CARDIOVASCULAR JOURNAL OF AFRICA • Volume 25, No 4, July/August 2014
172
AFRICA
described reduced myocardial deformation markers assessed
by STE in addition to abnormal tissue Doppler imaging (TDI)
parameters in RA patients compared to controls.
As a further finding, there was a significant increase in P
max
in the ECG of RA patients compared to the control group. The
increase in atrial strain, as well as dilatation and fibrosis bring
about a heterogenous and different conduction in the atrial
myocardium.
26-28
Such pathophysiological changes can trigger
atrial re-entry, thus playing an important role in the development
of atrial fibrillation.
26
One of the most important cytokines implicated in the
progression of chronic heart failure is TNF-alpha.
20
Although
treatment with anti-TNF-alpha agents represents a major
advance in the treatment of rheumatic disease, its impact on
cardiovascular risk, especially in RA patients with preserved LV
function (EF ≥ 50), remains controversial.
In a study by Santos
et al.
there was a decrease in cardiac
output and stroke volume in RA patients without clinical and
echocardiographical evidence of previous cardiac dysfunction.
29
On the other hand, Listing
et al.
showed that therapy with anti-
TNF-alpha agents is more likely to be beneficial than harmful
with regard to the risk of heart failure.
30
In the present study, we showed an improvement in LA global
strain and volume index parameters in patients who were treated
with infliximab, a monoclonal antibody against TNF-alpha.
We used conventional echocardiography and STE. STE is an
imaging technique, in which ultrasound speckles within the
image are tracked, and strain is derived from the displacement
of speckles relative to each other.
31
This new modality enables
accurate and reliable measurements of both global and regional
myocardial strain and strain rates without the confounding
effects of angle dependency (Fig. 1).
32
To the best of our knowledge, this is the first study evaluating
the effects of infliximab on LA function in RA patients. There
are only limited data on the pathophysiological mechanisms in
this regard.
In our study, significant improvement in LA global strain
and volume indices after infliximab treatment was clearly
demonstrated. In addition, there was also a remarkable
improvement in parameters of LV diastolic dysfunction as
Table 5. Effects of infliximab therapy on conventional echocardiographic parameters versus prednisolone-treated patients
Infliximab-treated RA patients (n
=
20)
Prednisolone-treated RA patients (n
=
18)
Baseline
3-month
p-value
Baseline
3-month
p-value
p-value
#
LV EDV (ml)
81.7
±
6.6
79.7
±
6.9
0.411
83.9
±
4.7
85.4
±
9.8
0.868
0.2
LV ESV (ml)
28.3
±
4.2
27.2
±
3.6
0.14
29.2
±
5.3
27.9
±
2.6
0.557
0.5
LV EF (ml)
63.8
±
4.0
64.6
±
2.8
0.096
64.1
±
3.3
64.9
±
2.8
0.35
0.71
IVS (mm)
9.7
±
1.7
9.5
±
3.9
0.267
9.5
±
2.5
9.4
±
4.6
0.316
0.06
PW (mm)
8.6
±
0.6
8.3
±
0.4
0.056
8.5
±
0.8
8.7
±
0.4
0.381
0.82
S
′
(cm/sec)
7.2
±
1.8
6.8
±
0.8
0.258
7.4
±
2.5
7.6
±
0.6
0.369
0.1
E
′
(cm/sec)
7.9
±
2.5
9.0
±
1.3
0.181
8.3
±
1.9
7.8
±
2.4
0.6
0.09
E/E
′
9.4
±
3.9
8.0
±
1.4
<
0.01
8.5
±
2.5
8.8
±
2.4
0.379
<
0.05
E (cm/s)
76.1
±
7.4
76.0
±
11.8
0.979
77.9
±
8.2
79.5
±
11.7
0.493
0.476
A (cm/s)
67.5
±
9.9
66.0
±
7.7
0.221
71.3
±
11.2
70.2
±
9.8
0.407
0.284
E/A
1.1
±
0.2
1.1
±
0.2
0.758
1.1
±
0.2
1.1
±
0.3
0.184
0.656
DT (ms)
199.1
±
35.3 203.0
±
34.1
0.609
198.6
±
30.3 211.5
±
22.4
0.055
0.858
IVRT (ms)
96.7
±
10.8
95.3
±
16.9
0.626
90.3
±
10.1
90.3
±
16.8
0.99
0.056
Values are expressed as mean
±
SD.
#
For comparisons between infliximab- and prednisolone-treated patients at baseline.
LV
=
left ventricle, EDV
=
end-diastolic volume, ESV
=
end-systolic volume, EF
=
ejection fraction, IVS
=
interventricular septum, PW
=
posterior
wall, DT
=
deceleration time, IVRT
=
isovolumic relaxation time.
Table 6. Effects of infliximab therapy on left atrial echocardiographic and electrocardiographic
parameters versus prednisolone-treated patients
Infliximab-treated RA patients (n
=
20) Prednisolone-treated RA patients (n
=
18)
Baseline
3-month
p-value
Baseline
3-month
p-value
p-value
#
LAVI
max
(ml/m
2
)
23.1
±
2.9 21.9
±
2.3
<
0.05
23.7
±
3.7 23.3
±
2.1
0.453
0.435
LAVI
preA
(ml/m
2
)
16.8
±
2.7 15.8
±
2.1
<
0.01
17.5
±
3.0 17.6
±
3.1
0.892
0.369
LAVI
min
(ml/m
2
)
11.4
±
2.2 11.0
±
2.1
0.082
10.4
±
2.9 10.1
±
1.5
0.368
0.066
P
max
(ms)
86.0
±
8.8 82.0
±
10.5
0.072
91.6
±
8.5 87.7
±
10.6
0.09
0.052
P
min
(ms)
42.5
±
7.8 41.0
±
12.5
0.505
43.8
±
6.9 42.7
±
14.4
0.749
0.568
P dispersion (ms)
43.5
±
7.4 41.0
±
7.1
0.056
47.7
±
4.2 45.0
±
7.8
0.172
<
0.05
LA global strain (%)
25.4
±
10.6 30.4
±
2.6
<
0.05
31.5
±
14.7 36.3
±
6.9
0.21
0.181
LA global systolic strain rate (ms)
1.6
±
0.3
1.7
±
0.2
0.073
1.7
±
0.3
1.7
±
0.4
0.536
0.59
LA global early diastolic strain rate (/s)
–1.1
±
0.3 –1.2
±
0.3
0.098
–1.2
±
0.3 –1.2
±
0.2
0.751
0.596
LA global late diastolic strain rate (/s)
–1.2
±
0.2 –1.2
±
0.2
0.567
–1.0
±
0.2 –1.1
±
0.2
0.367
<
0.01
Values are expressed as mean
±
SD.
#
For comparisons between infliximab- and prednisolone-treated patients at baseline.
LA
=
left atrium, LAVI
=
left atrial volume index.
