Valvular Heart Disease by Transthoracic Echocardiography Is Associated with Focal Brain Injury and Central Neuropsychiatric Systemic Lupus Erythematosus

Roldan, Carlos A.; Gelgand, Erika A.; Qualls, Clifford; Sibbitt, Wilmer L.

doi:10.1159/000099104

Cited by 31 publications

(15 citation statements)

References 49 publications

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“…In another TTE study, any valve abnormality detected in 44% of 71 patients was associated with past stroke/TIA (30). In 3 retrospective studies from our institution (2 using TEE), valve vegetations were associated with past stroke/TIA, non-focal NPSLE, and brain lesions on MRI (31–33). In a prospective not-controlled TTE study, Libman-Sacks vegetations detected in 11% of 342 SLE patients were associated with a higher incidence of stroke/TIA (14.8% in those with versus 3% in those without vegetations) during a 4-year follow-up (34).…”

Section: Discussionmentioning

confidence: 99%

Libman-Sacks Endocarditis and Embolic Cerebrovascular Disease

Roldan

Sibbitt

Qualls

et al. 2013

JACC: Cardiovascular Imaging

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Objective To determine whether Libman-Sacks endocarditis is a pathogenic factor for cerebrovascular disease (CVD) in systemic lupus erythematosus (SLE). Background A cardioembolic pathogenesis of SLE CVD manifested as 1) neuropsychiatric SLE (NPSLE) including stroke and transient ischemic attacks (TIA), 2) neurocognitive dysfunction, and 3) MRI focal brain lesions has not been established. Methods A 6-year study of 30 patients with acute NPSLE (27 women, age 38±12 years), 46 age-and-sex matched SLE controls without NPSLE (42 women, age 36±12 years), and 26 age-and-sex matched healthy controls (22 women, age 34±11 years) who underwent clinical and laboratory evaluations, TEE, carotid duplex, transcranial Doppler, neurocognitive testing, and brain MRI/MRA. NPSLE patients were re-evaluated after 4.5 months of therapy. All patients were followed clinically for a median of 52 months. Results Libman-Sacks vegetations (87%), cerebromicroembolism (27% with 2.5 times more events per hour), neurocognitive dysfunction (60%), and cerebral infarcts (47%) were more common in NPSLE than in SLE (28%, 20%, 33%, and 0%) and healthy controls (8%, 0%, 4%, and 0%, respectively) (all p≤0.009). Patients with vegetations had 3 times more cerebromicroemboli per hour, lower cerebral blood flow, more stroke/TIA and overall NPSLE events, neurocognitive dysfunction, cerebral infarcts, and brain lesion load than those without (all p≤0.01). Libman-Sacks vegetations were independent risk factors of NPSLE (OR=13.4, p<0.001), neurocognitive dysfunction (OR=8.0, p=0.01), brain lesions (OR=5.6, p=0.004), and all 3 outcomes combined (OR=7.5, p<0.001). Follow-up re-evaluations in 18 (78%) of 23 surviving NPSLE patients demonstrated improvement of vegetations, microembolism, brain perfusion, neurocognitive dysfunction, and lesion load (all p≤0.04). Finally, patients with vegetations had reduced event free survival time to stroke/TIA, cognitive disability, or death (p=0.007). Conclusion The presence of Libman-Sacks endocarditis in patients with SLE is associated with higher risk for embolic CVD. This suggests that Libman-Sacks endocarditis may be a source of cerebral emboli.

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Section: Discussionmentioning

confidence: 99%

Libman-Sacks Endocarditis and Embolic Cerebrovascular Disease

Roldan

Sibbitt

Qualls

et al. 2013

JACC: Cardiovascular Imaging

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“…Our literature search identified 234 publications, of which 23 unique studies were included in the review 13,21,22,[25][26][27][28][29][30][31][32][33][34][35][36][37][38][39][40][41][42][43][44] ( Figure 1). Studies were identified with the use of Embase (nϭ115), MEDLINE (nϭ97), Cochrane Library (nϭ0), and hand search (nϭ22) from August 1987 to December 2010.…”

Section: Literature Flow Chartmentioning

confidence: 99%

Increased Risk for Heart Valve Disease Associated With Antiphospholipid Antibodies in Patients With Systemic Lupus Erythematosus

Zuily¹,

Régnault²,

Selton-Suty³

et al. 2011

Circulation

157

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Background-Heart valve disease (HVD) is frequent in patients with systemic lupus erythematosus (SLE), and the role of antiphospholipid antibodies (aPL) is controversial. Thus, our objective was to estimate the risk of HVD, including Libman-Sacks endocarditis, associated with aPL in patients with SLE. Methods and Results-Studies were selected if they investigated the association between aPL and HVD in SLE patients and if aPL-negative patients were included for comparison. Data sources were MEDLINE, Embase, Cochrane Library, hand search, contact with investigators, and reference lists of studies, without language restrictions. Data on study and patient characteristics, risk estimates, and study quality were independently extracted by 2 investigators. Pooled effect estimates were obtained by using the DerSimonian-Laird method. Of 234 identified abstracts, 23 primary studies (15 cross-sectional, 7 cohort, 1 case-control) met inclusion criteria, including 1656 SLE patients and 508 cases of HVD. Compared with SLE patients without aPL (nϭ988), the overall pooled odds ratios for HVD and Libman-Sacks endocarditis in aPL-positive patients (nϭ668) were 3.13 (95% confidence interval, 2.31 to 4.24) and 3.51 (95% confidence interval, 1.93 to 6.38), respectively. The risk of HVD depending on aPL subtypes was the highest for lupus anticoagulant at 5.

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“…A prospective study of 70 SLE patients by Cervera et al [59] suggests a more benign prognosis, with only approximately 4% of patients developing clinically significant valvular disease and only approximately 2% requiring surgical intervention. Studies by Roldan et al demonstrate associations between valvular heart disease in SLE and both focal brain injury and nonfocal neuropsychiatric disease [67,71,72]. Similarly, other studies have demonstrated associations between valvular heart disease in SLE and central nervous system disease.…”

Section: Clinical Featuresmentioning

confidence: 88%