Outcomes of a Pharmacist-Managed Heart Failure Medication Titration Assistance Clinic.

BACKGROUND: National guidelines recommend angiotensin-converting enzyme (ACE) inhibitors or angiotensin-receptor blockers (ARBs) and ß-blockers (BBs) at target doses for morbidity and mortality benefits in heart failure with reduced ejection fraction (HFrEF); regardless, titration of these therapies in practice remains suboptimal. We implemented an outpatient pharmacist-managed HFrEF medication titration assistance clinic (MTAC) at one institution to improve titration for general cardiology (GC) patients. OBJECTIVE: To evaluate MTAC impact by determining the proportion of patients on target or maximum tolerated ACE inhibitor/ARB and BB doses. METHODS: A retrospective chart review of adult patients with documented ejection fraction ≤40% managed in the MTAC or GC from 2011 to 2013 was conducted. HFrEF medication regimens were collected at initial visit and months 1, 2, 3, 6, 9, and 12 to assess titration. Target doses were defined per guideline or dose at which ejection fraction recovered during the study. Maximum tolerated doses were defined as the highest dose patients tolerated without physiological limitations. RESULTS: Of 148 patients, the MTAC managed 51 and GC managed 97. At baseline, 90% of MTAC versus 82% of GC patients were prescribed ACE inhibitors/ARBs and BBs. In the MTAC, 4% were at target or maximum tolerated doses compared with 32% of GC patients ( P < 0.001). At 12 months, 95% of patients in the MTAC and 87% in GC were prescribed ACE inhibitors/ARBs and BBs. Of those prescribed ACE inhibitors/ARBs and BBs, 64% in the MTAC versus 40% in GC reached target or maximum tolerated doses ( P = 0.01). CONCLUSIONS: The pharmacist-managed MTAC increased the proportion of patients on optimal HFrEF therapies and are a resource for GC patients.

Coronary artery calcium may stabilize following islet cell transplantation in patients with type 1 diabetes.

Islet cell transplantation can functionally cure type 1 diabetes and also improve carotid intima-media thickness. This study provides a preliminary description of changes in coronary artery calcium following islet transplantation, and associated factors. Coronary artery calcium was measured in 14 patients with type 1 diabetes (11 had measures both pre- and post-transplant [mean 2.3 years]) in the University of Illinois at Chicago's clinical trial. Multivariable mixed-effects linear regression of repeated measures was used to quantify calcium change and determine if this change was longitudinally associated with risk/protective factors. Thirteen of the patients were female, with mean baseline age, diabetes duration, and BMI of 47.6 and 28.7 years, and 23.1, respectively. Over half (57%) had detectable coronary artery calcium pre-transplant. Minimal change (0.39 mm3 /y, P = .02) occurred in coronary artery calcium levels pre- to post-transplant. No patient met criteria for calcium progression. Coronary artery calcium was positively associated with total and small VLDL particles (P ≤ .02), statin dose (P = .02), and urine albumin-to-creatinine ratio (P = .04) and negatively associated with free fatty acids (P = .03), total HDL (P = .03), large HDL particles (P = .005), and tacrolimus dose (P = .02). Islet transplant may stabilize coronary artery calcium, with optimal management of lipids and kidney function remaining key therapeutic targets. [NCT00679041].

Computed Tomography of the Esophagus in Scleroderma and Lung Disease.

Systemic sclerosis, or scleroderma, is a collagen vascular disease characterized by hardening of the skin and involvement of internal organs, most commonly the esophagus. The most frequent cause of death in these patients is lung disease. Esophageal dysfunction has been implicated in the pathogenesis of interstitial lung disease. We previously developed a standard for the esophageal diameter on chest computed tomography (CT) and hypothesized that patients with esophageal dilation would be more likely to have interstitial lung disease than those without. In this study, we test this in 121 systemic sclerosis patients with interstitial lung disease and 48 of those without interstitial lung disease. For controls, we evaluated 121 patients followed at a general pulmonary clinic and the previously studied normal healthy standards. This study demonstrated that esophageal dilation is common in systemic sclerosis patients (66.3% for the maximal esophageal diameter more than or equal to 15 mm), that systemic sclerosis patients with interstitial lung disease have more dilated esophagi than those without interstitial lung disease (median 19.4 mm vs. 14.1 mm), and that esophageal parameters are negatively correlated with pulmonary function. We also found that patients from general pulmonary clinic were more likely to have dilated esophagi than normal controls (median 12.1 mm vs. 9.7 mm). The CT measurement of esophageal diameter may be a useful marker of patients at risk for developing lung disease.

