First Year of SLE Diagnosis Could be the Most Crucial

Researchers writing in theAnnals of the Rheumatic Diseases suggest that rheumatologists should screen patients with systemic lupus erythematosus for stroke risk - during the first visit. 

The recommendation comes as a result of a Swedish study that compared the risk of ischaemic stroke in systemic lupus erythematosus (SLE) patients and non-SLE patients. The risk of stroke in SLE patients is high, more than double that of the general population, but the first year post SLE diagnosis is associated with the highest relative risk ischaemic stroke.

“The first encounter with patients presents an opportunity for rheumatologists to screen for risk factors and intervene,” wrote researchers who were led by Dr. Elizabeth V. Arkema, of the Karolinska Institute.

The study, published online April 11, is based on the analysis of 3,390 adult patients with systemic lupus erythematosus who were identified through the Swedish National Patient Register. This data was compared to 16,730 non-SLE adults from the Total Population Register. Of the 3,390 SLE patients in the study, 126 experienced strokes (HR 2.2; 95% CI 1.7 to 2.8) as compared to 304 of the 16,730 non-SLE comparative group.

The hazard ratio (HR) for intracerebral haemorrhage was 1.4 (95% CI 0.7 to 2.8). There was effect modification by sex and age, with the highest HRs for females and individuals younger than 50 years old. The HR for ischaemic stroke was highest in the first year of follow-up (3.7; 95% CI 2.1 to 6.5).

Mortality after First-Ever Stroke

In a related Karolinska Institute study from a June 2016 issue of the Annals of the Rheumatic Diseases, researchers found that patients with SLE were found to have a greater rate of any cause or stroke-specific death after experiencing a stroke.

This was a prospective study of 467 SLE patients (mean age 66) and 1,775 non-SLE patients (mean age 77) who were treated for first-time strokes. The patients were followed from the occurrence of stroke until death or until November 2014 when the study ended.

There were 1,293 deaths in both groups. After adjusting for age, stroke patients with SLE had a 50% higher rate of all-cause death for all stroke types as compared to non-SLE patients, with the highest being for intracerebral haemorrhage (HR=2.0; 95% CI=1.3–3.1).

Within 90 and 180 days, SLE patients are at higher risk of death compared to non-SLE for all stroke types (95% CI=1.0–1.7). However, for SLE patients experiencing intracerebral haemorrhage, the hazard ratios for death were higher in the first 30 days (HR 1.99).

The hazard ratios were adjusted for comorbidities (hypertension, diabetes, congestive heart disease, atrial fibrillation and renal disease). And, for patients with records detailing the risk of stroke, researchers adjusted for smoking, aspirin and statin use at baseline (and thrombolysis for ischaemic stroke).

References:

Arkema EV, Svenungsson E, Von Euler M, et al Stroke in systemic lupus erythematosus: a Swedish population-based cohort study Annals of the Rheumatic Diseases Published Online First: 11 April 2017. doi: 10.1136/annrheumdis-2016-210973

Rossides M, Simard J, Svenungsson E, et al OP0171 Prognosis of Stroke Patients with Systemic Lupus Erythematosus: A Population-Based Cohort Study Annals of the Rheumatic Diseases 2016;75:120.