This is the third in a series dealing with issues encountered by people with vasculitis. In this article I wish to talk about heart disease, its recognition, diagnosis and prevention.
First of all the term ‘heart disease’ is a commonly used term generally taken to mean coronary artery disease- the disease process that leads to myocardial infarction (more commonly known as a heart attack).To clarify, heart disease connotes a general term that implies disease that involves the heart or associated structures In general there are six different ways that one can develop ‘heart problems’.
1) Coronary heart disease- this is the most common type and will be the focus of this discussion.This is also known as CAD ( coronary artery disease) and implies plaque or thickening or blockage of the interior lining ( endothelium) of the blood vessels of the heart.
2) Valvular disease- involves the valves of the heart where they become leaky or thickened and abnormal leading to restricted flow.
3)Pericardial disease- involves the wrapping around the heart. This is more common in patients with CSS and certain other types of autoimmune disease.
4) Myocardial disease ( also called cardiomyopathy)- disease involving the heart muscle usually from poor blood flow, infection, lack of trace elements , infiltation of the muscle or just unknown causes.
5) Endomyocardial disease or ( endocardial disease) this is probably the most rare type and patients with CSS are at no more risk from this that anyone else- this is a disease that involves the inner lining of the heart muscle itself.
6) Conduction system disease- this involves the electrical system of the heart which cause the heart muscle to contract. This can occur with aging and certain disease processes.
Any of these various parts of the heart when involved can be known as heart disease but we are going to talk about CAD or coronary artery disease. Patients that have CSS are at a significantly higher risk for CAD for the reasons that I will go into further.
First of all diagnosis and screening of CAD is rapidly changing. The tests that are being used today to screen for heart disease will probably be very different in another ten years. The current tests miss a lot of people that have the disease. Upon seeing your physician he or she will evaluate your cardiac risk by doing a thorough history and drawing blood to screen for CAD. Risk factors include age, sex (male or female- men have a higher risk), family history of heart disease, smoking, lack of exercise, high fat diet, obesity, metabolic syndrome or diabetes.Testing should include total cholesterol, HDL and LDL cholesterol ( good and bad cholesterol), triglycerides, high sensitivity CRP and possibly homocysteine should be drawn.
Patients with CSS have a propensity to have more than just average risk. The reasons for this are several. Vasculitis in itself produces a generalized inflammation. This can elevate CRP. More and more CAD is considered a disease of inflammation. Prednisone which is a mainstay drug for most of us generally promotes significant weight gain ( in a truncal or apple- like fashion), elevated triglycerides, elevated cholesterol and metabolic syndrome, even diabetes .We discussed metabolic syndrome in the last article .Remember metabolic syndrome includes abdominal obesity, elevated trigycerides, low levels of HDL ( good cholesterol) sometimes high blood pressure and insulin resistance with or without elevated glucose or blood sugar.. These factors that make up the syndrome increase the risk of CAD, diabetes and premature death.
The new guidelines for treating cholesterol in high risk individuals include getting your total cholesterol to 200 or less, LDL to 100 if no prior heart attacks, HDL to 50 mg/dl or above and triglycerides to 150 mg /dl or below. More recent studies have shown a benefit from decreasing LDL even further and this may actually help reverse the disease not just prevent it from getting worse.( REVERSAL Trial). So get your cholesterol numbers, triglycerides and CRP from your physician and discuss them with him or her .Get to goal- be aggressive!!
For people with a strong family history but no obvious lipid or cholesterol abnormalities, blood work may need to be evaluated further for genetic abnormalities or other subtypes that will not be picked up by routine testing There may be a variety of specialty labs around but the one well known to me is the Berkeley Heart Lab on the west coast
As for treatment of these disorders, statin drugs are usually the medicine of choice. Statins are drugs such as Lipitor, Zocor, Mevacor or Crestor. These are remarkably effective drugs and have little side effects vs benefits.The new medicine out there is a medicine called Vytorin which combines Zocor and Zetia ( a non systemic medicine) together in a pill. This medicine helps the statins work even better at a lower dose and also helps with lowering triglycerides. Statins may help with inflammation and may even reduce the elevated hs-CRP. Other meds are available for those who do not tolerate statin meds.
Hypertension or high blood pressure needs to be aggressively treated and taken down to guidelines of 130/80 or lower. For those with metabolic syndrome (syndrome x) or diabetes, glucose needs to be kept low, under 100 fasting and less than 139 after meals. HGBA1C needs to be normalized to prevent cardiovascular events. Remember metabolic syndrome is very common especially in those with vasculitis and those on prednisone who have had significant weight gain around the middle. This is where coronary artery disease starts…years before the blood sugar becomes abnormal.
Do not depend on symptoms of chest pain to start thinking about risks for heart disease. For a certain percentage of patients sudden death or a heart attack may be the first manifestation of heart disease. Two thirds of women who die of a heart attack had no prior symptoms.
Lastly, some doctors will also look at things like homocysteine and lipoprotein a to pick up more people who are at risk for CAD. It is not clear if homocysteine is a marker for heart disease or an actual disease that makes things worse. If treated, it is usually treated with folic acid. So get with your physician and go over the risks but these risks can be treated and hopefully normalized.
God bless all of you and go see your doctors.
Respectfully, Carol Kavanaugh D.O.