Women who have lupus, rheumatoid arthritis, or psoriasis tend to have a large number of doctors. They may see a rheumatologist or a dermatologist, and repeatedly get labs done, adjust their medications, and schedule their daily life around flares. The heart is almost never discussed in these situations. Dr. Maria Tehrani, a cardiac surgeon at Ronald Reagan UCLA Medical Center in Westwood, treats women in the Los Angeles area whose coronary disease developed much earlier in their lives than would be expected from their age or their cholesterol levels, and a significant portion of these women have autoimmune conditions. The connection between autoimmune diseases and heart disease is well documented, but has likely not reached most patients.

Damage of the Arteries by Chronic Inflammation

Atherosclerosis is not an accumulation of cholesterol in a blood vessel. It is an inflammatory process. Immune system cells enter the blood vessel wall, and unstable plaque forms in the blood vessel wall. Whether a blood vessel ruptures and causes a heart attack is determined by unstable plaque.

An autoimmune disease means immune system cells are always active. That same chronic inflammatory process damages arteries throughout the body. Even if inflammation is not present in the joints and skin, arteries are continuously damaged, year after year. Therefore, women who have healthy cholesterol, normal blood pressure, and a normal body mass index also may have an elevated risk of heart disease if their autoimmune disease has been active.

Lupus has the Highest Risk

There are gender differences for various autoimmune disorders. Systemic lupus erythematosus affects women far more than men, begins in the 20s and 30s, and has the highest risk of cardiovascular disease among the common autoimmune disorders. Young women with lupus experience heart attacks at significantly higher rates than their peers, and this is more pronounced within the age range where coronary disease is almost nonexistent.

Lupus has the potential to affect the heart directly instead of just affecting the arteries. Inflammation of the heart (pericarditis) is common, and so are abnormalities of the heart valves, which in some cases require surgery. Lupus patients also develop kidney disease, leading to high blood pressure, and therefore increasing the burden on the cardiovascular system.

A young woman with lupus chest pain is cause for concern, not easily explained by age.

Rheumatoid Arthritis

The risk of cardiovascular disease from rheumatoid arthritis is high enough to treat it similarly to diabetes. It is present throughout the entire course of the disease, and its extent is dependent on the control of inflammation.

Rheumatoid arthritis patients experience typical symptoms of joint discomfort, which can mask signs of heart disease. Because people with heart disease that manifest itself as exertional angina may not be able to walk as far as traditionally felt, the symptoms of chest tightness with shortness of breath may never reveal themselves. By the time heart disease is found, it may be discovered during a heart attack and not during traditional diagnosis. Additionally, rheumatoid arthritis patients suffer heart attacks with limited cases of any known symptoms beforehand.

Psoriasis and Psoriatic Arthritis

Psoriasis generally is considered a primarily skin-based condition, and the majority of the time the condition does not adversely affect the cardiovascular system. Extreme and chronic forms do begin to affect the cardiovascular system. The duration and extent of the condition combined with the presence of psoriatic arthritis cause the patient to become elevated risk.

Psoriasis also is linked with the clustering of the metabolic syndrome, obesity, insulin resistance, and high triglyceride levels and blood pressure. When these factors are combined and exist together, the patient is at an even greater risk than just the sum of these factors. The presence of severe psoriasis is reason enough for the patient to undergo routine blood glucose testing, lipid panel, and blood pressure testing.

Why Standard Risk Calculators Fall Short

Most risk calculators in regards to cardiovascular health consider age, sex, cholesterol, blood pressure, smoking, and diabetes. None of the widely used calculators consider the existence of an autoimmune disease. A patient can have fifteen years of lupus activity and rheumatoid arthritis, and the calculator can suggest they are low risk in the next ten years.

Treatment becomes more complicated. Taking corticosteroids for more than a few weeks will increase blood pressure, blood sugar, and lipids. Non-steroidal anti-inflammatory drugs (NSAIDs) are often used for joint pain, but increase blood pressure and have their own cardiovascular consequences. Just because there are concerns about these drugs, doesn’t mean they need to be stopped. No patient should be changing these medications on their own. The increased risk of cardiovascular issues associated with these medications should be recognized and discussed with the rheumatologist who prescribed them.

What Actually Reduces the Risk

Effective management of the inflammatory process reduces cardiovascular risk, making compliance with regular rheumatology appointments an important form of heart care.

There are other risk factors that become more important rather than less. The management of blood pressure, and glucose or HbA1c and lipids Health should be checked at least annually, with shortened intervals between checking and intervention for abnormally high readings compared to people without autoimmune disease. The rheumatoid disease is worsened by smoking, and is a major risk factor for coronary disease. Swimming, biking, and walking have a positive effect on both inflammation and cardiovascular health. If there has been prolonged exposure to steroids, a discussion with the physician on how to decrease the dose should be considered.

Probably the best advice is to make sure your autoimmune diagnosis is presented to ALL doctors you see. It changes their line of thinking when interpreting the symptoms you are having.

What are the signs that indicate I need to see a Cardiac Specialist?

You may need to be evaluated by a cardiac specialist for unexplained chest pain or pressure, shortness of breath, unusual fatigue, fast or irregular heartbeat, swelling of the legs, pain that gets worse when you lay down, and pain that gets better when you lean forward (pericarditis).

For patients with a longstanding autoimmune disease, prolonged steroid use, renal lupus, moderate to severe psoriasis with metabolic risk factors, and a family history of early heart disease, a cardiac evaluation is warranted even when they do not have any symptoms, and is indicated in the third and fourth decade of life instead of awaiting standard care screening.

Dr. Tehrani is a cardiac specialist who evaluates cardiac valve and coronary issues in chronic inflammatory patients. It is never too late to monitor and appreciate the importance of prevention.

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Maria Tehrani, MD
Cardiac Surgeon | Ronald Reagan UCLA Medical Center
Phone: 818-350-9899
Email: welcome@mariatehranimd.com
Address: 757 Westwood Plaza, Los Angeles, CA 90095
Hours: Monday–Friday, 9AM–5PM
Serving patients throughout Westwood, Brentwood, Beverly Hills, Santa Monica, Century City, Bel Air, Pacific Palisades, Marina del Rey, and Culver City.