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To the Editor:

We read with interest the editorial by Ahmed and Bruce¹ and the article by Wolak, et al². We recently used carotid artery ultrasonography in premenopausal female patients with systemic lupus erythematosus (SLE) and in age-matched controls, to detect carotid plaques, to evaluate risk factors associated with atherosclerosis, and to identify clinical and laboratory variables related to the presence of carotid plaques in these women.

Our study included 26 SLE patients and 20 female controls who underwent carotid ultrasound. All the SLE patients met American College of Rheumatology criteria for the classification of SLE³. Carotid intima media wall thickness (IMT) was measured in both left and right common carotid arteries using an HDI 1500 (ATL, Bothell, WA, USA) equipped with a 12.5 MHz vascular transducer. The main clinical features of the lupus patients at any time during the disease were: pancytopenia, serositis, polyarthritis, hemolytic anemia, thrombocytopenia/leukopenia, renal failure, nephrotic syndrome, cerebrovascular disease, cognitive dysfunction, and photosensitivity.

At the time of ultrasonography study, lupus patients were receiving oral prednisone, azathioprine, nonsteroidal antiinflammatory drugs, cytotoxic drugs, and hydroxychloroquine. Demographic and atherosclerotic risk factors of patients with SLE and controls are shown in Table 1. Compared with controls, SLE patients had greater carotid IMT, total cholesterol, triglycerides, and hypertension. Age, body mass index (BMI), LDL cholesterol, HDL, and C-reactive protein (CRP) of patients and controls were not statistically different. Seven (26.9%) of 26 patients showed carotid plaques, compared with only one (5%) of 20 controls. One patient from each group had past or present smoking history.

Table 1. Demographic and atherosclerosis risk factors of patients with SLE and controls. Values are mean ± standard deviation (SD).

Comparison of patients with and without carotid plaques (Table 2) showed a significant difference only in age (41.8 vs 30.6 years; t test, p = 0.006). Five of 7 patients with carotid plaques had moderate levels (20–80 U) of IgG cardiolipin antibodies (Relisa Cardiolipin IgG and IgM, Immuno Concepts, Sacramento, CA, USA) and 2 had low levels (5–20 U). Of the 7 patients with carotid plaques none had received cytotoxic drugs, while 7 of 19 patients without plaques had received cytotoxic agents (Fisher's exact test, p = 0.000). Variables significantly associated with carotid plaques by logistic regression analysis included age (OR 5.15, 95% CI 0.36–72.7, p = 0.001) and presence of anticardiolipin antibodies (OR 1.38, 95% CI 0.82–2.3, p = 0.008).

Table 2. Clinical and laboratory findings of patients with SLE with and without plaques. Values are mean ± SD.

In our study, subclinical atherosclerosis in premenopausal SLE patients was not related to traditional cardiovascular risk factors. Clinical or serologic measures of disease activity or serum levels of CRP were not significantly different, although all measures were obtained at the time of ultrasonography. As reported by Roman, et al⁴ and Asanuma, et al⁵, we also found that longterm therapy with corticosteroids was not associated with a significantly increased risk for carotid atherosclerosis. Plaques were more common among patients who had not received aggressive therapy with cytotoxic drugs than in those who had. Finally, a logistic regression model identified age and antiphospholipid antibodies as risk factors for atheroma.

ULISES MERCADO, MD, MS, FACR; LEONEL AVENDAÑO, PhD, Hospital General Mexicali and Universidad Autónoma de Baja California, Mexicali, México. E-mail: ulisesmercado@uabc.mx

REFERENCES

1. Ahmad Y, Bruce IN. Subclinical atherosclerosis in systemic lupus erythematosus. J Rheumatol 2004;31:841-3.

2. Wolak T, Todosoui E, Szendro G, et al. Duplex study of the carotid and femoral arteries of patients with systemic lupus erythematosus: A controlled study. J Rheumatol 2004;31:909-14.

3. Tan EM, Cohen AS, Fries JF, et al. The 1982 American College of Rheumatology revised criteria for the classification of systemic lupus erythematosus. Arthritis Rheum 1982;25:1271-7.

4. Roman MJ, Shanker BA, Davis A, et al. Prevalence and correlates of accelerated atherosclerosis in systemic lupus erythematosus. New Engl J Med 2003 349:2399-406.

5. Asanuma Y, Oeser A, Shintani AK, et al. Premature coronary artery atherosclerosis in systemic lupus erythematosus. New Engl J Med 2003;349:2407-15.