Arthritis Research & Therapy

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Predictors of the first cardiovascular event in patients with systemic lupus erythematosus - a prospective cohort study

Johanna Gustafsson1, Iva Gunnarsson1, Ola Börjesson1, Susanne Pettersson1, Sonia Möller1, Guo-Zhong Fei1, Kerstin Elvin2, Julia F Simard3, Lars-Olof Hansson4, Ingrid E Lundberg1, Anders Larsson5 and Elisabet Svenungsson1*

Author Affiliations

1 Rheumatology Unit, Department of Medicine Karolinska University Hospital, Solna, Karolinska Institutet, SE-171 76 Stockholm, Sweden

2 Unit of Clinical Immunology, Department of Clinical Immunology and Transfusion Medicine, Karolinska University Hospital, Karolinska Institutet, SE-171 76 Stockholm, Sweden

3 Clinical Epidemiology Unit, Karolinska Institutet, SE-171 76 Stockholm, Sweden

4 Department of Laboratory Medicine, Karolinska University Hospital, Karolinska Institutet, SE-171 76 Stockholm, Sweden

5 Department of Clinical Chemistry and Pharmacology, Akademiska Hospital, SE-751 85 Uppsala, Sweden

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Arthritis Research & Therapy 2009, 11:R186 doi:10.1186/ar2878

Published: 10 December 2009

Abstract

Introduction

Cardiovascular disease (CVD) is a major cause of premature mortality among Systemic lupus erythematosus (SLE) patients. Many studies have measured and evaluated risk factors for premature subclinical atherosclerosis, but few studies are prospective and few have evaluated risk factors for hard endpoints, i.e. clinically important cardiovascular events (CVE). We investigated the impact of traditional and lupus associated risk factors for the first ever CVE in a longitudinal cohort of SLE patients.

Methods

A total of 182 SLE patients (mean age 43.9 years) selected to be free of CVE were included. Cardiovascular and autoimmune biomarkers were measured on samples collected after overnight fasting at baseline. Clinical information was collected at baseline and at follow up. End point was the first ever CVE (ischemic heart, cerebrovascular or peripheral vascular disease or death due to CVD). Impact of baseline characteristics/biomarkers on the risk of having a first CVE was evaluated with Cox regression.

Results

Follow up was 99.5% after a mean time of 8.3 years. Twenty-four patients (13%) had a first CVE. In age-adjusted Cox regression, any positive antiphospholipid antibody (aPL), elevated markers of endothelial activation (von Willebrand factor (vWf), soluble vascular cellular adhesion molecule-1 (sVCAM-1)) and fibrinogen predicted CVEs. Of SLE manifestations, arthritis, pleuritis and previous venous occlusion were positively associated with future CVEs while thrombocytopenia was negatively associated. Among traditional risk factors only age and smoking were significant predictors. In a multivariable Cox regression model age, any positive aPL, vWf and absence of thrombocytopenia were all predictors of the first CVE.

Conclusions

In addition to age, positive aPL, biomarkers indicating increased endothelial cell activity/damage, and absence of thrombocytopenia were independent predictors of CVEs in this prospective study. Our results indicate that activation of the endothelium and the coagulation system are important features in SLE related CVD. Furthermore, we observed that the risk of CVEs seems to differ between subgroups of SLE patients.