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Increased Risk for Heart Valve Disease Associated With Antiphospholipid Antibodies in Patients With Systemic Lupus Erythematosus: Meta-Analysis of Echocardiographic Studies
Study Questions:
What is the risk of heart valve disease, including Libman-Sacks endocarditis, associated with antiphospholipid antibodies in patients with systemic lupus erythematosus (SLE)?
Methods:
In performing the meta-analysis, studies were selected if they investigated the association between antiphospholipid antibodies and heart valve disease in patients with SLE, and if antiphospholipid antibody-negative patients were included for comparison. Data sources were MEDLINE, Embase, Cochrane Library, hand search, contact with investigators, and reference lists of studies, with no language restrictions. Data reflecting study and patient characteristics, risk estimates, and study quality were independently extracted by two investigators. Pooled effect estimates were obtained by using the DerSimonian-Laird method.
Results:
Of 234 identified abstracts, 23 primary studies (15 cross-sectional, 7 cohort, 1 case-control) met inclusion criteria, including 1,656 SLE patients and 508 cases of heart valve disease. Compared to SLE patients without antiphospholipid antibodies (n = 988), the overall pooled odds ratios for heart valve disease and Libman-Sacks endocarditis in antiphospholipid antibody-positive patients (n = 668) were 3.13 (95% confidence interval [CI], 2.31-4.24) and 3.51 (95% CI, 1.93-6.38), respectively. The risk of heart valve disease depending on antiphospholipid antibody subtypes was the highest for lupus anticoagulant (5.88; 95% CI, 2.92-11.84) and IgG anticardiolipin antibodies (5.63; 95% CI, 3.53-8.97).
Conclusions:
Overall, the presence of antiphospholipid antibodies in patients with SLE is associated with an increased risk for heart valve disease, including Libman-Sacks endocarditis. The risk conferred by IgG anticardiolipin antibodies is as strong as that associated with lupus anticoagulant. Systematic echocardiographic examinations should be performed among patients with SLE and antiphospholipid antibodies.
Perspective:
Using a meta-analysis of existing literature, this study suggests that patients with both SLE and antiphospholipid antibodies (notably lupus anticoagulant and IgG anticardiolipin antibodies) have an increased risk of heart valve disease, and the authors recommend echocardiographic screening of all patients with SLE and antiphospholipid antibodies. Additional data reflecting the nature and clinical significance of heart valve disease probably should be used to help guide efforts to detect it—that is, detecting the presence of ‘valve thickening’ might not be of clinical importance, whereas hemodynamically significant regurgitation would be.
Keywords: Immunoglobulin G, Risk, Endocarditis, Antiphospholipid Syndrome, Lupus Erythematosus, Systemic, Heart Valve Diseases, Antibodies, Antiphospholipid
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