Lupus, Atrial Fibrillation (AFib) and Hydroxychloroquine

Did you know, that approximately half of individuals with lupus develop heart complications, which include rhythm disorders such as atrial fibrillation?  Learning more about the association between atrial fibrillation, lupus and how hydroxychloroquine may prove to be a valuable tool in symptom management.

 


Introduction

It can be frightening to experience any heart-related symptoms – a racing, pounding heart that feels like it is doing flip-flops in the chest is no exception. Though sometimes benign and fleeting, these signs can often linger and be symptomatic of a condition called atrial fibrillation (AFib) that requires immediate treatment. Individuals with SLE have an eight-times greater risk for stroke than the general population, making early diagnosis and treatment of AFIb imperative.

AFib occurs when the upper chambers of the heart (atria) beat irregularly and out of rhythm with the lower chambers of the heart (ventricles) instead of beating as one syncopated unit. AFib can actually feel like the heart is quivering as the atria continue to try to push blood into the ventricles. Blood may begin to pool in the atria as it sits, unable to move into the lower chambers of the heart, which can lead to the formation of blood clots (thrombosis). If a blood clot (thrombus) breaks free (emboli), it can travel through the blood stream and obstruct an artery (embolism), which can eventually cause stroke.

There are many reliable and effective treatments for AFib including medications for hypertension and blood thinners. Researchers have also found that the antimalarial drug, hydroxychloroquine, may help reduce the risk of developing AFib for individuals with lupus, many of who already take this drug for the management of their lupus symptoms.

Learning about the warning signs of AFib and how to effectively treat and manage this serious condition – including the possibilities of medications such as hydroxychloroquine – can play an important role in your healthcare.



Symptoms, Causes and Risk Factors for Atrial Fibrillation

Symptoms:  The symptoms of AFib may be somewhat unique to each individual, but typically include:

  • heart palpitations and irregular heartbeat;
  • fatigue and weakness;
  • dizziness and lightheadedness;
  • shortness of breath; and
  • chest pain.

If you experience any of these symptoms it is imperative to seek the advice of your healthcare practitioner immediately or call 911! 

Causes:  There are many underlying conditions that may cause AFib:

  • congenital heart defects;
  • abnormal heart valves;
  • high blood pressure;
  • heart attack;
  • coronary artery disease;
  • overactive thyroid gland;
  • metabolic imbalances;
  • exposure to caffeine, alcohol and tobacco;
  • adverse reactions to certain medications;
  • sick sinus syndrome when the heart’s natural pacemaker malfunctions;
  • lung disease;
  • previous heart surgery;
  • viral infection;
  • stress due to illness or surgery; and
  • sleep disturbances such as sleep apnea.

For some, there is no known cause that attributes to the development of AFib, and this condition is therefore called lone AFib.

Risks Factors:  The risk factors for AFib include:

  • family history of AFib;
  • older age;
  • heart disease or heart failure;
  • high blood pressure;
  • drinking alcohol;
  • smoking;
  • obesity;
  • other chronic health conditions such as kidney disease, liver disease, diabetes, sleep apnea or lung disease.
  • chronic obstructive pulmonary disease (COPD);
  • obstructive sleep apnea;
  • cerebrovascular accident; and
  • transient ischemic attack.

In a study published in 2019, researchers found that individuals with SLE are at a much greater risk of developing AFib and at a much younger age (less than 40 years) than the general population.  Men with SLE, specifically, may be at higher risk for developing AFib than women, especially men of African descent in their mid-to-late 30s.

Risk factors of AFib for individuals with lupus include:

  • Inflammation: Inflammation plays a key role in the development of heart conditions in individuals with lupus. Pericarditis alone is the most common cardiac manifestation of lupus and can affect up to 40% of individuals with SLE. Conditions such as pericarditis and myocarditis can also leave a person with SLE vulnerable to other conditions such as AFIb.
  • Hypertension: High blood pressure and can also lead to AFib. Approximately 50% of individuals with lupus chronically experience blood pressure higher than 140/90.
  • Coronary artery disease: Women with lupus between the ages of 35 to 44 years have more than a 50 times greater risk of developing coronary artery disease. Coronary artery disease in lupus is not typically associated with the typical risk factors including smoking and high cholesterol levels, but instead inflammation.
  • Anti-inflammatory drug therapy including corticosteroids and NSAIDs: Long-term use of both corticosteroids and over-the-counter drugs such as ibuprofen and naproxen have been shown to increase the risk of AFib. A 2010 study found that individuals taking anti-inflammatory medications were at a 44% greater risk of developing chronic AFib.

It is imperative that healthcare practitioners closely monitor the heart and cardiovascular health of individuals with lupus as well as check for any drug or treatment contraindications.


