.007). Dr Chowdhary and colleagues noted no other significant differences in cardiovascular risk factors between the 2 groups.
Over a median follow-up of 14.6 years (interquartile range [IQR]: 8.1 to 23.6 years) of follow-up, 41 patients experienced a cardiovascular event; 11 had myocardial infarctions, 22 had heart failure, 15 had cerebrovascular accidents, and 20 had peripheral arterial disease, with a 31.6% cumulative incidence of cardiovascular events (standard error [SE]: 4.7%). In the CLE cohort, the risk of cardiovascular events was not significantly higher than in the non-CLE cohort (hazard ratio [HR]: 1.22; 95% confidence interval [CI], 0.80 to 1.85).
Fifteen patients experienced a cerebrovascular accident during follow-up; cumulative incidence 20 years post-CLE diagnosis was 8.2 (SE: 2.6%), with a 2.8 times higher risk of a cerebrovascular accident compared to the non-CLE cohort (HR: 2.75; 95% CI, 1.13 to 6.70). Patients who experienced ischemic heart disease (n=32) had a 20% cumulative incidence of ischemic heart disease 20 years after diagnosis (SE: 4%), although ischemic heart disease risk was not significantly different compared to the non-CLE cohort (HR: 1.04; 95% CI, 0.64 to 1.66). Additionally, patients with CLE were not found to be at a higher risk for myocardial infarction compared to the non-CLE cohort (HR: 0.92; 95% CI, 0.37 to 2.27).
Among patients who experienced heart failure (n=22), cumulative incidence at 20 years after diagnosis was 12% (SE: 3.1%). Cumulative risk was not significantly different than within the non-CLE cohort (HR: 1.59; 95% CI, 0.84 to 3.00). Peripheral arterial disease (n=20) had a cumulative incidence rate at 20 years of 17.3% (SE: 3.9%), with a 2.5 times higher risk (HR: 2.46; 95% CI, 1.22 to 4.95).
The investigators also assessed cardiovascular mortality in the CLE and non-CLE cohorts, finding a cumulative risk of cardiovascular mortality at 20 years post-diagnosis of 7.85% (SE: 2.4%). Whereas cardiovascular mortality risk was elevated in the CLE cohort, it was not statistically significant (HR: 2.05; 95% CI, 0.98 to 4.27).
Summary and Clinical Applicability
Dr Chowdhary and colleagues noted that several key observations were made with this study — primarily that patients with CLE “are not at an increased risk of cardiovascular death, as compared to age-, sex, and calendar year-matched non-CLE subjects.” Similarly, there no increased risk was noted for ischemic heart disease or heart failure, but a 2.8 times higher cerebrovascular accident risk and 2.1 times higher peripheral arterial disease was identified.
“It is unclear why there was an apparent increase in risk of [cerebrovascular accidents] in patients with CLE…without an increase in the risk of [ischemic heart disease] or heart failure,” Dr Chowdhary and colleagues wrote. “This may be a true finding, and vascular inflammation associated with CLE may predispose patients to [cerebrovascular accidents].”
The researchers concluded that both rheumatology and dermatology clinicians should focus on management of conventional risk factors, including emphasizing the importance of smoking cessation and controlling both hypertension and diabetes, as a way to minimize cardiovascular disease risk in this patient population.
- The small sample size resulted in limited power for performing some detailed comparative analyse
- Due to the predominantly white population of Olmstead County, Minnesota, data may not be generalizable to patients of other ethnicities
- The retrospective nature of the study meant that researchers could not assess the impact CLE disease activity and treatment may have had on cardiovascular risk
- Severe cutaneous involvement may modulate cardiovascular risk, and while the risk was analyzed in generalized CDLE, the affect of skin disease in SCLE and lupus panniculitis is unknown.
Singh AG, Crowson CS, Singh S, et al. Risk of cerebrovascular accidents and ischemic heart disease in cutaneous lupus erythematosus: a population-based cohort study. Arthrit Care Res. 2016;68(11):1664-1670. doi:10.1002/acr.22892