CARDIOVASCULAR JOURNAL OF AFRICA • Volume 25, No 4, July/August 2014
168
AFRICA
Infliximab, an anti-TNF-alpha agent, improves left atrial
abnormalities in patients with rheumatoid arthritis:
preliminary results
Çetin Süha, Vural Mustafa Gökhan, Keskin Göksal, Yeter Ekrem, Do
ğ
an Mehmet, Öztürk Mehmet Akif
Abstract
Background:
Rheumatoid arthritis (RA) is associated with
increased cardiovascular morbidity and mortality. In the
current prospective study, we addressed the impact of RA on
left atrial (LA) function and electrical remodelling. Further,
we tried to demonstrate the effects of infliximab, an anti-TNF-
alpha agent, on echocardiographical LA abnormality in RA
patients with preserved left ventricular (LV) ejection fraction.
Methods:
We compared 38 female RA patients without
clinical evidence of heart disease and 30 female controls
without RA and clinical evidence of heart disease. Further,
we compared RA patients receiving infliximab and increasing
doses of prednisolone over a three-month period. At baseline
and post treatment, this study assessed (1) LA and LV param-
eters using conventional and speckle tracking echocardiogra-
phy (STE), and (2) electrocardiographic P-wave changes.
Results:
The values of C-reactive protein (CRP), isovolu-
mic relaxation time (IVRT), A wave, and deceleration time
(DT) were significantly higher in RA patients compared to
the control group (
p
<
0.05), whereas E/E
′
and E/A values
were found to be lower (
p
<
0.05) in RA patients. E/E
′
values
were lower in prednisolone- compared to infliximab-treated
patients (
p
<
0.05). After three months of infliximab and pred-
nisolone treatment, CRP and disease activity score (DAS 28)
values decreased in both groups (
p
<
0.05), and Duke activity
status index (DASI) increased (
p
<
0.05). Maximal left atrial
volume index (LAVI
max
), pre-contraction left atrial volume
index (LAVI
preA
) and maximum P wave (P
max
) of the RA
patients were higher compared to the control group (
p
<
0.05),
whereas LA global strain was found to be lower (
p
<
0.05).
There was no difference in P
max
values between groups before
and after the treatment period. E/E
′
, LAVI
max
and LAVI
preA
values of infliximab-treated patients decreased and LA global
strain increased after three months of therapy compared to
baseline (
p
<
0.05). At baseline in both treatment groups, E/E
′
and LA global late diastolic strain rate were lower in pred-
nisolone- compared to infliximab-treated patients (
p
<
0.05).
Conclusion:
There was echocardiographic LA abnormality
in these RA patients. In this patient group there was also a
meaningful increase in maximum P wave assessed by electro-
cardiography. Infliximab therapy for a period of three months
improved LA abnormality.
Keywords:
electrocardiography, infliximab, left atrium, rheuma-
toid arthritis, speckle tracking echocardiography
Submitted 14/1/14, accepted 13/6/14
Cardiovasc J Afr
2014;
25
: 168–175
DOI: 10.5830/CVJA-2014-036
Rheumatoid arthritis (RA) is a systemic autoimmune disease
affecting about 1% of the population.
1
It is also characterised by
an excess risk of cardiovascular disease and mortality, probably
via chronic systemic inflammation.
2
TNF-alpha represents the
major inflammatory cytokine in RA patients.
3
Apart from being
the major promoter and regulator of the inflammatory cascade
resulting in joint damage, it may mediate cardiac injury through
a variety of biological mechanisms.
4
Treatment of RA with
anti-TNF-alpha agents such as infliximab has been shown to be
effective in reducing signs and symptoms of the disease and in
preventing joint damage,
5-7
but their impact on cardiovascular
disease, especially in RA patients with preserved LV function
(EF ≥ 50) remains controversial.
In this prospective study we tried to elucidate (1) whether
myocardial abnormality as assessed by echocardiography is
present in RA patients compared to normal controls, (2) the
electrocardiographic P-wave changes in RA patients, and (3)
the impact of infliximab treatment on left ventricular (LV) and
left atrial (LA) echocardiographic parameters in comparison
to treatment with corticosteroids. We used conventional and
speckle tracking echocardiography (STE), a novel method for
the evaluation of myocardial abnormality.
Methods
Thirty-eight female patients (age 52.1
±
11.1 years) with RA
diagnosed by revised American Rheumatism Association
criteria, who had an inadequate response to disease-modifying
antirheumatic drugs (DMARDs) and corticosteroids were
recruited from the RA out-patient section of the Rheumatology
Unit, Ministry of Health, Di
ş
kapi Yildirim Beyazit Research
and Education Hospital, Ankara, Turkey, between January 2011
Department of Cardiology, 29 Mayis Hospital, Ankara, Turkey
Çetin Süha, MD,
Department of Cardiology, Di
ş
kapi Research and
Education Hospital, Ankara, Turkey
Vural Mustafa Gökhan, MD
Yeter Ekrem, MD
Do
ğ
an Mehmet, MD
Department of Internal Medicine, Di
ş
kapi Research and
Education Hospital, Ankara, Turkey
Keskin Göksal, MD
Department of Rheumatology, School of Medicine, Gazi
University, Ankara, Turkey
Öztürk Mehmet Akif, MD
