A 39-year-old woman comes to the emergency department with substernal chest pressure and palpitations. She was diagnosed with systemic lupus erythematosus 7 years ago and has had renal involvement. The patient was recently discharged from the hospital for an exacerbation of lupus nephritis. Her medications include prednisone and hydroxychloroquine. She does not use tobacco, alcohol, or illicit drugs. Her temperature is 37.2 C (99 F), blood pressure is 150/90 mm Hg, pulse is 128/min, and respirations are 26/min. During her visit to the emergency department, she sustains cardiac arrest with documented ventricular fibrillation and expires despite resuscitative efforts. Which of the following is the most likely cause of her death?

Question

A 39-year-old woman comes to the emergency department with substernal chest pressure and palpitations.  She was diagnosed with systemic lupus erythematosus 7 years ago and has had renal involvement.  The patient was recently discharged from the hospital for an exacerbation of lupus nephritis.  Her medications include prednisone and hydroxychloroquine.  She does not use tobacco, alcohol, or illicit drugs.  Her temperature is 37.2 C (99 F), blood pressure is 150/90 mm Hg, pulse is 128/min, and respirations are 26/min.  During her visit to the emergency department, she sustains cardiac arrest with documented ventricular fibrillation and expires despite resuscitative efforts.  Which of the following is the most likely cause of her death?

Quizplus · Accepted Answer

Explanation: Systemic lupus erythematosus (SLE) is a significant risk factor for the development of premature coronary atherosclerosis and coronary artery disease (CAD). SLE is associated with accelerated atherosclerosis due to a combination of traditional (eg, hypertension, hyperlipidemia) and disease-related risk factors (eg, chronic inflammation, glucocorticoid use). Compared to other women age 35-44, patients with SLE have an almost 50-fold increase in CAD risk. CAD is a significant contributor to premature death in SLE patients. For this reason, the most likely cause of this patient's death is myocardial infarction (with secondary ventricular arrhythmias) due to premature CAD. (Choice A) SLE is not associated with an increased risk of arterial dissection. (Choice B) Pericarditis is a common cardiac complication of SLE. These patients typically exhibit positional substernal chest pain with friction rub on auscultation. It is usually associated with other symptoms of serositis (eg, dyspnea due to pleural effusion). However, large pericardial effusions and/or tamponade are rare in patients with SLE. (Choice D) Coronary vasculitis is a rare complication of SLE and is unlikely to be the cause of myocardial infarction and death. (Choice E) SLE patients are at increased risk for non-Hodgkin lymphoma, especially diffuse large B-cell lymphoma (DLBCL). Patients with DLBCL typically have a rapidly enlarging symptomatic mass (usually in the neck or abdomen) that may cause vascular or airway compromise by compression. However, sudden cardiac arrest is not a known complication of DLBCL. Educational objective: Systemic lupus erythematosus (SLE) is a significant risk factor for the development of premature coronary atherosclerosis and coronary artery disease in young women. Cardiovascular events are the leading cause of mortality in patients with SLE. References: Cardiac involvement in systemic lupus erythematosus. (http://www.ncbi.nlm.nih.gov/pubmed/16218467) Coronary artery disease in systemic lupus erythematosus: A review of the literature. (http://www.ncbi.nlm.nih.gov/pubmed/11404827) Age-specific incidence rates of myocardial infarction and angina in women with systemic lupus erythematosus: comparison with the Framingham Study. (http://www.ncbi.nlm.nih.gov/pubmed/9048514)

A 39-Year-Old Woman Comes to the Emergency Department with Substernal