LAUSR

Abstract For patients with lupus erythematosus (LE) or dermatomyositis (DM), there is an urgent need to address their heightened risk of clinical events, chiefly heart attacks and strokes, caused by atherosclerotic cardiovascular disease (ASCVD). Patients with LE or DM frequently exhibit high levels of conventional risk factors for ASCVD events, particularly dyslipoproteinemia and hypertension, an amplified burden of atherosclerotic plaques, and increased age- and sex-adjusted rates of ASCVD events compared with the general population. The rate of ASCVD events exceeds what would be expected from conventional risk factors, suggesting that disease-specific autoimmune processes exacerbate specific, known pathogenic steps in atherosclerosis. Importantly, despite their heightened risk, LE and DM patients are often under-treated for known causal agents and exacerbators of ASCVD. Here, we propose an approach to assess and manage the heightened risk of ASCVD events in LE and DM patients. Our approach is modeled in large part on established approaches to patients with diabetes mellitus or stage 3 or 4 chronic kidney disease, which are well-studied conditions that also show heightened risk for ASCVD events and have been explicitly incorporated into standard clinical guidelines for ASCVD. Based on the available evidence, we conclude that patients with LE and DM require earlier and more aggressive screening and management of ASCVD. We suggest that physicians should consider implementing multipliers of conventional risk calculators to trigger earlier initiation of lifestyle modifications and medical therapies in primary prevention of ASCVD events, employ vascular imaging to quantify the burden of subclinical plaques, and treat to lower lipid targets using statins as well as newer therapies such as PCSK9 inhibitors that decrease ASCVD events in non-autoimmune cohorts. More clinical vigilance is needed regarding surveillance, prevention, risk modification, and treatment of dyslipidemias, hypertension, and smoking in patients with LE and DM. All of these goals are achievable.