<p>Sir,</p> <p>Systemic lupus erythematosus (SLE) is a chronic autoimmune disease affecting multiple organs of the body. <sup> <xref ref-type="bibr" rid="ref1">1</xref> </sup>Central nervous system (CNS) involvement has been considered one of the severe complications of SLE, which increases both morbidity and mortality rate in patients with SLE. <sup> <xref ref-type="bibr" rid="ref2">2</xref> </sup>, <sup> <xref ref-type="bibr" rid="ref3">3</xref> </sup>Histopathologic and radiological studies demonstrated various brain abnormalities in patients with SLE, such as micro and macroinfarcts, cortical atrophy, parenchymal hemorrhage and demyelination. <sup> <xref ref-type="bibr" rid="ref1">1</xref> </sup>These cerebral changes may present with headache, seizure, psychosis, cranial neuropathy and cerebrovascular attack (CVA). <sup> <xref ref-type="bibr" rid="ref1">1</xref> </sup></p> <p>CVA is an ominous event in SLE. About 3-20% of patients with SLE may experience an episode of stroke at some point during their course of disease. <sup> <xref ref-type="bibr" rid="ref4">4</xref> </sup>, <sup> <xref ref-type="bibr" rid="ref5">5</xref> </sup>This event may be in the ischemic or hemorrhagic form. Occurrence of stroke in patients with SLE may reflect the influence of different factors such as hypercoagulable state, hypertension, cerebral vasculopathy, atherosclerosis, thrombosis, and emboli of Libman-Sacks endocarditis. <sup> <xref ref-type="bibr" rid="ref3">3</xref> </sup>, <sup> <xref ref-type="bibr" rid="ref6">6</xref> </sup>, <sup> <xref ref-type="bibr" rid="ref7">7</xref> </sup></p> <p>Some studies have implied that common cardiovascular risk factors cannot obviously explain accelerated rate of stroke in patients with SLE. <sup> <xref ref-type="bibr" rid="ref8">8</xref> </sup>However, in our practice, we encounter some factors which may predict or contribute in stroke in patients with SLE. These factors include presence of antiphospholipid antibodies, a history of systemic thrombosis, renal involvement with SLE, and also presence of Framingham cardiovascular risk factors.</p> <p>It has been demonstrated that the risk for stroke in SLE is markedly higher among young patients. <sup> <xref ref-type="bibr" rid="ref6">6</xref> </sup>Moreover, presence of joint diseases, co-existing neuro-psychiatric disorders and the rate of stroke recurrence are the factors which restrain the recovery process and harden the rehabilitation. Therefore, stroke in SLE may hold more extended morbidities and impose great psychological and social burden.</p> <p>Previous studies revealed that stroke in SLE have a significant tendency to occur early in the course of SLE. <sup> <xref ref-type="bibr" rid="ref9">9</xref> </sup>In fact, most cases of stroke in SLE occurred in first 5 years of the disease, particularly during the first year. <sup> <xref ref-type="bibr" rid="ref4">4</xref> </sup>, <sup> <xref ref-type="bibr" rid="ref5">5</xref> </sup>This point puts emphasize on the importance of initiation of stroke prevention at the time of diagnosis of SLE.</p> <p>Stroke prevention in SLE has different aspects. A valuable achievement is eliminating or controlling the risk factors which are contributing to the atherosclerotic process. <sup> <xref ref-type="bibr" rid="ref10">10</xref> </sup>It is suggested to assess the presence of hypertension, hyperlipidemia, obesity, diabetes mellitus and smoking in the first visits of patients with SLE.