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Host 0:00
Welcome to The Expert Series brought to you by Lupus Foundation of America. Our health education team is here to bring you experts in lupus to discuss topics to help you live better. Thank you for tuning in today's episode. My name is Dwayne and I'll be your host. I'm very excited to welcome Dr. Murray Urowitz, who will help us continue the conversation on lupus and heart health. Dr. Urowitz is a senior staff rheumatologist at the Toronto Western Hospital and senior scientist at the Krembil Research Institute and the Schrader Arthritis Institute. He also is Professor of Medicine at the University of Toronto, and Director of the Centre for Prognosis Studies in the Rheumatic Diseases, as well as the Lupus Clinic at the Toronto Western Hospital. We are delighted to have you with us today, Dr. Urowitz.

Dr. Urowitz 0:55
Thank you. Nice to be here.

Host 0:58
Okay, we had a number of questions for you. Let's begin. What is coronary artery disease and cardiovascular disease? And how did these diseases affect people with lupus and why?

Dr. Urowitz 1:12
Okay, so that's not as simple of a question as it might seem. There are two components here. One is coronary artery disease and one is cardiovascular disease. The latter, the cardiovascular disease, is a more generic concept. That means anything that can go wrong with the heart. And coronary artery disease is specifically, injury or problems with the coronary arteries that go to the heart. Let me very quickly put it into perspective: Patients with lupus may suffer from cardiovascular disease that is, anything to do with the heart and the blood vessels because of their lupus or maybe because of the complications of lupus which happen even when their lupus is quiescent. So within lupus patients with lupus itself when the lupus is active, can have inflammation of the blood vessels to the lungs, coronary arteritis, which is not so common inflammation of the lining of the heart, which is pericarditis, which is more common, or inflammation of the heart muscle itself myocarditis, which is also not as common but important. So if you have those issues connected with lupus, you treat the lupus and you hope that the organ involved - the heart and it's an all aspects of the heart - will be brought under control with the treating the lupus. Then you have coronary artery disease that happens in patients with lupus it in the form of what we call a comorbidity. In other words, it's there; it's not due to active lupus now, but it's due to a combination of factors. And that's the important one. This condition is a condition that generally occurs in older people, older men more than older women, and it's what gives rise to heart attacks. So when you have coronary arteries involved with fatty infiltration into the artery, and therefore narrowing of the artery opening the lumen of the artery, the artery is narrowed. And then you get a number of symptoms and the end findings. So for instance, if your coronary artery is narrowed, you may with exercise experience a tightness in your chest and that is called angina. Now that tightness in your chest will generally settle down when the exercise when you stop exercising. But that's a clue to you that there's a problem there, and that you have to look after it. If the occlusion in the artery due to this fatty infiltration of the artery is very significant. It narrows the artery a lot, you can get a full-blown heart attack, which is called a myocardial infarction. And clearly, that has to be treated in the hospital appropriately. So how do we rationalize these two? Well, patients with lupus have inflammation throughout their entire body. And then if a number of other things happen, such as they have high blood pressure, or they have kidney disease, or they have high cholesterol, or they are overweight, or they have the wrong diet - any of those factors can also contribute to this narrowing of the arteries in addition to what the inflammation does. So for instance, people with lupus will develop heart problems, coronary artery disease, at a much younger age than is normal in the general population. So what an older man might get at the age of 65 or 70, a lupus man might get it at the age of 40 or 50, maybe 20 years earlier, and that because of a combination of factors there: their lupus has been active, and that's probably irritated or inflamed the artery linings. And then later one of those other things I told you about, they have high blood pressure, they're overweight or high, they have a high cholesterol, has accelerated this thing. And so they ended up getting coronary artery disease earlier than their age and sex match normal people. So those are the differences. The heart involvement from lupus itself, that's the inflammation part. And then later on in the course of lupus, because of the previous inflammation, and because of those factors I've just mentioned, they may get coronary artery narrowing, and they may end up with things like angina, or a full-blown myocardial infarction or heart attack.

