Anti-inflammatory treatment for carditis in acute rheumatic fever

 

Abstract

Background

Rheumatic heart disease remains the most important cause of acquired heart disease in developing countries. Although the prevention of rheumatic fever and the management of recurrences is well established the optimal management of active rheumatic carditis is still unclear.

Objectives

To assess the effects of anti-inflammatory agents such as aspirin, corticosteroids, immunoglobulin and pentoxifylline for preventing or reducing further heart valve damage in patients with acute rheumatic fever.

Search methods

We searched the Cochrane Central Register of Controlled Trials on The Cochrane Library (Issue 2, 2009), MEDLINE (1966 to June 2009), EMBASE (1998 to June 2009), LILACS (1982 to June 2009), Index Medicus (1950 to April 2001) and references lists of identified studies. No language restrictions were applied.

Selection criteria

Randomised controlled trials comparing anti-inflammatory agents (e.g. aspirin, steroids, immunoglobulins, pentoxifylline) with placebo or controls, or comparing any of the anti-inflammatory agents with one another, in patients with acute rheumatic fever diagnosed according to the Jones, or modified Jones criteria. The presence of cardiac disease one year after treatment was the major outcome criteria selected.

Data collection and analysis

Two reviewers independently extracted data and assessed trial quality.

Main results

Eight randomised controlled trials involving 996 people were included. Several steroidal agents viz. ACTH, cortisone, hydrocortisone, dexamethasone and prednisone, and intravenous immunoglobulin were compared to aspirin, placebo or no treatment in the various studies. Six of the trials were conducted between 1950 and 1965, whilst the remaining two were done in the last 10 years. Overall there was no significant difference in the risk of cardiac disease at one year between the corticosteroid-treated and aspirin-treated groups (relative risk 0.87, 95% confidence interval 0.66 to 1.15). Similarly use of prednisone (relative risk 1.78, 95% confidence interval 0.98 to 3.34) or intravenous immunoglobulins (relative risk 0.87, 95%confidence interval 0.55 to 1.39) when compared to placebo did not reduce the risk of developing heart valve lesions at one year.

Authors' conclusions

There is no benefit in using corticosteroids or intravenous immunoglobulins to reduce the risk of heart valve lesions in patients with acute rheumatic fever. The antiquity of most of the trials restricted adequate statistical analysis of the data and acceptable assessment of clinical outcomes by current standards. New randomised controlled trials in patients with acute rheumatic fever to assess the effects of corticosteroids such as oral prednisone and intravenous methylprednisone, and other new anti-inflammatory agents are warranted. Advances in echocardiography will allow for more objective and precise assessment of cardiac outcomes.

 

Plain language summary

Corticosteroids and immunotherapy to prevent heart damage as a result of rheumatic fever

Rheumatic fever is a late complication of a type of throat infection caused by streptococcus bacteria. It is an immune system disease that can lead to inflammatory disease of the heart (carditis), joints, brain and skin. Carditis can cause heart failure and death. Various anti-inflammatory drugs have been used to treat carditis, including corticosteroids, aspirin and immunoglobulins (immune therapy using antibodies). The review of trials found that there is no strong evidence to show that anti-inflammatory drugs can prevent heart damage that may occur following an episode of carditis.

 

摘要

背景

急性風濕熱之心臟炎的抗發炎療法

在開發中國家，風濕性心臟病仍為後天性心臟病的最重要成因。儘管風濕熱的預防及復發的處置都已確立，但急性風濕性心臟炎的最佳療法仍未確立。

目標

評估抗發炎藥物，如阿斯匹靈、皮質類固醇、免疫球蛋白及pentoxifylline對預防或減少急性風濕熱患者心臟瓣膜的進一步傷害的效果。

搜尋策略

我們對下列資料庫進行搜尋：Cochrane Central Register of Controlled Trials on The Cochrane Library (2007年第2期)，MEDLINE(1966年到2007年6月)，EMBASE(1998年到2007年6月)， LILACS(1982年到2007年6月)，Index Medicus(1950年到2001年4月)以及篩選出來的研究之參考文獻。此搜尋並未進行使用語言之限制。

選擇標準

根據Jones或修改後之Jones準則而診斷之急性風濕熱病人，做隨機分配試驗來進行抗發炎藥物(如：阿斯匹靈、類固醇、免疫球蛋白及pentoxifylline)與安慰劑或對照組的比較或抗發炎藥物之間的比較。治療1年後是否出現心臟疾病為選擇的主要結果。

資料收集與分析

2個檢閱者獨立地進行資料的擷取與試驗品質的評估。

主要結論

總共有8個隨機分配試驗涵括996個患者被收錄。在各個試驗中有數種類固醇類製劑(viz. ACTH，cortisone，hydrocortisone，dexamethasone與prednisone)及靜注免疫球蛋白與阿斯匹靈、安慰劑或不治療來進行比較。其中6個試驗在1950至1965年間進行，其他2個試驗在最近10間進行。總體來說，治療後1年發生心臟疾病的風險在皮質類固醇組與阿斯匹靈組之間並沒有顯著差異(相對風險0.87，95％信賴區間為0.66到1.15)。相似的結果可以在使用prednisone(相對風險1.78，95％信賴區間為0.98到3.34)或靜注免疫球蛋白(相對風險0.87，95％信賴區間為0.55到1.39)與安慰劑的比較時發現，上述藥物無法減少1年後發生心臟瓣膜病灶的風險。

作者結論

急性風濕熱患者使用皮質類固醇或靜注免疫球蛋白來減少心臟瓣膜病灶的風險並無益處。由於大多數試驗過於久遠而使資料要進行適當的統計分析是受限的，且要以現今的標準進行臨床結果的適當評估亦受限制。因此對急性風濕熱患者進行全新的隨機分配試驗來評估皮質類固醇，如口服prednisone和靜脈注methylprednisone，與其他新的抗發炎藥物的效果是必要的。心臟超音波的進步也使心臟結果的評估變得更客觀及準確。

翻譯人

本摘要由臺北榮民總醫院陳國維翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

皮質類固醇與免疫療法迄今顯示無法預防風濕熱引起之心臟傷害。風濕熱是一種鏈球菌引起喉嚨感染所致之晚期併發症。它是一種免疫系統的病變，會導致心臟(心臟炎)、關節、腦部與皮膚的發炎病變。心臟炎可引起心衰竭及死亡。許多種抗發炎藥物已被用於治療心臟炎，包含皮質類固醇、阿斯匹靈和免疫球蛋白(使用抗體作為免疫療法)。此回顧發現沒有強烈的證據顯示抗發炎藥物可以預防心臟炎之後可能發生的心臟傷害。