Increased risk of acute myocardial infarction and mortality in patients with systemic lupus erythematosus: Two nationwide retrospective cohort studies
Introduction
Systemic lupus erythematosus (SLE) is a chronic autoimmune connective tissue disorder with a broad range of clinical presentations that mainly affect women of childbearing age [1]. It represents a substantial global disease burden, with one United States estimate of prevalence finding 143.7 cases per 100,000 people [2]. Although the epidemiology, complications and treatment of SLE are well studied [1], [2], [3], poor quality of life and increased mortality from SLE are serious problems of global concern [4].
Over the past thirty years, many studies have provided clinical evidence regarding management of acute myocardial infarction (AMI) [5]. Although reductions in incidence and mortality of AMI have been investigated [6], [7], the high cost and social burden associated with this condition remain important issues [8], [9]. Epidemiological studies have documented that more than 90% of AMI cases are attributable to modifiable risk factors such as smoking, dyslipidemia, hypertension, abdominal obesity, and diabetes [10]. However, specific risk factors for AMI still need to be validated.
People with SLE have shown a higher prevalence of atherosclerosis, which is a traditional risk factor for cardiovascular diseases [11]. The significantly increased risk of cardiovascular diseases in patients with SLE also has been investigated [12], [13], [14], [15], [16], [17], [18], [19], [20]. Previous studies reported that people with SLE had higher risk of AMI compared with those without SLE [12], [13], [14], [15], [16]. However, these studies were limited by small sample size [15], focusing on specific populations [12], [14], [16], poor study design [13], [14], and inadequate adjustment for potential confounding factors [12], [15].
Using Taiwan's National Health Insurance Research Database, we conducted a retrospective cohort study to investigate the association between SLE and AMI with longitudinal design, a nationwide sample, and multivariate adjustment. We also performed a nested retrospective cohort study to verify the potentially higher risk of post-AMI adverse outcomes in patients with SLE when receiving cardiac surgery.
Section snippets
Data sources
The research data used in this study was obtained from reimbursement claims of Taiwan's National Health Insurance Program, which was implemented in 1995 and which covers more than 99% of 22.6 million Taiwan residents. The National Health Research Institutes established a National Health Insurance Research Database recording all beneficiaries' medical services, including inpatient and outpatient demographics, primary and secondary diagnoses, procedures, prescriptions and medical expenditures.
Results
Compared with non-SLE cohort (Table 1), cohort with SLE had higher proportions of living in very urbanized areas (27.9% vs. 23.5%, p = 0.0004), low income (3.3% vs. 2.1%, p = 0.0093), trauma (74.2% vs. 66.9%, p < 0.0001), mental disorders (34.1% vs. 24.8%, p < 0.0001), hyperlipidemia (12.7% vs. 10.2%, p = 0.0073), atherosclerosis (6.9% vs. 3.6%, p < 0.0001), liver cirrhosis (5.6% vs. 4.2%, p = 0.0293), and renal dialysis (2.7% vs. 0.5%, p < 0.0001). Patients with SLE had used more medication than non-SLE
Discussion
This nationwide retrospective cohort study reported increased risk of AMI among SLE patients compared with non-SLE cohort. The association was more significant in women than in men. We further investigated the impacts of emergency visit and hospital inpatient services among SLE patients having higher risk for AMI. A further retrospective cohort study found SLE patients after AMI had higher 30-day in-hospital postoperative mortality than non-SLE cohort when undergoing cardiac surgeries.
In the
Funding
This study was supported in part by a grant from the National Science Council Taiwan (NSC102-2314-B-038-021-MY3).
Competing interests
The authors report no relationships that could be construed as a conflict of interest.
Author contribution
All authors were involved in drafting the article, interpreting the data or revising it critically for important intellectual content, and all authors approved the final version to be published. Dr. Chen had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Acknowledgments
This study is based on data from the National Health Insurance Research Database provided by the National Health Research Institutes. The interpretation and conclusions contained herein do not represent those of the National Health Research Institutes.
