Review Question - QID 106746

This patient presents with a clinical history consistent with systemic lupus erythematosus (SLE). The most common cardiac manifestation of SLE is pericarditis.

SLE can affect the heart in numerous ways. Most commonly it causes pericarditis, with a pericardial effusion present in as many as half of patients. Patients are not typically symptomatic from pericarditis, but suggestive history includes substernal, pleuritic chest pain with an audible rub on examination. SLE can also cause valvular disease, most often mitral regurgitation. Large verrucous vegetations (typically mitral, aortic, or tricuspid) in the context of SLE is referred to as Libman-Sacks endocarditis.

Snyder et al. discuss the diagnosis and management of acute pericarditis. ECG findings in acute pericarditis include widespread concave ST-segment elevations and depression of the PR-segment. They highlight predictors of severe illness, including high fever, evidence of tamponade or a large effusion, or subacute onset; these factors warrant strong consideration of inpatient admission rather than outpatient treatment.

Farzaneh-Far et al. present a series of 200 patients with SLE who underwent extensive cardiac evaluation. They sought to assess the relationship between the presence of antiphospholipid antibodies (APL) and cardiac disease. They found a strong correlation between the presence of high levels of APL and mitral valve disease, including nodules and valvular regurgitation. APL levels did not correlate with altered LV size or function.

Figure A shows a typical "butterfly" (or malar) rash in a patient with SLE. This rash is photosensitive, spares the nasolabial folds, and occurs in up to half of patients with SLE.

Incorrect Answers:
Answer 2: Myocarditis can occur with SLE, and similarly is often asymptomatic, but is less common than pericarditis.
Answer 3: Conduction abnormalities typically represent scarring damage from prior myocarditis in SLE. When present, it is often a transient first-degree AV block.
Answer 4: Mitral valve disease (especially with resultant regurgitation) is a common cardiac manifestation of SLE, but pericarditis is more common. Mitral valve disease is especially associated with Libman-Sacks endocarditis.
Answer 5: Patients with SLE are at markedly increased risk for coronary artery disease, but it is still less common than pericarditis as a cardiac manifestation of SLE.