</p> <p>Since low dose aspirin may reduce the risk of stroke in some patients with SLE, <sup> <xref ref-type="bibr" rid="ref5">5</xref> </sup>it is beneficial to recommend it for all new cases of SLE and patients in high risk groups. Anticoagulants are in the first line of stroke prevention in the patients with a history of systemic thrombosis. Several studies have revealed the effects of anticoagulants in the prevention of both occurrence and recurrence of ischemic stroke in high risk groups. <sup> <xref ref-type="bibr" rid="ref5">5</xref> </sup></p> <p>In conclusion, regarding to the higher risk of various subtypes of stroke in young patients with SLE, stroke prevention should be an early purpose and essential component of therapeutic strategies in patients with SLE.</p> </sec> </body> <back> <ref-list> <ref id="ref1"> <label>1</label> <nlm-citation citation-type="journal"> <person-group person-group-type="author"> <name> <surname>Brey</surname> <given-names>RL</given-names> </name> </person-group> <article-title>Neuropsychiatric lupus: Clinical and imaging aspects</article-title> <source>Bull NYU Hosp Jt Dis</source> <year>2007</year> <volume>65</volume> <fpage>194</fpage> <lpage>9</lpage> </nlm-citation> </ref> <ref id="ref2"> <label>2</label> <nlm-citation citation-type="journal"> <person-group 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<given-names>B</given-names> </name> </person-group> <article-title>Predictors of neuropsychiatric damage in systemic lupus erythematosus: Data from the Maryland lupus cohort</article-title> <source>Rheumatology (Oxford)</source> <year>2004</year> <volume>43</volume> <fpage>1555</fpage> <lpage>60</lpage> </nlm-citation> </ref> <ref id="ref4"> <label>4</label> <nlm-citation citation-type="journal"> <person-group person-group-type="author"> <name> <surname>Krishnan</surname> <given-names>E</given-names> </name> </person-group> <article-title>Stroke subtypes among young patients with systemic lupus erythematosus</article-title> <source>Am J Med</source> <year>2005</year> <volume>118</volume> <fpage>1415</fpage> </nlm-citation> </ref> <ref id="ref5"> <label>5</label> <nlm-citation citation-type="journal"> <person-group person-group-type="author"> <name> <surname>Futrell</surname> <given-names>N</given-names> </name> <name> <surname>Millikan</surname> <given-names>C</given-names> </name> </person-group> <article-title>Frequency, etiology, and prevention of stroke in patients with systemic lupus erythematosus</article-title> <source>Stroke</source> <year>1989</year> <volume>20</volume> <fpage>583</fpage> <lpage>91</lpage> </nlm-citation> </ref> <ref id="ref6"> <label>6</label> <nlm-citation citation-type="journal"> <person-group person-group-type="author"> <name> <surname>Ward</surname> <given-names>MM</given-names> </name> </person-group> <article-title>Premature morbidity from cardiovascular and cerebrovascular diseases in women with systemic lupus erythematosus</article-title> <source>Arthritis Rheum</source> <year>1999</year> <volume>42</volume> <fpage>338</fpage> <lpage>46</lpage> </nlm-citation> </ref> <ref id="ref7"> <label>7</label> <nlm-citation citation-type="journal"> <person-group person-group-type="author"> <name> <surname>Ahmadi</surname> <given-names>B</given-names> </name> <name> <surname>Bonakdar</surname> <given-names>ZS</given-names> </name> <name> 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JRMS