Diagnosing and Treating Atrial Fibrillation

A healthcare practitioner can diagnose and treat AFib.  A cardiologist specializes in treating the heart.  Diagnosing AFib may include:

  • a physical exam where a healthcare practitioner will also review any current medications;
  • an electrocardiogram (ECG) test that records electrical signals in the heart;
  • a Holter heart monitor evaluation that records heart activity for a period of 24 hours to several days (some are about the size of a watch);
  • an event recorder or portable ECG device that works much like a Holter heart monitor;
  • an echocardiogram that uses sound waves to create a picture of the functioning heart;
  • blood tests that look for underlying problems like thyroid conditions or substances in the blood that can lead to AFib;
  • stress tests that evaluate the heart after exercise; and
  • chest X-rays that look at both the lungs and the heart to try to diagnose symptoms.

When treating AFib, the heart rhythm will need to be reset and regulated and blood clotting will need to be prevented.  Treatments, depending on the severity of AFib, may include:

  • Electrical cardioversion: Under sedation, an electric shock is delivered through the heart which interrupts and stops heart activity for a moment, allowing it to reset properly.
  • Anti-arrhythmic drugs: These drugs may be taking orally or administered through an IV which will help restore normal sinus rhythm and include: dofetilide, flecainide, propafenone, amiodarone and sotalol.
  • Anticoagulants: This drug class includes warfarin, dabigatran, rivaroxaban, apixaban (brand name Eliquis) and edoxaban. They prevent blood from excessive clotting.
  • Beta blockers: This class of drug can lower blood pressure and slow the heart rate during activity and at rest.
  • Digoxin: Digoxin can lower resting heart rate, but not when an individual is active.
  • Calcium channel blockers: Work similarly to beta blockers, but cannot be given to an individual with low blood pressure or heart failure.

If the above treatments fail to work, other, more invasive treatments may be used.

 


Hydroxychloroquine and Atrial Fibrillation

Recent studies have looked at the relationship between the antimalarial drug hydroxychloroquine (Plaquenil) and AFib in individuals with connective tissue diseases such as lupus and rheumatoid arthritis (RA). The results are somewhat mixed.

Over the course of 3 years, researchers studied 1646 individuals with lupus, 934 of which were taking hydroxychloroquine to manage lupus symptoms and 754 who were not. The researchers concluded that the individuals who regularly took the antimalarial drug had a “67% reduced risk of incident AFib” as compared to the group who were not prescribed hydroxychloroquine. Researchers speculate that one reason may be that hydroxychloroquine is a close relation to the quinidine, which is an anti-arrhythmic drug.

Conversely, the same team also studied the association of hydroxychloroquine and AFib in individuals with RA. In this study, the researchers followed individuals with RA for the same period of time (three years) as the SLE cohort. Out of 5,697 individuals with RA, 1,304 were taking hydroxychloroquine to manage their RA symptoms. Contrary to the results of the lupus study, the individuals with RA who took hydroxychloroquine has a 2 times greater risk of developing AFib.

The researchers of both studies agree that broader research needs to be conducted in order to conclusively determine the relationship between the antimalarial drug hydroxychloroquine and AFib in individuals with lupus, RA and possibly other connective tissue and/or autoimmune diseases.

Hydroxychloroquine comes with its own inherent risks as well as benefits. Individuals with lupus or any autoimmune disease should always speak with a healthcare practitioner about the pros and cons of starting any drug therapy to make sure the benefits outweigh the risks.

 


Managing Atrial Fibrillation

There are several things individuals with AFib can do to manage their symptoms, many of which they may already be doing in order to prevent lupus flares and manage chronic disease.

  • Eat heart-healthy foods: Eating a healthy, well-balanced diet can help to lower cholesterol and reduce the risk for heart disease.
  • Exercise: Even gentle exercise like practicing yoga, Tai chi or gentle stretches can help keep the body (and mind) healthy. If an individual is able to be more active, gentle cardiovascular exercises like walking or swimming can also be great options to get the body moving.
  • Achieve and maintain a healthy weight: Obesity is connected to diseases like diabetes, hypertension and cardiovascular disease. Maintaining and achieving a healthy weight can lower these risks.
  • Quit smoking: Smoking poses many serious and sometimes irreversible health risks. There are many smoking cessation programs out there these days that can help individuals quit smoking for good if they are finding it difficult to do so on their own.
  • Moderate or avoid alcohol: Alcohol can stimulate heart rate as well as cause other health issues such as liver damage. Drink alcohol in moderation.
  • Moderate caffeine intake: Caffeine can stimulate heart rate as well as increase blood pressure. It can also sometimes interfere with medications and cause difficulties with sleep.
  • Manage stress: Stress can cause blood pressure to spike, which in turn increases the risk of cardiovascular disease. Seeking mental health therapy and/or learning relaxation techniques can help to decrease feelings of tension, anxiety, depression and even anger.
  • Follow prescribed treatment plans: Stick to the plans a healthcare practitioner prescribes for you. If new symptoms arise, immediately reach out to a practitioner to discuss options.

