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Even low doses of steroids tied to higher heart-disease risk

PLoS Medicine
Reuters Health - 03/12/2020  -Even low doses of steroids are associated with a higher risk of cardiovascular disease (CVD), according to a large observational study from the U.K.

"The findings of our study highlight the importance of treating patients with the minimal effective dose of steroids for the shortest duration of time, while appropriately, promptly and regularly monitoring cardiovascular risk," Dr. Mar Pujades-Rodriguez of the University of Leeds told Reuters Health by email.

"Implementing and evaluating targeted intensive cardiovascular-risk-factor-modification interventions, beyond diagnosis of inflammatory arthropathies and systemic lupus erythematosus, even when prescribing low glucocorticoid doses, is essential," she added.

To quantify glucocorticoid dose-dependent CV risk, the researchers analyzed the medical records of more than 87,000 adults with common immune-mediated inflammatory diseases and no prior CVD. Their mean age was 56 years and 34% were men.

During a median follow up of five years, 15% people developed CVD events, including atrial fibrillation, heart failure and acute myocardial infarction.

After one year, the cumulative risk of a CVD event was 1% in periods of no steroid use, 4% with a daily prednisolone-equivalent dose (PED) of up to 4.9 mg and 9% for a PED of 25.0 mg or higher.

After five years, the CVD risk was 7% with non-use, 20% with daily PED up to 4.9 mg and 28% for daily PED at or above 25.0 mg, the researchers report in PLoS Medicine.

There were significant dose-response estimates for current daily doses of <5.0 mg for all immune-mediated diseases (hazard ratio, 1.74) across all CV outcomes, including atrial fibrillation, heart failure, acute myocardial infarction, peripheral arterial disease, cerebrovascular disease and abdominal aortic aneurysm.

The researchers note that modifiable CV risk factors were common in the population studied and included current smoking, overweight/obesity and hypertension.

"Patients with immune-mediated inflammatory diseases often receive courses of oral steroids to reduce disease activity and inflammation during the initial episode and subsequent episodic flares," Dr. Pujades-Rodriguez said.

"For some conditions, low-dose steroids may be needed for many months or years. Theoretically, by reducing this chronic inflammation one might expect glucocorticoids to reduce inflammation in the vascular wall and heart. However, glucocorticoids have many other direct and indirect effects on the cardiovascular system, which could plausibly be detrimental. Our data cannot define these processes, but highlight the need to address this important question with further research," she added.

She stressed that glucocorticoids should not be stopped suddenly "since this may lead to life-threatening complications or flares in the underlying inflammatory disease. Changes in treatment need to be undertaken in discussion with the patient's treating clinician."

SOURCE: https://bit.ly/2Ib9Krq PLoS Medicine, online December 3, 2020.

By Megan Brooks

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