Hydroxychloroquine Plus Low-Dose Aspirin Reduces Cardiovascular Events in Systemic Lupus Erythematosus

Serena Fasano, MD, from the Department of Clinical and Experimental Medicine, Rheumatology Section, Second University of Naples, Italy, and colleagues evaluated 189 patients who had SLE without a cardiovascular event (CVE) before their first clinical visit at a single center for a median of 13 years. Patients met SLE criteria from either the 1997 American College of Rheumatology and/or 2012 Systemic Lupus Collaborating Clinics classification criteria and were monitored for ASA use, cumulative HCQ (c-HCQ), and thrombotic events every 3 to 6 months.

“A CVE was defined as the occurrence of angina or myocardial infarction (MI), heart failure, a transient ischemic attack (TIA), stroke, or atherosclerotic peripheral ischemia identified by hospital discharge records and/or specific laboratory and radiologic tests [i.e., cerebral or myocardial imaging techniques, namely, central nervous system (CNS) computerized tomography, magnetic resonance, echocardiography, or myocardial scintigraphy],” Dr Fasano and colleagues wrote in their study.

The researchers recorded a CVE in 10 patients during follow-up, with a higher percentage of patients without a CVE in the ASA plus c-HCQ >600 g group compared with the ASA-only group and the ASA plus c-HCQ <600 g group (log-rank test chi-square, 4.01; P =.045), according to a Kaplan-Meier analysis. In a multivariate analysis, HCQ use over the course of 5 years (hazard ratio [HR], 0.04; 95% CI, 0.004-0.48) and ASA use (HR, 0.04; 95% CI, 0.003-0.54) remained significantly associated with fewer CVEs, whereas antiphospholipid antibody positivity (HR, 17.96; 95% CI, 1.48-217.61) and hypertension (HR 18.05; 95% CI, 1.64-198.76) were significantly associated with thrombosis.

“Although rigorous management of all potential risk factors for thrombosis is warranted in patients with SLE, given the lack of evidence-based recommendations, most patients with SLE without previous thrombotic manifestations do not receive any prophylactic treatment,” Dr Fasano and colleagues wrote. “Noninvasive assessment of carotid intima-media thickness and plaque should be used to predict CVE in asymptomatic patients with SLE, and studies are required to analyze effects of treatment on subclinical atherosclerosis.”The researchers noted that HCQ’s long-term protection against thrombosis effect indicated its use for all patients with SLE.

“Our results support the prolonged use of HCQ in all patients with SLE, as previously advocated,” Dr Fasano and colleagues wrote. “Nevertheless, larger, controlled prospective studies are needed to better define the involvement of HCQ in primary CV prevention in patients with SLE.”

Limitations & Disclosures 

The researchers noted that the rate of ischemic events in the study was 5 times higher than in the Italian population, and also noted the study’s observational nature and reliance on patient adherence to treatment.

The researchers report no relevant financial disclosures.

Reference

Fasano S, Pierro L, Pantano I, et al. Longterm hydroxychloroquine therapy and low-dose aspirin may have an additive effectiveness in the primary prevention of cardiovascular events in patients with systemic lupus erythematosus. J Rheumatol. doi:10.3899/jrheum.161351