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Acute myocardial dysfunction in lupus: outcomes in Asian Indians

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Abstract

Background

Acute myocardial dysfunction is an uncommon but potentially fatal complication in systemic lupus erythematosus (SLE). We describe the outcome in a small series of Asian Indian patients and examine associated factors.

Methods

SLE patients who fulfilled the 2012 SLICC criteria and developed new-onset myocardial dysfunction were included in this retrospective case series. Acute myocardial dysfunction was defined as global hypokinesia and left ventricular ejection fraction (LVEF)<50% on echocardiography (with or without symptoms) in patients with SLE. Survival was assessed using Kaplan-Meier survival analysis and Cox regression.

Results

This study included 37 patients with mean age 28.2 ± 11.2 years and median (range) LVEF of 35% (18–48%) at presentation. A majority had active disease, with SLEDAI-2k ≥ 5 in 26 (of 28). All patients received oral corticosteroids and a majority received additional immunosuppression, including pulse methylprednisolone in 28 and cyclophosphamide in 27. Nine patients died during hospitalisation (25%), a majority due to infections. Death was significantly associated with elevated procalcitonin at presentation (p = 0.05), elevated white cell count (p = 0.02) and low complement C3 (p = 0.03). In those who survived, long-term outcomes were good, with complete myocardial recovery in 14 (64%). A higher ejection fraction at presentation was associated with complete recovery.

Conclusions

In this small series of patients of SLE with acute myocardial dysfunction, we report a significant in-hospital mortality due to infections. Many of the patients who died had elevated procalcitonin at presentation. A diligent search for infection seems prudent in lupus patients who present with acute myocardial dysfunction.

Key Points

• In patients of SLE with acute myocardial dysfunction who were treated with immunosuppression, there was significant short-term mortality due to infections.

• This mortality was associated with elevated procalcitonin at baseline and may suggest some of them had pre-existing hidden sepsis.

• A prudent search for infections in these patients before immunosuppression may help to decrease short-term mortality.

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Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

References

  1. Deng W, Xie M, Lv Q, Li Y, Fang L, Wang J (2020) Early left ventricular remodeling and subclinical cardiac dysfunction in systemic lupus erythematosus: a three-dimensional speckle tracking study. Int J Cardiovasc Imaging. https://doi.org/10.1007/s10554-020-01816-6

  2. Guo Q, Wu LM, Wang Z, Shen JY, Su X, Wang CQ, Gong XR, Yan QR, He Q, Zhang W, Xu JR, Jiang M, Pu J (2018) Early detection of silent myocardial impairment in drug-naive patients with new-onset systemic lupus erythematosus: a three-center prospective study. Arthritis Rheumatol 70(12):2014–2024. https://doi.org/10.1002/art.40671

    Article  CAS  PubMed  Google Scholar 

  3. Burkard T, Trendelenburg M, Daikeler T, Hess C, Bremerich J, Haaf P, Buser P, Zellweger MJ (2018) The heart in systemic lupus erythematosus - a comprehensive approach by cardiovascular magnetic resonance tomography. PLoS One 13(10):e0202105. https://doi.org/10.1371/journal.pone.0202105

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  4. Leone P, Cicco S, Prete M, Solimando AG, Susca N, Crudele L, Buonavoglia A, Colonna P, Dammacco F, Vacca A, Racanelli V (2020) Early echocardiographic detection of left ventricular diastolic dysfunction in patients with systemic lupus erythematosus asymptomatic for cardiovascular disease. Clin Exp Med 20(1):11–19. https://doi.org/10.1007/s10238-019-00600-8

    Article  CAS  PubMed  Google Scholar 

  5. Ishimori ML, Agarwal M, Beigel R, Ng RK, Firooz N, Weisman MH, Siegel RJ (2014) Systemic lupus erythematosus cardiomyopathy-a case series demonstrating a reversible form of left ventricular dysfunction. Echocardiography 31(5):563–568. https://doi.org/10.1111/echo.12425

    Article  PubMed  Google Scholar 

  6. Schultz M, Wimberly K, Guglin M (2019) Systemic lupus and catastrophic antiphospholipid syndrome manifesting as cardiogenic shock. Lupus 28(11):1350–1353. https://doi.org/10.1177/0961203319871099

    Article  CAS  PubMed  Google Scholar 

  7. Doherty NE, Siegel RJ (1985) Cardiovascular manifestations of systemic lupus erythematosus. Am Heart J 110(6):1257–1265. https://doi.org/10.1016/0002-8703(85)90023-7