Host 5:51
Well, that's really good to know. And thank you for explaining the distinction between those two different types of diseases in lupus. What are the warning signs people with lupus should know about regarding the heart?

Dr. Urowitz 6:02
Okay, so if the heart is you know, involved with active lupus, you're going to have lupus and other places in your body and you're going to know your lupus is active. But in the second situation where the heart disease is a comorbidity, the lupus is usually quiet. So there's nothing else there. And so you're going to get the symptoms associated with narrowing of the coronary arteries. And those symptoms are, first of all, I told you the angina, which is a pain in the chest, often described as a heaviness, a pressure pressing down in the central part of the chest, that pressure may also radiate up into your jaws or radiate down into your left arm. Now, if that goes away, when you stop exercising, that's called angina. And you need to see your doctor and say, Boy, I'm getting angina. What do I do if it happens again, and what do I do to prevent it from going further. On the other hand, if this pain comes and doesn't go away, when you stop exercising, or lasts more than 15 or 20 minutes, you go to the emergency department because if there's narrowing in the in the coronary arteries, enough to give you prolonged discomfort, then you may need more immediate help. Now, in addition to the pain, if you have narrowing a lot of narrowing of your coronary arteries, your heart muscle is not going to get enough nutrition, so to speak; it's not going to get enough oxygen supply. And so it loses some of its normal function. So it can't pump as well as it usually pumps. And that can lead to what's called heart failure. That is, you will feel more short of breath, you may notice that that you have significant swelling in your legs. And all of that is because the heart is not pumping as vigorously as it should pump. And again, this requires medical attention both to number one, get rid of this extra fluid that's being retained in your body. And number two medications that could potentially strengthen the heart muscle and maybe even treat those narrowed coronary arteries to mitigate that those symptoms due to heart failure. So the chest pain and the heart failure are the two most common symptoms that can arise from this narrowing of the coronary arteries.

Host 8:27
In a previous episode of The Expert Series dealing with heart health. Dr. Jim Oates of the Medical University of South Carolina mentioned that people with lupus have a seven to nine times greater heart disease involvement than the general population. Has there been any change and how it affects younger lupus patients?

Dr. Urowitz 8:49
Yeah, so you know, if you look at all the old series, the increased prevalence might be as much as 50 times, you know, anywhere between five and 50 times, depending on which population you looked at. However, there's a good news to this story. That's when you looked at cohorts of patients that have been followed from the 70s and 80s up until today. If you look at today, we are finding that the incidence of this coronary artery comorbidity is significantly less than it was say 20 years ago. And we've actually shown that in our study, and that when we took our patients in the 70s and 80s, and we took our patients in the 2000s and 2015s, there is a dramatic fall, maybe a fourfold lower prevalence in the newer era than in the older era. You say, "Wow, what's happened?" Well, what in fact happened are really two things: Number one, we've been able to control lupus earlier and better. Remember, I told you the inflammation is important on what effect the inflammation has on the blood vessels. So we are controlling our lupus better now than we did in the in the 80s. The second issue is we became aware of this complication. So when I first reported the higher incidence and the cause of mortality of atherosclerosis and lupus, that was in the mid-1970s. And then we started to recognize this in our younger people. And then newer medicines became available in the 90s or so for the treatment of the other risk factors like cholesterol and blood pressure. And so what we're seeing now is a significant fall in the prevalence of heart disease of atherosclerotic heart disease in our patients with lupus, that doesn't mean we're off the hook; it means that we have found ways to control it. And we don't want to let up our vigilance. Meaning, we want to get the disease under control as soon as possible. We've always wanted to do that. But secondly, we look for those risk factors which contribute to the atherosclerosis. So we test our patients frequently for hypertension, for high blood pressure, we test them for high cholesterol, we test them for their body weight to make sure that they are not overweight, right? And we also check with them as to whether they're keeping active because exercise is an important preventative factor. So by applying all of those factors now and treating them, we have been able to decrease the prevalence of atherosclerosis. That is the good news. The lesson we need to learn from that is we cannot let up. We must continue to be vigilant regarding all of those risk factors, continue to treat them and continue to be successful in our lupus management, which is becoming better and better all the time. And then we'll be able to decrease this complication even further. It's not gone, but it's better than it was.