Increased high-density lipoprotein cholesterol predicts the pioglitazone-mediated reduction of carotid intima-media thickness progression in patients with type 2 diabetes mellitus.

BACKGROUND: Measurement of carotid intima-media thickness (CIMT) has been validated as a measure of atherosclerosis and as a predictor of future cardiovascular events. Compared with glimepiride, pioglitazone has been shown to slow the progression of atherosclerosis measured by CIMT in patients with type 2 diabetes mellitus. METHODS AND RESULTS: We evaluated individual cardiovascular risk factors as predictors of the change in CIMT produced by pioglitazone treatment by determining whether their addition to a baseline model resulted in loss of significance for the treatment effect on CIMT. Pioglitazone treatment led to improvement in levels of multiple cardiovascular risk markers, including high-sensitivity C-reactive protein, apolipoprotein B, apolipoprotein A1, high-density lipoprotein (HDL) cholesterol, triglyceride, insulin, and free fatty acid. At 24 weeks, there were significant differences in HDL cholesterol, triglyceride, total cholesterol, low-density lipoprotein cholesterol, insulin, body mass index, hip circumference, and high-sensitivity C-reactive protein between the pioglitazone and glimepiride treatment groups. After adjustment for 24-week on-treatment values of cardiovascular risk factors, only inclusion of the changes in HDL cholesterol and insulin significantly impacted the magnitude and significance of the treatment effect on CIMT. Furthermore, irrespective of treatment assignment, increased HDL cholesterol at 24 weeks was a significant predictor of reduced CIMT progression at 72 weeks. CONCLUSIONS: The beneficial effect of pioglitazone on HDL cholesterol at 24 weeks predicted its beneficial effect for reducing CIMT progression at 72 weeks. Changes in HDL cholesterol at 24 weeks, irrespective of treatment, predicted less progression of CIMT at 72 weeks. These results suggest that suppression of atherosclerosis with pioglitazone therapy is linked to its ability to raise HDL cholesterol.

Cardiovascular events with absent or minimal coronary calcification: the Multi-Ethnic Study of Atherosclerosis (MESA).

BACKGROUND: Elevated coronary artery calcium (CAC) is a marker for increase risk of coronary heart disease (CHD). Although most CHD events occur among individuals with advanced CAC, CHD can also occur in individuals with little or no calcified plaque. In this study, we sought to evaluate the characteristics associated with incident CHD events in the setting of minimal (score

Relationship of traditional and nontraditional cardiovascular risk factors to coronary artery calcium in type 2 diabetes.

We evaluated correlates of coronary atherosclerosis, measured by coronary artery calcium, in a racially diverse group of male and female subjects with type 2 diabetes. Age, systolic blood pressure, sex, and race/ethnicity were significant determinants of coronary artery calcium. Among lipoproteins, cholesterol level contained in a particle excluded from direct measures of LDL and HDL cholesterol (designated triglyceride-rich lipoprotein cholesterol) was most strongly linked to coronary artery calcium. Neither inflammatory markers nor metabolic factors correlated with coronary artery calcium in models adjusted for age and sex, but measures of adipose distribution did. Waist-to-hip ratio and the ratio of visceral to total abdominal tissue were positively associated with coronary artery calcium. In fully adjusted multivariate models, the relationship of adiposity measures to coronary artery calcium was no longer significant after inclusion of apolipoprotein B or triglyceride-rich lipoprotein cholesterol. Traditional risk factors and race/ethnicity remain important correlates of coronary artery calcium in a cohort at elevated risk of cardiovascular disease because of type 2 diabetes. Adiposity measures are significantly associated with coronary artery calcium score, but their importance may be largely explained by apolipoprotein B or triglyceride-rich lipoprotein cholesterol.