    Article  CAS  PubMed  Google Scholar 

  8. Chazal T, Kerneis M, Guedeney P, Haroche J, Mathian A, Rufat P, Cohen Aubart F, Montalescot G, Amoura Z (2020) Coronary artery disease in systemic lupus: a case-controlled angiographic study. Autoimmun Rev 19(1):102427. https://doi.org/10.1016/j.autrev.2019.102427

    Article  PubMed  Google Scholar 

  9. Faurschou M, Mellemkjaer L, Starklint H, Kamper AL, Tarp U, Voss A, Jacobsen S (2011) High risk of ischemic heart disease in patients with lupus nephritis. J Rheumatol 38(11):2400–2405. https://doi.org/10.3899/jrheum.110329

    Article  PubMed  Google Scholar 

  10. Tselios K, Deeb M, Gladman DD, Harvey P, Akhtari S, Mak S, Butany J, Urowitz MB (2019) Antimalarial-induced cardiomyopathy in systemic lupus erythematosus: as rare as considered? J Rheumatol 46(4):391–396. https://doi.org/10.3899/jrheum.180124

    Article  CAS  PubMed  Google Scholar 

  11. Tselios K, Gladman DD, Harvey P, Akhtari S, Su J, Urowitz MB (2019) Abnormal cardiac biomarkers in patients with systemic lupus erythematosus and no prior heart disease: a consequence of antimalarials? J Rheumatol 46(1):64–69. https://doi.org/10.3899/jrheum.171436

    Article  CAS  PubMed  Google Scholar 

  12. Oud L (2020) Epidemiology and outcomes of sepsis among hospitalizations with systemic lupus erythematosus admitted to the ICU: a population-based cohort study. J Intensive Care 8:3. https://doi.org/10.1186/s40560-019-0424-y

    Article  PubMed  PubMed Central  Google Scholar 

  13. Lin Y, Xu Y, Zhang Z (2020) Sepsis-induced myocardial dysfunction (SIMD): the pathophysiological mechanisms and therapeutic strategies targeting mitochondria. Inflammation. https://doi.org/10.1007/s10753-020-01233-w

  14. Du Toit R, Herbst PG, van Rensburg A, du Plessis LM, Reuter H, Doubell AF (2017) Clinical features and outcome of lupus myocarditis in the Western Cape, South Africa. Lupus 26(1):38–47. https://doi.org/10.1177/0961203316651741

    Article  PubMed  Google Scholar 

  15. Petri M, Orbai AM, Alarcon GS, Gordon C, Merrill JT, Fortin PR, Bruce IN, Isenberg D, Wallace DJ, Nived O, Sturfelt G, Ramsey-Goldman R, Bae SC, Hanly JG, Sanchez-Guerrero J, Clarke A, Aranow C, Manzi S, Urowitz M, Gladman D, Kalunian K, Costner M, Werth VP, Zoma A, Bernatsky S, Ruiz-Irastorza G, Khamashta MA, Jacobsen S, Buyon JP, Maddison P, Dooley MA, van Vollenhoven RF, Ginzler E, Stoll T, Peschken C, Jorizzo JL, Callen JP, Lim SS, Fessler BJ, Inanc M, Kamen DL, Rahman A, Steinsson K, Franks AG Jr, Sigler L, Hameed S, Fang H, Pham N, Brey R, Weisman MH, McGwin G Jr, Magder LS (2012) Derivation and validation of the systemic lupus international collaborating clinics classification criteria for systemic lupus erythematosus. Arthritis Rheum 64(8):2677–2686. https://doi.org/10.1002/art.34473

    Article  PubMed  PubMed Central  Google Scholar 

  16. Tanwani J, Tselios K, Gladman DD, Su J, Urowitz MB Lupus myocarditis: a single center experience and a comparative analysis of observational cohort studies:1477–0962 (Electronic)

  17. Hattori T, Nishiyama H, Kato H, Ikegami S, Nagayama M, Asami S, Usami M, Suzuki M, Murakami I, Minoshima M, Yamagishi H, Yuasa N (2014) Clinical value of procalcitonin for patients with suspected bloodstream infection. Am J Clin Pathol 141(1):43–51. https://doi.org/10.1309/ajcp4gv7zfdtangc

    Article  CAS  PubMed  Google Scholar 

  18. Franklyn K, Lau CS, Navarra SV, Louthrenoo W, Lateef A, Hamijoyo L, Wahono CS, Chen SL, Jin O, Morton S, Hoi A, Huq M, Nikpour M, Morand EF (2016) Definition and initial validation of a lupus low disease activity state (LLDAS). Ann Rheum Dis 75(9):1615–1621. https://doi.org/10.1136/annrheumdis-2015-207726