Host 11:58
Well, that's great, encouraging news, and thank you for sharing those updated statistics with us. Our next question: according to the American Heart Association, women in communities of color, experience more heart health issues, and we know lupus disproportionately affects the same group of women. Is there an increase of heart disease involvement, in particular with women of color who have lupus?

Dr. Urowitz 12:21
Well, you know, it's actually a difficult question, because in the lupus populations, it depends which cohorts you're looking at. Some cohorts have predominantly Black patients, and other cohorts who have a smaller number of black patients. In our cohort where the Caucasians are about 60%, and Blacks are about 15%, and then there are others such as Asians, etc, are mixed, the difference between Caucasians and Blacks is not so dramatic. As matter of fact, in our population, the Caucasian women were more likely to have it than the Black women. So that may be because of the nature of our cohort, you know. But what we should say is this: Look, women with lupus have a higher tendency for developing coronary artery disease, both Caucasians, Blacks, Hispanics, etc. Therefore, if you have a higher prevalence, they should all be treated the same way control the risk factors that we have control over, right? Now, if you look at our cohort, the other predisposing factors other than the things I told you about, like the cholesterol, the blood pressure, etc, etc. You also have male sex. So male gender is more associated with atherosclerosis than females. And that's because males in general are more predisposed than females. So if a male gets lupus, and they have this increased tendency for atherosclerosis, because they have lupus, they have a double hit: they have the hit, because of the tendency to the fact that they're male and also now because they have lupus. And of course, atherosclerosis tends to occur in older people. So if you have an older male with lupus, watch out because they've got all the factors that could contribute to lupus, or to, sorry, to contribute to coronary artery disease.

Host 14:16
Okay, thank you. And that actually leads into my next question, which is, please explain any differences in the way heart disease progresses or presents in men and women with lupus, what are the distinctions?

Dr. Urowitz 14:31
Yeah, so the distinctions are, as I said, that males and age, older age, are both predisposing factors. So if you have an older male, they're going to progress faster, to develop the atherosclerosis, than a younger female. But that doesn't mean the younger female's off the hook; it just means the older male has a number of extra predisposing factors. So you know, I look at all of my patients the same way: I say, Look, I'm going to get their lupus under control. I'm hopeful that that's the case. And in most instances, it works. I've got to prevent that other thing that happens to them when they're well. Can you imagine getting better from lupus and then develop a developing heart disease early in your life - like if you're a woman and you develop coronary artery disease in your 40s or 50s, that's 20 or 25 years earlier than you would have developed this, you didn't have lupus. So I treat my women and my men the same way, treat the risk factors. Because I know I'm going to get their lupus under control, I got to make sure that they don't develop the secondary illness later on.

Host 15:40
Well, let's follow on with that. What are some effective strategies that can help people with lupus reduce their risk of developing heart disease?