CT of the normal esophagus to define the normal air column and its extent and distribution.

OBJECTIVE: This study was designed to quantify and characterize the air-containing thoracic esophagus on CT to help diagnose diseases and facilitate correlation with lung diseases that may be associated with aspiration. SUBJECTS AND METHODS: The maximal air-containing esophageal lumina on each section of standard CT scans of 110 subjects were measured. These subjects came from a cohort of 10,132 self-reported healthy individuals who underwent CT for measurement of coronary artery calcium. Measurements were interpolated to account for variation in the length of the thoraces. RESULTS: Greater than 60% of the esophageal segments contained no air. On average the maximum air column was 10.5 (SD, 5.0) mm. Only 7.9% of the lumina were > 10 mm. Only 2% were > 15 mm, and only 0.2% were > 20 mm. The average number of lumina > 10 mm as a proportion of the entire esophageal length was 8% (14%). The average size at the carina was 2.6 (4.1) mm. In the upper 30% and from 61% to 75% down the length of the esophagus, < 5% of the lumina were > 10 mm. Less than 3% of subjects had air in the lowest two sections, indicating that the normal lower esophageal sphincter was closed. CONCLUSION: Esophageal air of > 10 mm should be considered abnormal in all segments except between the cardiac ventricles and lower esophageal sphincter. In this area, > 15 mm should be considered abnormal. An air-fluid level is abnormal.

Impact of treatment guidelines on clinical and economic outcomes of acute decompensated heart failure.

BACKGROUND: No data exist that demonstrate the impact of comprehensive acute decompensated heart failure (ADHF) treatment guidelines on clinical and economic outcomes in hospitalized patients with this condition. OBJECTIVES: To compare clinical and economic outcomes before and after implementation of treatment guidelines for ADHF. METHODS: A single-center, retrospective, chart review study was conducted in a university hospital. ADHF treatment guidelines were developed and implemented on January 1, 2004. Patients hospitalized for ADHF between January 2003 and November 2004 were identified using the Acute Decompensated Heart Failure Registry. Study periods were 12 months prior to and the 11 months following guideline implementation. RESULTS: This cohort was comprised of 683 ADHF hospitalizations (357 preguideline, 326 postguideline); several patients were admitted more than once. There was a trend toward increased use of intravenous vasoactive drugs (VADs) following guideline implementation (19.9% vs 24.2%; p = 0.05). The duration of intravenous VAD use decreased by more than 40% following guideline implementation, but this was not statistically significant after risk adjustment (p = 0.22). The need for intensive care unit monitoring decreased from 45.1% before guideline implementation to 25.3% following guideline implementation (p < 0.02) in patients treated with intravenous VADs. The need for mechanical ventilation was reduced by nearly 80% (p = 0.04) following guideline implementation. Significantly more patients of the postguideline cohort were prescribed beta-blockers at discharge (54.9% vs 75.2%; p = 0.0001). Costs were not significantly different between the groups. CONCLUSIONS: Implementation of ADHF treatment guidelines was associated with reduced need for mechanical ventilation, improved utilization of beta-blockers at discharge, and trends toward increased use of intravenous VADs, while not significantly changing total costs. More rigorous studies need to be conducted to estimate the true effect of treatment guidelines on ADHF care and outcomes.

Women and non-cardiac chest pain: gender differences in symptom presentation.

A substantial number of individuals evaluated for complaints of chest pain do not suffer from coronary heart disease (CHD). Studies show that many patients who complain of symptoms that might be caused by CHD, such as shortness of breath or chest pain, may actually have an anxiety disorder. Gender differences in how patients present with these symptoms have not been adequately explored. The purpose of this study was to explore possible gender differences in the presentation of patients with CHD-like symptoms. Two groups were examined, one comprising 6,381 individuals self-referred for electron beam tomography (EBT) studies and a subset of these individuals who defined a "low-risk" group based on the absence of risk factors for CHD and low coronary artery calcium (CAC) scores. We explored gender differences in symptom presentation in each group after controlling for relevant variables by using logistic regression models. These analyses showed that women were significantly more likely than men to endorse CHD symptoms that might also be caused by an anxiety disorder. Women in the low risk group reported CHD symptoms also referable to anxiety more often than men, but unlike men did not complain primarily of chest pain. Women were also more likely to have been prescribed antianxiety or antidepressant medication. In previous studies, non-cardiac chest pain has been considered a hallmark of anxiety in individuals seen in medical settings. This study suggests that in individuals with low risk for CHD chest pain was not related to gender, but other anxiety-related symptoms including heart flutter, lightheadedness, nausea, and shortness of breath were more likely to be reported in women than in men.