References (45)
- et al.
Systemic lupus erythematosus
Lancet
(2007) - et al.
Acute myocardial infarction
Lancet
(2008) - et al.
Burden of acute myocardial infarction
Int J Cardiol
(2011) - et al.
Cost and length of hospitalization in Hispanic patients with acute myocardial infarction in the United States
Int J Cardiol
(2009) - et al.
Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case–control study
Lancet
(2004) - et al.
Effect of rheumatoid arthritis or systemic lupus erythematosus on the risk of first-time acute myocardial infarction
Am J Cardiol
(2004) - et al.
Major adverse cardiovascular events and mortality in systemic lupus erythematosus patients after successful delivery: a population-based study
Am J Med Sci
(2014) - et al.
Quantifying links between acute myocardial infarction and depression, anxiety and schizophrenia using case register databases
J Affect Disord
(2008) - et al.
The low incidence of myocardial infarction in patients with portal cirrhosis of the liver: a review of 639 cases of cirrhosis of the liver from 17,731 autopsies
Am Heart J
(1960) - et al.
Non-alcoholic fatty liver disease and cardiovascular risk
Int J Cardiol
(2013)
Dyslipoproteinemia in systemic lupus erythematosus: effect of corticosteroids
Am J Med
Systemic lupus erythematosus
N Engl J Med
Epidemiology and sociodemographics of systemic lupus erythematosus and lupus nephritis among US adults with Medicaid coverage, 2000–2004
Arthritis Rheum
Two aspects of the clinical and humanistic burden of systemic lupus erythematosus: mortality risk and quality of life early in the course of disease
Arthritis Rheum
Reduction in acute myocardial infarction mortality in the United States: risk-standardized mortality rates from 1995–2006
JAMA
Population trends in the incidence and outcomes of acute myocardial infarction
N Engl J Med
Prevalence and correlates of accelerated atherosclerosis in systemic lupus erythematosus
N Engl J Med
Age-specific incidence rates of myocardial infarction and angina in women with systemic lupus erythematosus: comparison with the Framingham Study
Am J Epidemiol
Premature morbidity from cardiovascular and cerebrovascular diseases in women with systemic lupus erythematosus
Arthritis Rheum
Cardiovascular event in systemic lupus erythematosus in northern Sweden: incidence and predictors in a 7-year follow-up study
Lupus
The cardiovascular burden of lupus: a complex challenge
Arch Intern Med
Systemic lupus erythematosus and the risk of cardiovascular disease: results from the nurses' health study
Arthritis Rheum
Cited by (47)
Factors associated with cardiovascular events in systemic lupus erythematosus in a monocentric cohort with up to 40 years of follow-up
2023, Seminars in Arthritis and RheumatismManagement and long-term outcomes of patients with chronic inflammatory diseases experiencing ST-segment elevation myocardial infarction: The SCALIM registry
2022, Archives of Cardiovascular DiseasesLipid-lowering therapy: Guidelines to precision medicine
2021, Clinica Chimica ActaCitation Excerpt :A similar relationship between rheumatic diseases and CVD could also be observed among psoriatic patients, as the prevalence of CVD and MACE are elevated synergistically [79]. According to the results, the odds ratio (OR) for MI in psoriatic patients was approximately 1.6 to 1.9 within the severity of psoriasis [80]. The risk of CVD, including hypertension, dyslipidemia, and obesity, was also verified to be increased in psoriatic patients [81].
Cardiovascular disease in lupus
2021, Lahita’s Systemic Lupus ErythematosusPostimplantation Syndrome Is Not Associated with Myocardial Injury after Noncardiac Surgery after Endovascular Aneurysm Repair
2020, Annals of Vascular Surgery
- 1
Chiao-Yi Lin and Ta-Liang Chen contributed equally to this work.