Dr. Urowitz 15:50
Okay, that's really an important question because lupus patients and lupus doctors have to have this comorbidity on their radar screen. They can't, they can't let up on this. So what are the factors? Well, number one is, you know, I tried to mention them before, is weight. Obesity is a major predisposing factor. And along with weight, because it's diet and exercise, because exercise definitely is preventative for heart disease. This is in anybody in normal people or lupus patients. So weight, control of weight and exercise are very important. Now for the doctor, they must control the blood pressure. And the American Heart Association has now revised its normal blood pressure levels, it used to be 140, over 90, and that was proved to be too high. The normal level is now 130 over 80. And we have actually shown in our cohort, that the patients in whom their blood pressure was 140, over 90 did worse than the patients who were below 130 over 80. So the American Heart Association is correct, you must get the blood pressure down to 130 over 80. The next thing, of course, that the doctor has to do is manage the cholesterol. So we take cholesterol values in our patients frequently. And we even though patients with lupus, unfortunately, are taking lots of drugs, etc. If the cholesterol is significantly high, especially the bad cholesterol, we say to them, oh, you've got to take a cholesterol-lowering medicine and they say oh no, not another pill. And then you must sit down and explain to them how important it is. Because they don't want to end up with a new condition once lupus is well controlled. So those are the important things that have to happen. Now there's one other thing we have out actually shown now that patients with lupus will have signs of coronary artery disease way before they even know it. And there are a number of ways for testing for these two or three different good testing methods - carotid artery thickness or ability, a heart perfusion test shows how well your heart pumps with exercise, etc. These are a number of tests. And you know, there are some doctors now after a number of years of taking of being treated for lupus, and where they're approaching that age when the current coronary artery disease may start to manifest itself are actually doing some of these tests in advance. Right? In other words, is this patient already being predisposed to coronary disease, even though they haven't yet had the pain etc. And if those tests show that, then you have to be even more aggressive in the control of the risk factors that I told you. You can't be lackadaisical if there are already signs in those tests that this patient is beginning to develop coronary artery disease. So that's pre-treating, so to speak, you know, before they get clinical stage, and that's how we prevent and minimize those conditions. That's not always available to everybody. But you know, I think we are certainly moving in that direction that the test is being done in your center to measure coronary early coronary artery disease before it's clinically present. They're becoming much more prevalent than available and if they are lupus patients should be considered for those for sure.

Host 19:31
Okay, so our final question is for those who are caregivers, what about those who are caring for someone with lupus? How can they help their loved ones to stay active?

Dr. Urowitz 19:42
Yeah, so the first thing to do and we see this in many caregivers and helpers and family members, is to understand what these people are going through. They have a very difficult life both because of the multiple sets symptoms they get and because of the multiple medications they have to take. So the first thing is, when you're talking to a patient with lupus say I understand, you know, and not to say, "Come on, get off your butt!" That's the worst approach. The best approach is to say, "I understand how difficult it is, but staying true to your medication is, number one, very important. And then number two is do the preventative things that are going to make your life better when your lupus is under control. So diet and exercise are very important." Now you can't say to somebody, you know, with lupus say we're going to exercise Come on, we're going to run a mile. You've got to be realistic, you know, you've got to start slowly. And for cardiovascular exercise, you don't need to run a mile. You know, if you do walking, or cycling on a stationary cycle, or do aquatic exercises, or do aerobics, like yoga or tai chi, all of those will help as a preventative as a prophylactic, for patients with lupus. So understand, try to get them involved in these other areas, and encourage them to continue to be diligent with their ongoing medications.

Host 21:17
Wow, this has been a very interesting and helpful conversation Dr. Urowitz. Thank you very much for your time today and for continuing the conversation of heart health and lupus. Our listeners can find more information on lupus on the National Resource Center on Lupus by visiting lupus.org/resources. For the latest information on lupus and COVID-19. Please visit lupus.org/coronavirus. To listen to additional episodes of the experts series, you can visit lupus.org/theexpertseries, all one word. There you can also subscribe to get alerts when podcasts are released. And you'll find the earlier referenced episode lupus and heart health under season two, episode three. If you'd like to speak with one of our health education specialists, you can go to lupus.org/healtheducator or call us at 1-800-558-0121. And finally, to connect with others with lupus from all over the world, I invite you to check out our online support community LupusConnect where you can talk with others, find emotional support, and discuss practical insights for coping with the daily challenges of living with lupus. You can find the community at lupus.org/resources/lupusconnect. Thank you everyone and have a wonderful day.

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The Expert Series: The heart and lupus