J Res Med Sci

Journal of Research in Medical Sciences

1735-1995 1735-7136

Medknow Publications Pvt Ltd

India

JRMS-17-894

23826023

Letter to Editor

The necessity of stroke prevention in patients with systemic lupus erythematosus

Saadatnia

Mohammad

Sayed-Bonakdar

Zahra

Mohammad-Sharifi

Ghasem

Sarrami

Amir H

Isfahan Neurosciences Research Center, Isfahan University of Medical Sciences,Isfahan, Iran Department of Rheumatology, Isfahan University of Medical Sciences,Isfahan, Iran Isfahan Neurosciences Research Center, Isfahan University of Medical Sciences,Isfahan, Iran Isfahan Neurosciences Research Center, Isfahan University of Medical Sciences,Isfahan, Iran

Address for correspondence:Amir Sarrami, Alzahra Hospital, Isfahan University of Medical Sciences, Soffeh Street, Isfahan, Iran a_sarrami@edc.mui.ac.ir

September 2012

17 9 894 895

2012

This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

<p>Sir,</p> <p>Systemic lupus erythematosus (SLE) is a chronic autoimmune disease affecting multiple organs of the body. <sup> <xref ref-type="bibr" rid="ref1">1</xref> </sup>Central nervous system (CNS) involvement has been considered one of the severe complications of SLE, which increases both morbidity and mortality rate in patients with SLE. <sup> <xref ref-type="bibr" rid="ref2">2</xref> </sup>, <sup> <xref ref-type="bibr" rid="ref3">3</xref> </sup>Histopathologic and radiological studies demonstrated various brain abnormalities in patients with SLE, such as micro and macroinfarcts, cortical atrophy, parenchymal hemorrhage and demyelination. <sup> <xref ref-type="bibr" rid="ref1">1</xref> </sup>These cerebral changes may present with headache, seizure, psychosis, cranial neuropathy and cerebrovascular attack (CVA). <sup> <xref ref-type="bibr" rid="ref1">1</xref> </sup></p> <p>CVA is an ominous event in SLE. About 3-20% of patients with SLE may experience an episode of stroke at some point during their course of disease. <sup> <xref ref-type="bibr" rid="ref4">4</xref> </sup>, <sup> <xref ref-type="bibr" rid="ref5">5</xref> </sup>This event may be in the ischemic or hemorrhagic form. Occurrence of stroke in patients with SLE may reflect the influence of different factors such as hypercoagulable state, hypertension, cerebral vasculopathy, atherosclerosis, thrombosis, and emboli of Libman-Sacks endocarditis. <sup> <xref ref-type="bibr" rid="ref3">3</xref> </sup>, <sup> <xref ref-type="bibr" rid="ref6">6</xref> </sup>, <sup> <xref ref-type="bibr" rid="ref7">7</xref> </sup></p> <p>Some studies have implied that common cardiovascular risk factors cannot obviously explain accelerated rate of stroke in patients with SLE. <sup> <xref ref-type="bibr" rid="ref8">8</xref> </sup>However, in our practice, we encounter some factors which may predict or contribute in stroke in patients with SLE. These factors include presence of antiphospholipid antibodies, a history of systemic thrombosis, renal involvement with SLE, and also presence of Framingham cardiovascular risk factors.</p> <p>It has been demonstrated that the risk for stroke in SLE is markedly higher among young patients. <sup> <xref ref-type="bibr" rid="ref6">6</xref> </sup>Moreover, presence of joint diseases, co-existing neuro-psychiatric disorders and the rate of stroke recurrence are the factors which restrain the recovery process and harden the rehabilitation. Therefore, stroke in SLE may hold more extended morbidities and impose great psychological and social burden.</p> <p>Previous studies revealed that stroke in SLE have a significant tendency to occur early in the course of SLE. <sup> <xref ref-type="bibr" rid="ref9">9</xref> </sup>In fact, most cases of stroke in SLE occurred in first 5 years of the disease, particularly during the first year. <sup> <xref ref-type="bibr" rid="ref4">4</xref> </sup>, <sup> <xref ref-type="bibr" rid="ref5">5</xref> </sup>This point puts emphasize on the importance of initiation of stroke prevention at the time of diagnosis of SLE.