Cardiac Manifestations in Systemic Lupus Erythematosus: A Case Report and Review of the Literature

Abstract

BACKGROUND Systemic Lupus Erythematosus (SLE) is a chronic autoimmune disease with a wide range of clinical features and variable clinical course. SLE tends to affect women during childbearing years and is characterized by multi-organ involvement. Cardiac complications in SLE, which have been described to occur in about 50% of the cases, contributes to significant morbidity and mortality in this population. We describe a patient with SLE and established lupus nephritis who subsequently developed cardiac manifestations including valvular abnormalities, arrythmia and end stage heart failure. The clinical features, work up and management will be discussed. CASE PRESENTATION A 35 year-old African American woman diagnosed with SLE in her twenties presented to our hospital for evaluation of shortness of breath. After SLE diagnosis, the patient had been prescribed hydrochloroquine and low dose steroids for joint and skin manifestations. Four years after initial presentation, she developed biopsy proven lupus nephritis for which standard induction therapy was administered. She was placed on maintenance immunosuppression with stable renal function. On admission, the patient's symptoms included dyspnea on exertion, chest pain, palpitations, and a non-productive cough. Initial evaluation identified atrial fibrillation and new onset of heart failure given elevated brain natriuretic peptide (BNP) levels and left ventricular ejection fraction (EF) of 15% by echocardiogram. Cardiac catheterization revealed global hypokinesis and non-obstructive coronary artery disease (CAD). The patient was deemed not a suitable candidate for cardiac transplant and was offered a life vest as bridging to an implantable cardioverter (ICD). Twenty-four months after discharge, the patient continued to be managed medically and has not had any subsequent hospitalizations. CONCLUSION Cardiac complications, reported in about 50% of SLE patients, are associated with high morbidity and mortality. Pericarditis is the most common, however conduction defects, valvular damage and heart failure are also observed among SLE patients. The pathogenesis of cardiac involvement seems to be multifactorial. The management of heart failure in SLE entails medical therapy and implantable device use. Further research is needed to explore new options to arrest the development and progression of cardiac disease among lupus patients.