The state of current management of the heightened risk for atherosclerotic cardiovascular events in an established cohort of patients with lupus erythematosus

Background Patients with lupus erythematosus (LE) are at a heightened risk for clinical events, chiefly heart attacks and strokes, caused by atherosclerotic cardiovascular disease (ASCVD). We recently proposed new guidelines to categorize levels of risk for future ASCVD events specifically in LE patients, with recommendations for management. Here, we assessed the state of current management of ASCVD event risk in light of these new recommendations. Methods We studied our entire UPenn Longitudinal Lupus Cohort of patients with cutaneous LE, without or with concurrent systemic LE, for whom we had full access to medical records (n=370, LE-ASCVD Study Cohort, years 2007-2021). Results Of our LE-ASCVD Study Cohort, 336/370 (90.8%) had a designated primary-care physician. By the new guidelines, the most recent plasma LDL cholesterol levels were above goal for 252/370 (68.1%) of the Cohort. Two hundred sixty-six (71.9%) had hypertension, which was under- or un-treated in 198/266 (74.4%). Of current smokers, 51/63 (81.0%) had no documented smoking cessation counseling or referrals. Diabetes was generally well-managed, and hypertriglyceridemia was uncommon. Of the Cohort, 254 patients qualified for two widely used online calculators in primary prevention that estimate the risk of an ASCVD event in the next 10 years: the ACC-ASCVD Risk Estimator Plus and QRisk3. We also stratified these 254 patients into the categories of ASCVD event risk we recently defined specifically for LE. Surprisingly, these three methods for estimating ASCVD event risk showed clinically meaningful agreement for only 100/254 (39.4%), i.e., discordance for over 60% that could affect clinical management. The documented rate of ASCVD events in the first 10 years after enrollment was 22.3% (95% CI 16.9%, 27.4%), indicating a high-risk population despite a preponderance of women and a median age at enrollment of only 47 years. Conclusion Cutaneous LE patients are under-treated compared with the new guidelines and, accordingly, they experience a substantial burden of ASCVD events. Moreover, it is unclear how to accurately assess future ASCVD event risk in these patients – except that it is high – and this uncertainty may complicate clinical management. Efforts are underway to improve ASCVD event risk estimation and guideline implementation in lupus patients. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This study was supported by funding from the Lupus Foundation of America. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: University of Pennsylvania IRB gave ethical approval for this work. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable. Yes All data produced in the present study are available upon reasonable request to the authors. * ACC : American College of Cardiology AHA : American Heart Association apoB : apolipoprotein-B ASCVD : atherosclerotic cardiovascular disease CLE : cutaneous lupus erythematosus HbA1c : glycated hemoglobin HDLc : high-density lipoprotein cholesterol Lp(a) : lipoprotein(a) LDLc : low-density lipoprotein cholesterol LE : lupus erythematosus MAACE : major adverse atherosclerotic cardiovascular event MACE : major adverse cardiovascular event MI : myocardial infarction, OGTT : oral glucose tolerance test PAD : peripheral arterial disease PCP : primary care physician SLE : systemic lupus erythematosus TC : total cholesterol TG : triglycerides UPHS : University of Pennsylvania Health System