Background/Purpose

Central nervous system involvement is common in Systemic Lupus Erythematosus (SLE) and was first described in 1873.  Though ischemic involvement is more common than Intra-Cerebral Hemorrhage (ICH) in SLE, hemorrhagic involvement is more life threatening and disabling. Several studies have shown that SLE patients with ICH present with higher frequency of Anti-Phospho-Lipid-Antibody (aPL) syndrome.  In our study we tried to investigate if SLE or aPL syndrome independently predicts risk of ICH in CVA.

Methods

We queried the Healthcare Cost and Utilization Project’s (HCUP) Nationwide Inpatient Sample (NIS) between 2004 and 2010 and separated the hospitalizations due to or with stroke using ICD 9 diagnostic codes previously established by HCUP. Among this population, we examined the patients with SLE and patients with aPL syndrome and compared their risk of ICH to the all stroke population using the logistic regression model. The model was controlled for confounders which included age, sex, atrial fibrillation, chronic kidney disease, diabetes mellitus, rheumatoid arthritis, chronic rheumatic heart disease and diseases of endocardium. Using SAS 9.2, survey procedures were used to identify multivariate predictors of stroke.

Results

A total of 1,799,560 (weighted N= 8,874,475) who were hospitalized with stroke were available for analysis out of which 6,890 (weighted N= 33,882) had SLE and 13,769 (weighted N=68,069) had aPL syndrome. On univariate analysis, among patients with SLE 1.41% developed ICH as compared to 1.29% in patients without SLE (p = 0.06); and among patients with aPL syndrome 3.5% developed ICH as compared to 1.28% in patients without aPL syndrome (p<0.001). After controlling for confounders mentioned above, co-morbid SLE was associated with decreased risk of having ICH (Odds Ratio (OR)= 0.68, Confidence Interval (CI)=0.53-0.89, p < 0.0039) in patients with stroke. Whereas, co-morbid aPL was associated with increased risk of having ICH (OR= 1.93, CI=1.72-2.17, p<0.0001), in patients with stroke.

Table 1: Multivariable predictors of ICH in the study population for stroke (N= 1,799,560)

Variables	Model
	OR with 95% CI	P value
Age	0.984 (0.982-0.985)	<0.0001
Female Gender	1.039 (1.001-1.079)	0.0434
Race(African American vs Caucasian)	1.154 (1.083-1.229)	<0.0001
CCI	1.097 (1.081-1.113)	<0.0001
Systemic Lupus Erythematosus	0.683 (0.528-0.885)	0.0039
Antiphosholipidantibody syndrome	1.932 (1.716-2.176)	<0.0001
Chronic Kidney Disease	0.909 (0.864-0.955)	0.0002
Atrial fibrillation	1.583 (1.512-1.658)	<0.0001
Diseases of endocardium	0.706 (0.658-0.757)	<0.0001
Rheumatic heart disease	0.857 (0.774-0.948)	0.0028
Rheumatoid Arthritis	0.778 (0.679-0.891)	0.0003
Scleroderma	0.744 (0.428-1.294)	0.2951
Diabetes Mellitus	0.631 (0.606-0.656)	<0.0001
Teaching Hospital Status	2.252 (2.024-2.507)	<0.0001

^*CCI = Charlson Co-morbidity Index.

Conclusion

In addition to the understanding of increased risk of CVA in SLE and aPL Syndrome patients, further understanding of the nature of the cerebrovascular disease can influence treatment strategies. Our study showed that SLE patients are at decreased risk of hemorrhagic stroke in comparison to general stroke population. However, aPL Syndrome patients are at increased risk of hemorrhagic stroke in comparison to general stroke population. This suggests that aPL component of the disease spectrum predisposes the patients to ICH.

---

« Back to 2014 ACR/ARHP Annual Meeting

ACR Meeting Abstracts - https://acrabstracts.org/abstract/risk-of-intra-cranial-hemorrhage-among-patients-with-anti-phospho-lipid-antibody-apl-syndrome-vs-systemic-lupus-erythematosus-sle-in-stroke-population-a-nationwide-analysis/