Background/Purpose: Atherosclerotic vascular events (AVEs) are a major cause of mortality and morbidity in systemic lupus erythematosus (SLE) with a prevalence of 8-12%.   We aimed to determine the changing pattern of AVE occurrence over the decades and to discern the effect of change in management of both classic risk factors for AVE and SLE.

Methods: Inception patients who entered the Lupus Clinic between 1975 and 1987 and followed to 1992 (Cohort 1) and between 1999 and 2011 and followed to 2016 (Cohort 2) were studied. AVEs (MI, angina, congestive heart failure, pace maker insertion, transient ischemic attach, stroke), attributed to atherosclerosis, and occurring during the 17 years, were identified. Lupus disease activity and therapy as well as hypertension, hypercholesterolemia, hyperglycemia and smoking were assessed. Analysis included descriptive statistics on baseline characteristics, traditional risk factors over the follow up, outcome rates by each 100 person years; Kaplan-Meier cumulative AVE curves, as well as competing risk Cox models adjusted by Inverse Probability Weights (IPW).

Results: There were 234 patients in Cohort 1 and 262 in Cohort 2. At enrollment the two cohorts were similar other than a greater number of Caucasians in Cohort 1 and more use of antimalarials and immunosuppressives in Cohort 2.  Cohort 2 patients were more often treated with anti-hypertensives, lipid lowering therapy and smoking cessation and more often used antimalarials and immunosuppressives during the years of follow-up. 28 (12%) of patients in Cohort 1 had an AVE compared with 10 of 262 (3.8%) in Cohort 2. The rate per 100 patient-years of follow-up was 1.9 in Cohort 1 and 0.44 in Cohort 2 (P < 0.0001) (Table). Percent of time with normal risk factors over the 17 year period was better in Cohort 2 (Table). The hazard ratio from IPW weighted model is 0.38 (95%CI: 0.22, 0.66) comparing cohort 2 to Cohort 1,  a reduction of 62% in the risk for AVE in Cohort 2 (p = 0.0007).

Conclusion: The incidence of AVE in SLE in the modern era has declined in large part due to more effective management of classic coronary artery disease risk factors and SLE disease activity and treatment.