Effect of pioglitazone compared with glimepiride on carotid intima-media thickness in type 2 diabetes: a randomized trial.

CONTEXT: Carotid artery intima-media thickness (CIMT) is a marker of coronary atherosclerosis and independently predicts cardiovascular events, which are increased in type 2 diabetes mellitus (DM). While studies of relatively short duration have suggested that thiazolidinediones such as pioglitazone might reduce progression of CIMT in persons with diabetes, the results of longer studies have been less clear. OBJECTIVE: To evaluate the effect of pioglitazone vs glimepiride on changes in CIMT of the common carotid artery in patients with type 2 DM. DESIGN, SETTING, AND PARTICIPANTS: Randomized, double-blind, comparator-controlled, multicenter trial in patients with type 2 DM conducted at 28 clinical sites in the multiracial/ethnic Chicago metropolitan area between October 2003 and May 2006. The treatment period was 72 weeks (1-week follow-up). CIMT images were captured by a single ultrasonographer at 1 center and read by a single treatment-blinded reader using automated edge-detection technology. Participants were 462 adults (mean age, 60 [SD, 8.1] years; mean body mass index, 32 [SD, 5.1]) with type 2 DM (mean duration, 7.7 [SD, 7.2] years; mean glycosylated hemoglobin [HbA1c] value, 7.4% [SD, 1.0%]), either newly diagnosed or currently treated with diet and exercise, sulfonylurea, metformin, insulin, or a combination thereof. INTERVENTIONS: Pioglitazone hydrochloride (15-45 mg/d) or glimepiride (1-4 mg/d) as an active comparator. MAIN OUTCOME MEASURE: Absolute change from baseline to final visit in mean posterior-wall CIMT of the left and right common carotid arteries. RESULTS: Mean change in CIMT was less with pioglitazone vs glimepiride at all time points (weeks 24, 48, 72). At week 72, the primary end point of progression of mean CIMT was less with pioglitazone vs glimepiride (-0.001 mm vs +0.012 mm, respectively; difference, -0.013 mm; 95% confidence interval, -0.024 to -0.002; P = .02). Pioglitazone also slowed progression of maximum CIMT compared with glimepiride (0.002 mm vs 0.026 mm, respectively, at 72 weeks; difference, -0.024 mm; 95% confidence interval, -0.042 to -0.006; P = .008). The beneficial effect of pioglitazone on mean CIMT was similar across prespecified subgroups based on age, sex, systolic blood pressure, duration of DM, body mass index, HbA(1c) value, and statin use. CONCLUSION: Over an 18-month treatment period in patients with type 2 DM, pioglitazone slowed progression of CIMT compared with glimepiride. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00225264

Electron-beam tomography coronary artery calcium and cardiac events: a 37-month follow-up of 5635 initially asymptomatic low- to intermediate-risk adults.

BACKGROUND: Conventional coronary artery disease (CAD) risk factors fail to explain nearly 50% of CAD events. This study examines the association between electron-beam tomography (EBT) coronary artery calcium (CAC) and cardiac events in initially asymptomatic low- to intermediate-risk individuals, with adjustment for the presence of hypercholesterolemia, hypertension, diabetes, and a history of cigarette smoking. METHODS AND RESULTS: The study was performed in 8855 initially asymptomatic adults 30 to 76 years old (26% women) who self-referred for EBT CAC screening. Conventional CAD risk factors were elicited by use of a questionnaire. After 37+/-12 months, information on the occurrence of cardiac events was collected and confirmed by use of medical records and death certificates. In men, events (n=192) were associated with the presence of CAC (RR=10.5, P<0.001), diabetes (RR=1.98, P=0.008), and smoking (RR=1.4, P=0.025), whereas in women, events (n=32) were linked to the presence of CAC (RR=2.6, P=0.037) and not risk factors. The presence of CAC provided incremental prognostic information in addition to age and other risk factors. CONCLUSIONS: The association between EBT CAC and cardiac events observed in this study of initially asymptomatic, middle-aged, low to intermediate-risk individuals presenting for screening suggests that in this group, knowledge of the presence of EBT CAC provides incremental information in addition to that defined by conventional CAD risk assessment.