</p> <p>Stroke prevention in SLE has different aspects. A valuable achievement is eliminating or controlling the risk factors which are contributing to the atherosclerotic process. <sup> <xref ref-type="bibr" rid="ref10">10</xref> </sup>It is suggested to assess the presence of hypertension, hyperlipidemia, obesity, diabetes mellitus and smoking in the first visits of patients with SLE.</p> <p>Since low dose aspirin may reduce the risk of stroke in some patients with SLE, <sup> <xref ref-type="bibr" rid="ref5">5</xref> </sup>it is beneficial to recommend it for all new cases of SLE and patients in high risk groups. Anticoagulants are in the first line of stroke prevention in the patients with a history of systemic thrombosis. Several studies have revealed the effects of anticoagulants in the prevention of both occurrence and recurrence of ischemic stroke in high risk groups. <sup> <xref ref-type="bibr" rid="ref5">5</xref> </sup></p> <p>In conclusion, regarding to the higher risk of various subtypes of stroke in young patients with SLE, stroke prevention should be an early purpose and essential component of therapeutic strategies in patients with SLE.</p> </sec> </body> <back> <ref-list> <ref id="ref1"> <label>1</label> <nlm-citation citation-type="journal"> <person-group person-group-type="author"> <name> <surname>Brey</surname> <given-names>RL</given-names> </name> </person-group> <article-title>Neuropsychiatric lupus: Clinical and imaging aspects</article-title> <source>Bull NYU Hosp Jt Dis</source> <year>2007</year> <volume>65</volume> <fpage>194</fpage> <lpage>9</lpage> </nlm-citation> </ref> <ref id="ref2"> <label>2</label> <nlm-citation citation-type="journal"> <person-group person-group-type="author"> <name> <surname>Ainiala</surname> <given-names>H</given-names> </name> <name> <surname>Dastidar</surname> <given-names>P</given-names> </name> <name> <surname>Loukkola</surname> <given-names>J</given-names> </name> <name> <surname>Lehtimäki</surname> <given-names>T</given-names> </name> <name> <surname>Korpela</surname> <given-names>M</given-names> </name> <name> <surname>Peltola</surname> <given-names>J</given-names> </name> <etal /> </person-group> <article-title>Cerebral MRI abnormalities and their association with neuropsychiatric manifestations in SLE: A population-based study</article-title> <source>Scand J Rheumatol</source> <year>2005</year> <volume>34</volume> <fpage>376</fpage> <lpage>82</lpage> </nlm-citation> </ref> <ref id="ref3"> <label>3</label> <nlm-citation citation-type="journal"> <person-group person-group-type="author"> <name> <surname>Mikdashi</surname> <given-names>J</given-names> </name> <name> <surname>Handwerger</surname> <given-names>B</given-names> </name> </person-group> <article-title>Predictors of neuropsychiatric damage in systemic lupus erythematosus: Data from the Maryland lupus cohort</article-title> <source>Rheumatology (Oxford)</source> <year>2004</year> <volume>43</volume> <fpage>1555</fpage> <lpage>60</lpage> </nlm-citation> </ref> <ref id="ref4"> <label>4</label> <nlm-citation citation-type="journal"> <person-group person-group-type="author"> <name> <surname>Krishnan</surname> <given-names>E</given-names> </name> </person-group> <article-title>Stroke subtypes among young patients with systemic lupus erythematosus</article-title> <source>Am J Med</source> <year>2005</year> <volume>118</volume> <fpage>1415</fpage> </nlm-citation> </ref> <ref id="ref5"> <label>5</label> <nlm-citation citation-type="journal"> <person-group person-group-type="author"> <name> <surname>Futrell</surname> <given-names>N</given-names> </name> <name> <surname>Millikan</surname> <given-names>C</given-names> </name> </person-group> <article-title>Frequency, etiology, and prevention of stroke in patients with systemic lupus erythematosus</article-title> <source>Stroke</source> <year>1989</year> <volume>20</volume> <fpage>583</fpage> <lpage>91</lpage> </nlm-citation> </ref> <ref id="ref6"> <label>6</label> <nlm-citation citation-type="journal"> <person-group