Lipid management in systemic lupus erythematosus according to risk classifiers suggested by the European Society of Cardiology and disease-related risk factors reported by the EULAR recommendations

BACKGROUND: The European Alliance of Associations for Rheumatology recommended that lipid-lowering therapy (LLT) in systemic lupus erythematosus (SLE) should follow general population guidelines. We examined the eligibility for LLT in SLE according to Systematic Coronary Risk Evaluation (SCORE), with and without the addition of vascular ultrasound (VUS) and disease-related features. METHODS: 210 patients with SLE without prior cardiovascular events, diabetes or antiphospholipid syndrome underwent cardiovascular risk assessment with SCORE. LLT eligibility was evaluated in low-risk and moderate-risk patients following European Society of Cardiology (ESC) guidelines. Atherosclerotic plaques on carotid ultrasound (cUS)) and carotid and femoral ultrasound (cfUS), prolonged disease duration (PDD, ≥10 years), failure to achieve lupus low disease activity state (LLDAS(no)), cumulative glucocorticoid ‘cardiovascular harm’ dose (GC(CVH), optimal cut-off to predict ultrasound-detected plaques) and antiphospholipid antibody positivity (aPL(pos)) were tested as SCORE risk enhancers for classification ability (phi coefficient) and agreement (Cohen’s kappa) using SCORE plus cfUS as a reference modality for LLT eligibility. RESULTS: Plaques were detected in 9.9% of low-risk cases and 54.6% of moderate-risk cases. SCORE alone would indicate 0% of low-risk patients and 3% of moderate-risk patients for LLT eligibility. According to SCORE+cfUS, 9.9% of low-risk patients and 57.6% of moderate-risk patients, respectively, would be eligible for LLT based on ESC guidelines. Ιn low-risk/moderate-risk patients, phi values for SCORE+PDD, GC(CVH) (cut-off ≥11 g), LLDAS(no) and aPL(pos) in antiplatelet-naïve antiphospholipid antibody-positive (aPL(pos)/(APT−)) cases were 0.06/0.13, 0.23/0.20, 0.07/0.16 and 0.06/0.33, respectively. Agreement for LLT eligibility to SCORE+cfUS was better for SCORE+PDD in moderate-risk patients and for SCORE+cUS in both groups of patients. SCORE+GC(CVH) and SCORE+aPL(pos) showed at least fair agreement (kappa ≥0.20) to SCORE+cfUS in low-risk or moderate-risk and in aPL(pos)/APT− moderate-risk patients, respectively. CONCLUSION: Disease-related and VUS features, in addition to SCORE, may help to improve LLT decision making in SLE. GC(CVH) and aPL(pos) improve LLT eligibility similarly and to a greater degree than PDD or LLDAS(no).