The prevalence of coronary artery calcium among diabetic individuals without known coronary artery disease.

OBJECTIVES: We sought to examine the age and gender distribution of coronary artery calcium (CAC) by diabetes status in a large cohort of asymptomatic individuals. BACKGROUND: Among individuals with diabetes, coronary artery disease (CAD) is a major cause of morbidity and mortality. Electron-beam tomography (EBT) quantifies CAC, a marker for atherosclerosis. METHODS: Screening for CAC by EBT was performed in 30,904 asymptomatic individuals stratified by their self-reported diabetes status, gender, and age. The distribution of CAC across the strata and the association between diabetes and CAC were examined. RESULTS: Compared with nondiabetic individuals (n = 29,829), those with diabetes (n = 1,075) had higher median CAC scores across all but two age groups (women 40 to 44 years old and men and women > or =70 years old). Overall, the likelihood of having a CAC score in the highest age/gender quartile was 70% greater for diabetic individuals than for their nondiabetic counterparts. CONCLUSIONS: Younger diabetic individuals appear to have calcified plaque burden comparable to that of older individuals without diabetes. These findings call for future research to determine if EBT-CAC screening has an incremental value over the current CAD risk assessment of individuals with diabetes.

Pilot study of coronary atherosclerotic risk and plaque burden in HIV patients: 'a call for cardiovascular prevention'.

BACKGROUND: Highly active antiretroviral therapy (HAART) has dramatically improved the life expectancy of patients with human immunodeficiency virus (HIV) prompting increasing concerns related to chronic management. Suggestions of greater cardiovascular risk, partially related to recently proposed HAART-induced dyslipidemia and glucose intolerance, amplify these concerns. At this time, further corroboration of the emerging evidence for increased coronary risk, as well as complimentary estimates of coronary artery atherosclerotic burden, would be valuable to practicing physicians. METHODS: Seventeen HIV patients on HAART (all from the same HIV clinic population) without coronary artery disease (CAD) were referred to Preventive Cardiology for treatment of dyslipidemia ('referred group'). Upon entry, they underwent computed tomography (CT) of the coronary arteries. Subsequently, the referred group was matched (1:4) for age, gender and traditional risk to non-HIV non-CAD subjects (matched group, n=68) from the University of Illinois CT database. A serial review of 90 subjects from the original HIV population was sampled to determine general cardiovascular risk. RESULTS: Thirteen (76%) of the 17 referred patients revealed the presence of coronary calcium compared with 63% in the matched HIV seronegative controls (P=0.18). Log-transformed median calcium score was 2.93+/-2.3 in the referred group versus 1.97+/-2.5 in the matched group (P=0.09). Fifty one percent of the overall population smoked cigarettes, 11% were diabetic (30% diagnosed pre-HAART and 70% post-HAART) and 30% were hypertensive (33% diagnosed pre-HAART and 67% post-HAART). CONCLUSIONS: In a particularly dyslipidemic subgroup of HIV subjects without known CAD we found evidence for atherosclerosis in three-quarters based on coronary calcium. Further, in this population of HIV patients on HAART, we found an enhanced prevalence of traditional cardiovascular risk. This pilot study encourages the development of preventive strategies in this population.

Comparison of low risk and higher risk profiles in middle age to frequency and quantity of coronary artery calcium years later.

Little is known about the relation of having favorable levels of all major cardiovascular risk factors (low risk [LR]) earlier in life to coronary artery calcium (CAC) later in life. From 2002 to 2003, CAC was compared in participants aged >60 years who were LR (n = 42) with those not LR (n = 39) at baseline (from 1967 to 1973). Despite adverse changes in risk factors, the prevalence of measurable CAC and mean CAC scores were less for LR participants than for non-LR participants (60% vs 77%, p = 0.09, and 217 vs 443, p = 0.05, respectively).