    Article  CAS  PubMed  Google Scholar 

  19. Law WG, Thong BY, Lian TY, Kong KO, Chng HH (2005) Acute lupus myocarditis: clinical features and outcome of an oriental case series. Lupus 14(10):827–831. https://doi.org/10.1191/0961203305lu2228oa

    Article  CAS  PubMed  Google Scholar 

  20. Sato R, Nasu M (2015) A review of sepsis-induced cardiomyopathy. J Intensive Care 3:48. https://doi.org/10.1186/s40560-015-0112-5

    Article  PubMed  PubMed Central  Google Scholar 

  21. Micheloud D, Calderon M, Caparrros M, D'Cruz DP (2007) Intravenous immunoglobulin therapy in severe lupus myocarditis: good outcome in three patients. Ann Rheum Dis 66(7):986–987. https://doi.org/10.1136/ard.2006.058784

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  22. Thomas G, Cohen Aubart F, Chiche L, Haroche J, Hie M, Hervier B, Costedoat-Chalumeau N, Mazodier K, Ebbo M, Cluzel P, Cordel N, Ribes D, Chastre J, Schleinitz N, Veit V, Piette JC, Harle JR, Combes A, Amoura Z (2017) Lupus myocarditis: initial presentation and long term outcomes in a multicentric series of 29 patients. J Rheumatol 44(1):24–32. https://doi.org/10.3899/jrheum.160493

    Article  CAS  PubMed  Google Scholar 

  23. Zawadowski GM, Klarich KW, Moder KG, Edwards WD, Cooper LT Jr (2012) A contemporary case series of lupus myocarditis. Lupus 21(13):1378–1384. https://doi.org/10.1177/0961203312456752

    Article  CAS  PubMed  Google Scholar 

  24. Zhang L, Zhu YL, Li MT, Gao N, You X, Wu QJ, Su JM, Shen M, Zhao LD, Liu JJ, Zhang FC, Zhao Y, Zeng XF (2015) Lupus myocarditis: a case-control study from China. Chin Med J 128(19):2588–2594. https://doi.org/10.4103/0366-6999.166029

    Article  PubMed  PubMed Central  Google Scholar 

  25. Mavrogeni S, Bratis K, Markussis V, Spargias C, Papadopoulou E, Papamentzelopoulos S, Constadoulakis P, Matsoukas E, Kyrou L, Kolovou G (2013) The diagnostic role of cardiac magnetic resonance imaging in detecting myocardial inflammation in systemic lupus erythematosus. Differentiation from viral myocarditis. Lupus 22(1):34–43. https://doi.org/10.1177/0961203312462265

    Article  CAS  PubMed  Google Scholar 

  26. Mavrogeni S, Koutsogeorgopoulou L, Markousis-Mavrogenis G, Bounas A, Tektonidou M, Lliossis SC, Daoussis D, Plastiras S, Karabela G, Stavropoulos E, Katsifis G, Vartela V, Kolovou G (2017) Cardiovascular magnetic resonance detects silent heart disease missed by echocardiography in systemic lupus erythematosus. Lupus:961203317731533. https://doi.org/10.1177/0961203317731533

  27. Gartshteyn Y, Tamargo M, Fleischer S, Kapoor T, Li J, Askanase A, Winchester R, Geraldino-Pardilla L (2020) Endomyocardial biopsies in the diagnosis of myocardial involvement in systemic lupus erythematosus. Lupus 29(2):199–204. https://doi.org/10.1177/0961203319897116

    Article  CAS  PubMed  PubMed Central  Google Scholar 

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Acknowledgements

AD was supported by CSIR, New Delhi, through a fellowship grant.

Author information

Authors and Affiliations

  1. Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India

    Aadhaar Dhooria, Adarsh MB, GSRSNK Naidu, Shefali Sharma, Aman Sharma, Sanjay Jain & Varun Dhir

  2. Department of Cardiology, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India

    Atit Gawalkar, Krishna Santosh & Ajay Bahl

Authors
  1. Aadhaar Dhooria
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  2. Atit Gawalkar
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  3. Krishna Santosh
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  4. Ajay Bahl
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  5. Adarsh MB
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  7. Shefali Sharma
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  10. Varun Dhir
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Contributions

VD and AD: plan, analysis, manuscript

AG, KS, AM, GN: data acquisition, analysis

AS, SS, SJ, AB: data acquisition, plan

Corresponding author

Correspondence to Varun Dhir.

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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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Informed consent was obtained from all individual participants included in the study.

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Dhooria, A., Gawalkar, A., Santosh, K. et al. Acute myocardial dysfunction in lupus: outcomes in Asian Indians. Clin Rheumatol 39, 3661–3667 (2020). https://doi.org/10.1007/s10067-020-05177-2

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  • DOI: https://doi.org/10.1007/s10067-020-05177-2

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