| BackgroundRheumatoid arthritis(RA)is a chronic systemic autoimmune disease which may affect many organs and tissues,with 1%global morbidity in adults.Among them,patients combined with cardiovascular disease(CVD)show up higher morbidity and mortality than patients without CVD.At present CVD is a significant cause to the death of RA patients.Studies indicate that Disease Modifying anti-Rheumatoid Drugs(DMARDs)reduce the morbidity and mortality of CVD while improving disease activity of RA.Meanwhile,compared to methotrexate,new anti-rheumatoid drugs such as IL-6 related monoclonal antibodies have not been proved protective or harmful to cardiovascular system.That is to say,there is no unified consensus about whether monoclonal antibody could decrease the risk of major adverse cardiovascular events(MACE)or not.PurposeA meta-analysis is performed to analyze the correlation of the application of IL-6 related monoclonal antibodies in rheumatoid arthritis with the risk of MACE(including cardiovascular mortality,non-fatal myocardial infraction and non-fatal stroke)by retrospecting relevant literature,aiming to evaluate the safety of IL-6 monoclonal antibodies about cardiovascular events and compare the differences between Tocilizumab,Sarilumab and Sirukumab.MethodsPubMed,Ovid,Cochrane Library databases and Cochrane Controlled Trials Register System was searched for relevant randomized controlled trials(RCTs)before October 1,2019.The data extracted including first author,year of publication,sample size,type of drugs,drug-delivery methods,dose of drugs,medication time,ratio of MACE,ratio of composite terminal event and ratio of other adverse events.The results choose odds ratio(OR)and 95%confidence interval for binary data to show up.According to the degree of heterogeneity,random effect model or fixed effect model is adopted for analysis.The reliability and possible sources of heterogeneity of the study results were explored through single study impact analysis.Funnel plot visual symmetry test was used to evaluate the publication bias.ResultsA total of 9905 patients from 12 RCTs were subjected to this study according to admitted criteria,included 6860 in IL-6 related monoclonal antibodies group and 3045 in controlled group.Three different drugs were taken into the study,which are Tocilizumab,Sarilumab and Sirukumab.Analysis showed that compared to the controlled group,the risk of MACE.did not elevate after using IL-6 related.monoclonal antibodies in rheumatoid arthritis patients(P=0.51,OR=1.23,95%CI[0.67?2.24],I2=0%).However,the usage of IL-6 related monoclonal antibodies could significantly increase the incidence of composite terminal events in cardiovascular disease including heart failure,arrhythmia,CVD,hypertension,myocardial disease,syncope and infectious heart disease(P=0.0009,OR=2.38,95%CI[1.42?3.98],I2=63%).These drugs also can increase the incidence of hypertension(P<0.00001,OR=1.85,95%CI[1.42?2.41],I2=27%).As for other adverse effects,the incidence of elevated transaminase(P<0.00001,OR=2.69,95%CI[1.75?4.13],I2=72%),reduced neutrophil(P<0.0001,OR=11.16,95%CI[3.72?33.51],I2=52%)and severe infection(P=0.0003,OR=1.90,95%CI[1.34?2.70],I2=0%)was prominently increased.But there showed no statistical difference on thromboembolic,hemorrhage and anemia in RA patients using IL-6 related monoclonal antibodies.Meanwhile,Tocilizumab can increase the incidence of composite terminal events in cardiovascular disease(P<0.00001,OR=2.84,95%CI[1.94?4.14],I2=39%)and the incidence of hypertension(P<0.00001,OR=2.82,9%CI[1.89?4.19],I2=32%).Sarilumab will elevate transaminase(P=0.004,OR=1.76,95%CI[1.19?2.60],I2=15%)and reduced neutrophil(P<0.00001,OR=25.26,95%CI[9.78?65.23],I2=0%),while Sirukumab was proved to elevate transaminase(P<0.0001,OR=3.40,95%CI[1.88?6.14],I2=77%),the incidence of severe infection(P=0.0002,OR=2.52,95%CI[1.55?4.08],I2=0%)and the incidence of severe adverse effects(P=0.0005,OR=1.64,95%CI[1.24?2.17],I2=0%).ConclusionConsider of the risk of MACE,IL-6 related monoclonal antibodies might be unharmful drugs to RA patients in cardiovascular systems.Meanwhile,the increased incidence of composite terminal events in cardiovascular disease urge us to reappraise the damage that IL-6 related monoclonal antibodies may do,and to choose prudently in RA patients at high-risk of heart.disease.Besides,more studies should be done with high pertinence for further