APS Program Community Q&A Series
Antiphospholipid syndrome (APS) is a chronic autoimmune disease that can impact many different parts of the body, including the heart and how well it functions. In this edition of the APS Program Community Q&A Series, Dr. Yu (Ray) Zuo discusses how APS can affect the heart and what you can do to keep your heart healthy.
There are several ways that APS can affect heart health. The two most common complications are coronary artery disease and heart valve damage.
Coronary artery disease (CAD)
Excessive inflammation and the presence of antiphospholipid antibodies (aPL) can damage the blood vessels and cause a build-up of bad cholesterol in them. CAD happens when this built-up cholesterol decreases blood flow in the arteries that supply blood to the heart muscle. When blood flow to the heart is completely blocked, the result is a heart attack.
Heart valve damage
Our heart has four chambers, along with four valves that regulate blood flow between them. Excessive inflammation and aPL can cause patients with APS to develop thickened heart valves, which makes the valves stiffer, potentially narrowing the passageways between the chambers. Sometimes, the irregular flow of blood through damaged valves can be heard with a stethoscope as a “heart murmur”. When a valve is damaged, the heart may have to work harder to pump blood, leading to it wearing out over time. And, in some patients with APS, the valves don’t just thicken, but also develop wart-like growths on their surfaces. This condition is called endocarditis, which is a significant risk factor for infection and stroke.
Studies of heart disease in APS patients
Heart disease remains the number one killer in the U.S., and heart problems are not uncommon among APS patients. One study of 1,000 APS patients from Europe reported that 5.5% of patients developed a heart attack, accounting for 19% of deaths in this cohort (1). Heart valve disease can be detected in 10% to 60% of APS patients, with the significant variation between studies likely due to the various imaging techniques used for assessing heart valve damage. The risk of heart valve problems may be especially high in APS patients who also have lupus. A small percentage of people with APS-associated heart valve problems (roughly 5%) may go on to develop heart failure that requires valve surgery (2).
Although studies are ongoing (including by our group), there are probably several reasons that APS patients are more likely to develop heart problems:
- Inflammation: This accelerates cholesterol build-up in the arteries, slowly narrowing blood vessels and blocking blood flow to the heart. Inflammation can also thicken and promote scarring of the heart valves.
- Damage from aPL: Circulating aPL can damage and inflame blood vessels and make the blood more likely to clot inappropriately. The antibodies can also inflame heart valve tissue and promote scarring and thickening.
- High blood pressure and/or high cholesterol: Some APS patients have high blood pressure, which forces the heart to work harder, contributing to the hardening of the vessels and increasing the risk of a heart attack. Some APS patients also have too much bad cholesterol called LDL, which can clog arteries. Meanwhile, the good cholesterol in the body, called HDL, may not always act as it should. For example, a recent study from our group showed that people with some types of aPL have “dysfunctional” HDL, which actually causes more inflammation and further contributes to the buildup of cholesterol in the vessels, thereby increasing the future risk of CAD among those individuals (3).
While heart disease can cause problems for some people with APS, the good news is that there are lots of things you can do to help keep your heart healthy:
- Quit smoking if you do smoke.
- Eat a healthy diet.
- Get regular exercise.
- Manage your stress.
- Take your medications.
- Keep your blood pressure and cholesterol under control.
- Ask your doctor whether you will need extra testing, such as an ultrasound of your heart.
In summary, APS can have a wide range of manifestations, and the involvement of the heart is not uncommon. If you have APS, your heart health deserves special attention. While you can’t change the fact that you have APS, there are several heart disease risk factors that you can control. Take an active part in controlling those risk factors - your heart will thank you!
- R. Cervera et al., Morbidity and mortality in the antiphospholipid syndrome during a 10-year period: a multicentre prospective study of 1000 patients. Ann Rheum Dis 74, 1011-1018 (2015).
- T. Kolitz, S. Shiber, I. Sharabi, A. Winder, G. Zandman-Goddard, Cardiac Manifestations of Antiphospholipid Syndrome With Focus on Its Primary Form. Front Immunol 10, 941 (2019).
- Y. Zuo et al., Prevalence of Antiphospholipid Antibodies and Association With Incident Cardiovascular Events. JAMA Netw Open 6, e236530 (2023).
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