Conventional coronary artery disease risk factors and coronary artery calcium detected by electron beam tomography in 30,908 healthy individuals.

PURPOSE: Electron beam tomography (EBT) is a noninvasive measure of coronary artery calcium (CAC), a marker for atherosclerosis. In this study we examined the association between conventional risk factors for coronary artery disease (CAD) and CAC. METHODS: EBT CAC screening was performed on 30,908 asymptomatic individuals aged 30 to 90 years. Prior to EBT screening, individuals provided demographic and CAD risk factor information. EBT utilized a C-100 EBT scanner, and the amount of CAC was determined using the Agatston scoring method. RESULTS: The results of this study demonstrate that for both men and women, all conventional risk factors were significantly associated with the presence of any detectable CAC, and the mean CAC score increased in proportion to the number of CAD risk factors. In age-adjusted (multivariable) logistic regression analysis, cigarette use, histories of hypercholesterolemia, diabetes, and hypertension were each significantly associated with mild to extensive CAC scores (> or =10.0). CONCLUSION: CAD risk factors are associated with higher atherosclerotic plaque burden in both men and women. The odds ratios associated with each risk factor relative to the extent of CAC are similar to those reported for the development of clinical CAD, suggesting the existence of an association between CAC (subclinical disease) and CAD (clinical disease).

Alpha-chlorofatty Acid and coronary artery or aorta calcium scores in women with systemic lupus erythematosus. A pilot study.

OBJECTIVE: Alpha-chlorofatty acid (α-ClFA) is one product of myeloperoxidase activity in vivo during atherogenesis and may be a biomarker for cardiovascular disease (CVD). We investigated if serum α-ClFA is associated with subclinical CVD as measured by coronary artery and aorta calcium scores (CAC and AC, respectively) in women with and without systemic lupus erythematosus (SLE). METHODS: This pilot project analyzed baseline data from 173 women with SLE and 186 women without SLE participating in a 5-year longitudinal investigation of the Study of Lupus Vascular and Bone Long-term Endpoints (SOLVABLE). Data collection included demographic information, CVD and SLE risk factors, and laboratory assessments. Alpha-ClFA was measured in stored serum by liquid chromatography-mass spectrometry. CAC and AC were measured by computed tomography. Outcome measures were CAC and AC present (CAC > 0 or AC > 0) versus absent (CAC = 0 or AC = 0). Associations between risk factors and CAC or AC were tested with descriptive statistics and multivariate analyses. RESULTS: Women with SLE had higher α-ClFA levels than women without SLE (42.0 fmol/25 µl ± 37.3 vs 34.5 fmol/25 µl ± 21.9; p = 0.020). In analyses including individual CVD risk factors, having SLE was independently associated with the presence of CAC (OR 3.42, 95% CI 1.72 to 6.78) but not AC. Alpha-ClFA was not associated with the presence of CAC or AC in patients with SLE. CONCLUSION: SLE, but not serum α-ClFA, was associated with the presence of CAC in this pilot project.

Adverse pregnancy outcomes and subsequent risk of cardiovascular disease in women with systemic lupus erythematosus.

BACKGROUND/OBJECTIVE: Patients with systemic lupus erythematosus (SLE) are at increased risk for adverse pregnancy outcomes and cardiovascular disease (CVD). The objective of this exploratory study was to investigate the association between a history of adverse pregnancy outcomes and subsequent risk of subclinical CVD assessed by imaging studies and verified clinical CVD events in 129 women with SLE. METHODS: The occurrence of adverse pregnancy outcomes, specifically pre-eclampsia, preterm birth and low birth weight was ascertained by questionnaire. Subclinical CVD was assessed by coronary artery calcium (CAC) as measured by electron beam CT and carotid plaque measured by B mode ultrasound. Clinical CVD events were verified by medical record review. Logistic regression was used to estimate the association of pregnancy complications with occurrence of subclinical CVD and clinical CVD with a priori adjustment for age, which is associated with CVD and SLE disease duration as a measure of SLE disease burden. RESULTS: Fifty-six women reported at least one pregnancy complication while 73 had none. Twenty-six women had at least one pregnancy complicated by pre-eclampsia and were more likely to have a CAC score greater than or equal to 10 (adjusted OR=3.7; 95% CI 1.2 to 11.9), but the presence of plaque was not associated with this pregnancy complication, OR=1.1, (95% CI 0.4 to 2.8). Low birth weight and preterm birth were not associated with CAC or plaque. CONCLUSIONS: Patients with SLE with a history of pre-eclampsia had a higher rate of subclinical CVD as measured by CAC score. Future studies are needed to confirm the relationship between adverse pregnancy outcomes and subsequent subclinical CVD and clinical CVD events.