person-group-type="author"> <name> <surname>Ward</surname> <given-names>MM</given-names> </name> </person-group> <article-title>Premature morbidity from cardiovascular and cerebrovascular diseases in women with systemic lupus erythematosus</article-title> <source>Arthritis Rheum</source> <year>1999</year> <volume>42</volume> <fpage>338</fpage> <lpage>46</lpage> </nlm-citation> </ref> <ref id="ref7"> <label>7</label> <nlm-citation citation-type="journal"> <person-group person-group-type="author"> <name> <surname>Ahmadi</surname> <given-names>B</given-names> </name> <name> <surname>Bonakdar</surname> <given-names>ZS</given-names> </name> <name> <surname>Hashemi</surname> <given-names>SM</given-names> </name> <name> <surname>Sadrkabir</surname> <given-names>SM</given-names> </name> <name> <surname>Karimifar</surname> <given-names>M</given-names> </name> </person-group> <article-title>Endothelial dysfunction in Iranian lupus patients</article-title> <source>Rheumatol Int</source> <year>2011</year> <volume>31</volume> <fpage>27</fpage> <lpage>31</lpage> </nlm-citation> </ref> <ref id="ref8"> <label>8</label> <nlm-citation citation-type="journal"> <person-group person-group-type="author"> <name> <surname>EsdaileJM</surname> <given-names></given-names> </name> <name> <surname>AbrahamowiczM</surname> <given-names></given-names> </name> <name> <surname>GrodzickyT</surname> <given-names></given-names> </name> <name> <surname>Li</surname> <given-names>Y</given-names> </name> <name> <surname>Panaritis</surname> <given-names>C</given-names> </name> <name> <surname>du Berger</surname> <given-names>R</given-names> </name> <etal /> </person-group> <article-title>Traditional Framingham risk factors fail to fully account for accelerated atherosclerosis in systemic lupus erythematosus</article-title> <source>Arthritis Rheum</source> <year>2001</year> <volume>44</volume> <fpage>2331</fpage> <lpage>7</lpage> </nlm-citation> </ref> <ref id="ref9"> <label>9</label> <nlm-citation citation-type="journal"> <person-group person-group-type="author"> <name> <surname>Bessant</surname> <given-names>R</given-names> </name> <name> <surname>Hingorani</surname> <given-names>A</given-names> </name> <name> <surname>Patel</surname> <given-names>P</given-names> </name> <name> <surname>MacGregor</surname> <given-names>A</given-names> </name> <name> <surname>Isenberg</surname> <given-names>DA</given-names> </name> <name> <surname>Rahman</surname> <given-names>A</given-names> </name> </person-group> <article-title>Risk of coronary heart disease and stroke in a large British cohort of patients with systemic lupus erythematosus</article-title> <source>Rheumatology (Oxford)</source> <year>2004</year> <volume>43</volume> <fpage>924</fpage> <lpage>9</lpage> </nlm-citation> </ref> <ref id="ref10"> <label>10</label> <nlm-citation citation-type="journal"> <person-group person-group-type="author"> <name> <surname>AkimotoT</surname> <given-names></given-names> </name> <name> <surname>KobayashiS</surname> <given-names></given-names> </name> <name> <surname>TamuraN</surname> <given-names></given-names> </name> <name> <surname>Ohsawa</surname> <given-names>T</given-names> </name> <name> <surname>Kawano</surname> <given-names>T</given-names> </name> <name> <surname>Tanaka</surname> <given-names>M</given-names> </name> <etal /> </person-group> <article-title>Risk factors for recurrent thrombosis: Prospective study of a cohort of Japanese systemic lupus erythematosus</article-title> <source>Angiology ;;-</source> <year>9</year> <volume></volume> <fpage></fpage> <comment>Risk factors for recurrent thrombosis: Prospective study of a cohort of Japanese systemic lupus erythematosus Angiology 2005;56;601-9</comment> </nlm-citation> </ref> <ref id="ref11"> <label>11</label> <nlm-citation citation-type="journal"> <person-group person-group-type="author"></person-group> <article-title></article-title> <source></source> <year></year> <volume></volume> <fpage></fpage> </nlm-citation> </ref> </ref-list> </back> </article>