confirming.PurposeTo discuss the causes,pathogenesis,diagnosis and treatment process of Dressler syndrome,we reported the clinical manifestations,diagnosis,treatment processes and follow-up of one case of Dressler syndrome secondary to PCI after acute ST segment elevation myocardial infarction.We aim to deepen the understanding of Dressler syndrome,so as to reduce misdiagnosis and mistreatment of Dressler syndrome.MethodThis paper retrospectively analyzed the case data of one patient with Dressler syndrome secondary to PCI after an acute ST segment elevation myocardial infarction,with relevant literature consulted through Pubmed database.Combined with the case,the clinical manifestations,diagnostic points,possible pathogenesis,treatments and prognosis of Dressler syndrome were summarized.ResultThe 68-year-old male patient was admitted to the hospital for acute ST segment elevation myocardial infarction,and the secondary total occlusion of LCX segment was found in the emergency coronary angiography examination.One stent was released in the LCX segment after re-opening,and after that,the patient was treated with regular medicine for AMI.Three days after the operation,the patient presented chest pain,chest tightness,dyspnea,decreased urine volume and other symptoms.The results of electrocardiogram reviews showed that the ST segment of V2-V5 leads continued low saddle elevation,showing obvious J wave.The lead images of ?,?,aVF,I and aVL were consistent with the typical dynamic changes of acute ST segment elevation myocardial infarction.Bedsides echocardiography results showed LA:34mm,LV:50mm,LVEF:0.45,left ventricular enlargement pericardial effusion,pleural effusion,severe mitral regurgitation,segmental hypomotility of left ventricular wall.According to a 1985 diagnosis standard proposed by Dressier W,the patient was diagnosed with Dressler syndrome,pericardial effusion and pleural effusion,giving NSAIDs,steroid hormones as special treatments.The patient was improved after treatment,follow-up of the patient's electrocardiogram returned to normal,with cardiac structure function recovered,clinical symptoms eased and activity stamina increased.His cardiac function and heart size recovered obviously,and the quality of life has improved significantly.Reviewing the literatures,post-myocardial infarction syndrome usually shows the development in the second or third week after an acute myocardial infarction,but may appear as early as 24 hours to several months after a myocardial infarction.The pathogenesis of this syndrome is not clear yet,and it is speculated that it is the result of self-sensitization to myocardial antigens released into circulation during the infarction.Clinically,post myocardial infarction syndrome is characterized by fever,general fatigue,chest pain,and the presence of pericarditis and possible pleural pericardial friction.After reperfusion treatment,the patient presented chest pain again.The ECG showed that the ST segment of the V2-V5 leads continued low saddle elevation,with obvious J wave.The lead area was anatomically inconsistent with the blood supply range of LCX.However,the lower,posterior and lateral wall leads' ST segments of the patients presented typical dynamic changes after myocardial infarction,and cardiac ultrasound tracing revealed that the patients had impaired pericardial effusion,pleural effusion and worse left ventricular function.Dressler syndrome was confirmed by effective steroid hormone therapy.ConclusionDressler syndrome mainly occurs several weeks after myocardial infarction.Typical clinical symptoms are characterized by pericarditis,pleurisy and other non-specific inflammation.The mechanism may be the antigenic antibody response caused by the necrotic myocardium after AMI.When the changes of electrocardiogram leads are inconsistent with the anatomical scope of blood supply from criminal blood vessels,the pericardial effusion and pleural efusion should be determined by cardiac ultrasound and chest X-ray in time to avoid misdiagnosis and missed diagnosis.Treatments with non-steroidal anti-inflammatory drugs and steroid hormone therapy are believed as the first principle,while necessary puncture drainage effusion should be carried out.In the case of acute heart failure,applying anti-heart failure treatment and anti-ventricular remodeling treatment in time would alleviate the cardiomyopathy caused by AMI. |
PDF Full Text Request