Differences in subclinical cardiovascular disease between African American and Caucasian women with systemic lupus erythematosus.

Racial differences exist in disease rates and mortality in both cardiovascular disease (CVD) and systemic lupus erythematosus (SLE). The objective of this cross-sectional study was to compare the frequency and risk factors for subclinical CVD in African American (AA) and Caucasian women with SLE and no prior CVD events. Traditional CVD risk factors and SLE-related factors were assessed in 309 SLE women. Subclinical CVD was assessed by carotid ultrasound to measure intimamedial thickness (IMT) and plaque, and electron beam computed tomography (EBCT) was used to measure coronary artery calcium (CAC). AA women had less education and higher levels of body mass index, blood pressure, lipoprotein(a), C-reactive protein (CRP), fibrinogen, and erythrocyte sedimentation rate (ESR). However, AA women had lower albumin, more and longer duration of corticosteroid use, higher SLE disease activity and damage, and more dsDNA antibodies compared with Caucasian women after adjustment for age and study site. More AA women had carotid plaque (adjusted odds ratio [OR], 1.94; 95% confidence interval [CI], 1.03-3.65) and higher carotid IMT (0.620 vs 0.605 mm, P = 0.07) but similar CAC compared with Caucasians. A multivariate analysis revealed that the following risk factor variables were significantly different between the racial groups and associated with plaque: blood pressure, current corticosteroid use, SLE disease activity, and SLE damage. All factors contributed to the result, but no individual risk factor fully accounted for the association between race and plaque. In conclusion, the presence of carotid plaque was higher in AA compared with Caucasian women with SLE, in contrast to studies of non-SLE subjects, in which AA have similar or less plaque than Caucasians. A combination of SLE-related and traditional CVD risk factors explained the racial difference in plaque burden.

25-hydroxyvitamin D and cardiovascular risk factors in women with systemic lupus erythematosus.

OBJECTIVE: Low serum levels of 25-hydroxyvitamin D (25[OH]D; vitamin D) are associated with a higher frequency of cardiovascular disease and risk factors in the general population. Vitamin D deficiency has also been noted in systemic lupus erythematosus (SLE). The objective of this study was to evaluate the associations of serum 25(OH)D levels with cardiovascular risk factors in women with SLE. METHODS: Data collected in 181 women with SLE included demographics, SLE activity and damage assessments, cardiovascular risk factors, medications, and laboratory assessments of inflammatory markers and 25(OH)D levels. Multiple linear and logistic regressions were used to estimate the association of 25(OH)D levels with cardiovascular risk factors. RESULTS: The mean age and disease duration were 43.2 and 11.9 years, respectively. The mean 25(OH)D level was 27.1 ng/ml and 62.2% had 25(OH)D levels <30 ng/ml. In unadjusted analyses, lower 25(OH)D levels were significantly associated with higher diastolic blood pressure, low-density lipoprotein cholesterol, lipoprotein(a), body mass index (BMI), and fibrinogen levels, as well as self-reported hypertension and diabetes mellitus. Lower 25(OH)D levels were also significantly associated with higher SLE disease activity and damage scores. After adjustment for age, seasonal variation, and race/ethnicity, lower 25(OH)D levels were also significantly related to higher fasting serum glucose. With further adjustment for BMI, associations between 25(OH)D and cardiovascular risk factors were no longer significant. CONCLUSION: This study demonstrates that vitamin D levels are low in women with SLE and significant associations exist with selected cardiovascular risk factors, although most of these associations can be explained by BMI.