Title:Tumor Necrosis Factor Blocking Therapy and Congestive Heart Failure in Patients with Inflammatory Rheumatic Disorders: A Systematic Review
Volume: 22
Issue: 16
Author(s): S.C. Heslinga, A.M. Van Sijl, K. De Boer, V.P. Van Halm and M.T. Nurmohamed
Affiliation:
Keywords:
Ankylosing spondylitis, congestive heart failure, juvenile idiopathic arthritis, osteoarthritis, psoriatic arthritis,
rheumatoid arthritis, tumor necrosis factor.
Abstract: Introduction: Tumour necrosis factor (TNF) blocking therapy is an effective treatment for
chronic inflammatory arthritis. As circulating TNF might induce or exacerbate the development of
congestive heart failure (CHF), several trials have investigated the effect of TNF blocking therapy on
CHF. However, due to inefficacy and even a risk of exacerbation of CHF, TNF blocking therapy has
since then been contraindicated in patients with advanced CHF, New York Heart Association class III and IV. We review
current knowledge on the pathophysiological mechanisms and safety of TNF blocking therapy in chronic inflammatory
arthritis patients with regard to CHF. Methods: A systematic search of the literature published up till December 2013 was
conducted in MEDLINE, EMBASE and the Cochrane Library to identify all studies investigating the effect of TNF blocking
therapy on the occurrence and risk of CHF in patients with rheumatoid arthritis (RA), ankylosing spondylitis (AS) and
psoriatic arthritis (PsA). All articles reporting data on the prevalence or incidence of CHF during treatment with TNF
blocking therapy in patients with in RA, AS or PsA were included. Also imaging studies and studies with biomarkers, investigating
the effect of TNF blocking therapy on cardiac function were included. Results: In total, 54 studies were included.
Results from large prospective registries suggest that first, a potentially harmful effect of TNF blocking therapy on
the incidence of CHF in older RA patients cannot be excluded and that no harmful effect was observed of TNF blocking
therapy in other patients. Second, we found that TNF blocking therapy potentially improves several echocardiographic parameters
of cardiac function in RA, AS and PsA, but due to small sample sizes, these results require validation in larger
studies. Third, we found improvement in NT-proBNP levels after use of TNF blocking therapy in both RA and AS. Conclusion:
Based on current literature, in patients with chronic inflammatory arthritis and concomitant symptomatic mild-tomoderate
CHF (NYHA class I or II), treatment with TNF blocking therapy is not contraindicated. In chronic inflammatory
arthritis patients with concomitant symptomatic moderate-to-severe CHF, NYHA class III-IV, treatment with TNF blocking
therapy should be avoided if possible. Whenever, treatment with TNF-blocking therapy is considered in these patients
consultation with a cardiologist is recommended before treatment is initiated.
