Study finds higher rate of complications after heart attack in people with autoimmune diseases

After a heart attack, people with an autoimmune disease were more likely to die, develop heart failure, or have a second heart attack than people without an autoimmune disease, according to a new study published today in Journal of the American Heart Association.

Autoimmune diseases such as rheumatoid arthritis, systemic lupus erythematosus and psoriasis are known to increase the risk of cardiovascular disease, which is likely due to several factors. People with an autoimmune disease have a higher prevalence of traditional cardiovascular risk factors (such as hypertension, type 2 diabetes, or kidney disease), in addition to aspects of the autoimmune disease that are also associated with higher cardiovascular risk, such as chronic inflammation, autoimmune antibodies, and long-term use of steroid drugs. A new study looked at whether having an autoimmune disease affects a person’s health after a heart attack compared to having none.

“The evidence on the risk of adverse events after a heart attack in people with autoimmune diseases is less robust than the evidence for people without these diseases and comes primarily from small or single-center studies,” said Amgad Mentias, MD, M.Sc. senior author of the study and assistant professor of medicine at the Cleveland Clinic Lerner College of Medicine in Cleveland. “We conducted our study to examine in a large cohort whether there is a difference in the treatment of heart attack patients with versus without autoimmune diseases and whether there is a difference in the risk of death, heart failure or recurrent heart attacks over the long term.”

Researchers identified 1,654,862 people in the United States aged 65 and older in the Medicare Provider Analysis and Review (MedPAR) file who were hospitalized with a diagnosis of heart attack between 2014 and 2019. MedPAR is a government database of all inpatient hospital bills submitted to Medicare for payment in the United States. Of these records, 3.6% (60,072) had an inflammatory autoimmune disease on their medical records in the previous year. The most common disease was rheumatoid arthritis, followed by systemic lupus, psoriasis, systemic sclerosis, and myositis/dermatomyositis. They found several important differences between people with and without an autoimmune disease who had a heart attack:

• People with an autoimmune disease were slightly younger – the median age was 77.1 years versus 77.6 years for people without an autoimmune disease.
• There were more women among the patients with an autoimmune disease (66.9% vs. 44.2%).
• Those with an autoimmune disease were more likely to have had a non-ST-elevation myocardial infarction (NSTEMI) myocardial infarction (77.3% vs. 74.9%), and they were less likely to have had a myocardial infarction with ST-elevation myocardial infarction (STEMI). (18.7% vs. 22.1%).

An NSTEMI, the most common type of heart attack recorded in the database, is caused by a partial blockage of one of the coronary arteries that supply oxygenated blood to the heart muscle. A STEMI heart attack, which is usually more dangerous, results from a complete blockage of one or more of the heart’s main arteries.

The researchers compared each heart attack patient with autoimmune disease to the records of three heart attack patients without autoimmune disease based on age, sex, race and type of heart attack. After matching (and excluding people who were not enrolled in Medicare for at least a year before their heart attack), investigators compared health outcomes for about 2 years. The final dataset included 59,820 heart attack records from people with an autoimmune disease and 178,547 from people without an autoimmune disease.

The analysis found that people with an autoimmune disease:

• 15% more likely to die from any cause;
• 12% more likely to be hospitalized for heart failure;
• 8% more likely to have another heart attack; and
• 6% more likely to have an additional artery opening procedure (if they had one at the time of their heart attack).

“Patients with autoimmune diseases and cardiovascular diseases are preferably treated by a cardio-rheumatologist in collaboration with a rheumatologist to optimize cardiovascular health. Traditional cardiovascular risk factors are emphasized in this population, and the manner in which these risk factors manifest themselves is also unique,” ​​said study lead author Heba Wassif, MD, MPH, assistant professor of medicine at Cleveland Clinic’s Lerner College of Medicine and Director of Cardiorheumatology at the Cleveland Clinic.

“For example, cholesterol levels are affected by inflammation, therefore patients with active inflammatory disease have lower cholesterol levels, a phenomenon known as the lipid paradox,” Wassif said. “Physical activity, which is highly recommended to improve cardiovascular outcomes, can be limited by joint pain. In addition, some disease-modifying agents may increase cardiovascular risk. Knowing these nuances and taking a team-based approach can improve results.”

The researchers also found that people with an autoimmune disease were less likely to need cardiac catheterization to evaluate narrowed coronary arteries, or to have artery opening or bypass surgery, regardless of the type of heart attack.

“It’s possible that people with an autoimmune disease were not healthy enough to undergo these procedures, or that their coronary anatomy was less suitable for procedures to reopen narrowed or blocked vessels,” Mentias said. These problems can put you at greater risk of procedure-related complications. “However, if it is possible, these procedures should be considered as options if someone is a suitable candidate. The presence of an autoimmune disease in itself should not preclude someone from potentially life-saving procedures.”

The researchers had no information about the anatomy of the patients’ coronary arteries, which limited their ability to assess whether anatomical differences might have influenced decision-making about vascular opening procedures. The analysis is also limited by the lack of laboratory data on the severity and activity of the patients’ autoimmune disease, leaving the researchers unable to assess whether the risk of complications and death after a heart attack is higher in patients with severe forms of the autoimmune disease compared with those who have a milder form or disease in remission.

“Future research on drugs and interventions that might reduce the increased risk of poor outcomes in heart attack patients with autoimmune diseases is needed,” said Wassif, “such as investigating whether different immunomodulators and immunosuppressive therapies are used to control and treat the autoimmune disease.” Illness has no impact on improving outcomes after a heart attack.”

Co-authors are Marwan Saad, MD, Ph.D.; Rajul Desai, MD, MPH; Rula A. Hajj-Ali, MD; Venus Menon, MD; Pulkit Chaudhury, MD; Michael Nakhla, MD; Rishi Puri, MD, Ph.D.; Sameer Prasada, MD; Grant W. Reed, MD, MSc; Khaled Ziada, MD; Samir Kapadia, MD; and Milind Desai, MD, MBA