 


In Conclusion

While AFib is not curable, it is treatable. Understanding what AFib is, what exacerbates it and how to properly treat it can help take away some of the fear that surrounds it. Remembering to stick to treatment plans and maintaining healthy habits can not only bring symptom relief, but can also give an individual a sense of control over their own healthcare journey.

 

References

Atrial fibrillation. (2019). Mayo Clinic. Retrieved July 21, 2020 from https://www.mayoclinic.org/diseases-conditions/atrial-fibrillation/symptoms-causes/syc-20350624#:~:text=faster%20than%20normal.-,Atrial%20fibrillation%20is%20an%20irregular%20and%20often%20rapid%20heart%20rate,to%20175%20beats%20a%20minute.

Barnado, A., Carroll, R., Casey, C., Wheless, L., Denny, J., & Crofford, L. (2018). Phenome-wide association studies uncover a novel association of increase atrial fibrillation in male patients with systemic lupus erythematosus. Arthritis Care & Research, 70(11), 1630-1636. doi: 10.1002/acr.23552. Retrieved July 21, 2020 from https://onlinelibrary.wiley.com/doi/epdf/10.1002/acr.23553

Caterina, R., Ruigomez, A., & Rodriguez, L. (2010). Long-term use of anti-inflammatory drugs and risk of atrial fibrillation. Archives of Internal Medicine, 170(16), 1450-1455. doi: 10.1001/archinternmed.2010.305. Retrieved July 21, 2020 from https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/225928

Gupta, A., Joshi, A., Chester-Wasko, M., & Sharma, T. (2018). Association of hydroxychloroquine use and incident atrial fibrillation in systemic lupus erythematosus: A retrospective study [abstract]. Arthritis & Rheumatology. Retrieved July 21, 2020 from https://acrabstracts.org/abstract/association-of-hydroxychloroquine-use-and-incident-atrial-fibrillation-in-systemic-lupus-erythematosus-a-retrospective-study/

Gupta, A., Joshi, A., Saleem, O., Chester-Wasko, M., & Sharma, T. (2018). Association of hydroxychloroquine use and incident atrial fibrillation in rheumatoid arthritis: A retrospective study [abstract]. Arthritis & Rheumatology. Retrieved July 21, 2020 from https://acrabstracts.org/abstract/association-of-hydroxychloroquine-use-and-incident-atrial-fibrillation-in-rheumatoid-arthritis-a-retrospective-study/

How does lupus affect the cardiovascular system. (2020). Johns Hopkins Lupus Center. Retrieved July 21, 2020 from

https://www.hopkinslupus.org/lupus-info/lupus-affects-body/lupus-cardiovascular-system/#:~:text=Fifty%20percent%20of%20people%20with,normal%20120%2F80%20mmHg%20limit.

Soybilgic, A., Clop, G., Midon, F., Zuily, S., & Erkan, D. (2019). Top 10 series: Lupus and heart conditions. Hospital for Special Surgery. Retrieved July 21, 2020 from https://www.hss.edu/conditions_top-ten-series-lupus-heart-conditions.asp#4

Structure of the heart. (n.d.). National Cancer Institute. Retrieved July 21, 2020 from https://training.seer.cancer.gov/anatomy/cardiovascular/heart/structure.html

Yim, S. (2019). 42 systemic lupus erythematosus is a risk factor for atrial fibrillation: A nation-wide population-based study [abstract}. Lupus Science & Medicine. doi: 10.1136/lupus-2019/Ism.42. Retrieved July 21, 2020 from https://lupus.bmj.com/content/6/Suppl_1/A31

 

Author: Liz Heintz

Liz Heintz is a medical research writer who received her BA in Communications, Advocacy, and Relational Communications from Marylhurst University in Lake Oswego, Oregon. She most recently worked for several years in the healthcare industry. A native of San Francisco, California, Liz now calls the beautiful Pacific Northwest home.

All images unless otherwise noted are property of and were created by Kaleidoscope Fighting Lupus. To use one of these images, please contact us at [email protected] for written permission; image credit and link-back must be given to Kaleidoscope Fighting Lupus.

All resources provided by us are for informational purposes only and should be used as a guide or for supplemental information, not to replace the advice of a medical professional. The personal views expressed here do not necessarily encompass the views of the organization, but the information has been vetted as a relevant resource. We encourage you to be your strongest advocate and always contact your healthcare practitioner with any specific questions or concerns.