anti-tnf, scompenso cardiaco e cardiopatia · pdf fileanti-tnf, scompenso cardiaco e...
TRANSCRIPT
![Page 1: Anti-TNF, scompenso cardiaco e cardiopatia · PDF fileAnti-TNF, scompenso cardiaco e cardiopatia ischemica : “Controversie e raccomandazioni” Alberto Moggi Pignone SOD Medicina](https://reader038.vdocuments.mx/reader038/viewer/2022102803/5a7a54027f8b9a0d098c09b6/html5/thumbnails/1.jpg)
Anti-TNF, scompenso cardiacoe cardiopatia ischemica :
“Controversie e raccomandazioni”
Alberto Moggi PignoneSOD Medicina InternaAd alta complessità
Assistenziale 2DEA - AOUC
![Page 2: Anti-TNF, scompenso cardiaco e cardiopatia · PDF fileAnti-TNF, scompenso cardiaco e cardiopatia ischemica : “Controversie e raccomandazioni” Alberto Moggi Pignone SOD Medicina](https://reader038.vdocuments.mx/reader038/viewer/2022102803/5a7a54027f8b9a0d098c09b6/html5/thumbnails/2.jpg)
TNF-ɑ, Rheumatoid arthritisand heart fealure:
“A rheumatologicaldilemma”
P. Sarzi-Puttini et al LUPUS 2005
![Page 3: Anti-TNF, scompenso cardiaco e cardiopatia · PDF fileAnti-TNF, scompenso cardiaco e cardiopatia ischemica : “Controversie e raccomandazioni” Alberto Moggi Pignone SOD Medicina](https://reader038.vdocuments.mx/reader038/viewer/2022102803/5a7a54027f8b9a0d098c09b6/html5/thumbnails/3.jpg)
Biologics and heart fealure inrheumatoid arthritis: are we any wiser ?
M Danila et al; Curr Opin Rheum 2008
![Page 4: Anti-TNF, scompenso cardiaco e cardiopatia · PDF fileAnti-TNF, scompenso cardiaco e cardiopatia ischemica : “Controversie e raccomandazioni” Alberto Moggi Pignone SOD Medicina](https://reader038.vdocuments.mx/reader038/viewer/2022102803/5a7a54027f8b9a0d098c09b6/html5/thumbnails/4.jpg)
Does TNFα inhibitionPromote or PreventHeart fealure in patientsWith RA ?
Listing J et al;Arthritis Rheum 2008
![Page 5: Anti-TNF, scompenso cardiaco e cardiopatia · PDF fileAnti-TNF, scompenso cardiaco e cardiopatia ischemica : “Controversie e raccomandazioni” Alberto Moggi Pignone SOD Medicina](https://reader038.vdocuments.mx/reader038/viewer/2022102803/5a7a54027f8b9a0d098c09b6/html5/thumbnails/5.jpg)
Ma perché taledilemma dal
momento che le citochine
Proinfiammatorie(IL1,6,18,TNFalfa)
…………..
REUMATOLOGO
![Page 6: Anti-TNF, scompenso cardiaco e cardiopatia · PDF fileAnti-TNF, scompenso cardiaco e cardiopatia ischemica : “Controversie e raccomandazioni” Alberto Moggi Pignone SOD Medicina](https://reader038.vdocuments.mx/reader038/viewer/2022102803/5a7a54027f8b9a0d098c09b6/html5/thumbnails/6.jpg)
• riducono direttamente la contrattilitàmiocardica,probabilmente attraverso l’attivazione di metallo - proteasi;
• Inducono ipertrofia della Miocellulacardiaca;
• Promuovono meccanismi di apoptosi e fibrosi;
• Contribuiscono al rimodellamentocardiaco;
![Page 7: Anti-TNF, scompenso cardiaco e cardiopatia · PDF fileAnti-TNF, scompenso cardiaco e cardiopatia ischemica : “Controversie e raccomandazioni” Alberto Moggi Pignone SOD Medicina](https://reader038.vdocuments.mx/reader038/viewer/2022102803/5a7a54027f8b9a0d098c09b6/html5/thumbnails/7.jpg)
Lee DS et al: novel markersfor heart failure diagnosisand prognosis. Curr Opin Cardiol 2008
Braunwald E: BiomarkersIn heart failure.N Engl J Med 2008
![Page 8: Anti-TNF, scompenso cardiaco e cardiopatia · PDF fileAnti-TNF, scompenso cardiaco e cardiopatia ischemica : “Controversie e raccomandazioni” Alberto Moggi Pignone SOD Medicina](https://reader038.vdocuments.mx/reader038/viewer/2022102803/5a7a54027f8b9a0d098c09b6/html5/thumbnails/8.jpg)
E ancora ……… TNF alpha èstato trovato aumentato in unaampia popolazione di pazienticon HF, associato con una
riduzione della sopravvivenzae per questo suggerito come
un utile marker per determinareun indice di rischio nell’HF.
Shannon MD et. Al.: Circulation 2008
![Page 9: Anti-TNF, scompenso cardiaco e cardiopatia · PDF fileAnti-TNF, scompenso cardiaco e cardiopatia ischemica : “Controversie e raccomandazioni” Alberto Moggi Pignone SOD Medicina](https://reader038.vdocuments.mx/reader038/viewer/2022102803/5a7a54027f8b9a0d098c09b6/html5/thumbnails/9.jpg)
To date, the role that TNF αplays in HF has not been
fully elucidated and warrantsfurther investigation
Shannon MD et. Al.: Circulation 2008
![Page 10: Anti-TNF, scompenso cardiaco e cardiopatia · PDF fileAnti-TNF, scompenso cardiaco e cardiopatia ischemica : “Controversie e raccomandazioni” Alberto Moggi Pignone SOD Medicina](https://reader038.vdocuments.mx/reader038/viewer/2022102803/5a7a54027f8b9a0d098c09b6/html5/thumbnails/10.jpg)
HF: a complex neurohumouraland inflammatory syndrome
![Page 11: Anti-TNF, scompenso cardiaco e cardiopatia · PDF fileAnti-TNF, scompenso cardiaco e cardiopatia ischemica : “Controversie e raccomandazioni” Alberto Moggi Pignone SOD Medicina](https://reader038.vdocuments.mx/reader038/viewer/2022102803/5a7a54027f8b9a0d098c09b6/html5/thumbnails/11.jpg)
…… E inoltre ci sono molte evidenze sul coinvolgimento del TNF-ɑ nel determinismo
del danno endoteliale
![Page 12: Anti-TNF, scompenso cardiaco e cardiopatia · PDF fileAnti-TNF, scompenso cardiaco e cardiopatia ischemica : “Controversie e raccomandazioni” Alberto Moggi Pignone SOD Medicina](https://reader038.vdocuments.mx/reader038/viewer/2022102803/5a7a54027f8b9a0d098c09b6/html5/thumbnails/12.jpg)
![Page 13: Anti-TNF, scompenso cardiaco e cardiopatia · PDF fileAnti-TNF, scompenso cardiaco e cardiopatia ischemica : “Controversie e raccomandazioni” Alberto Moggi Pignone SOD Medicina](https://reader038.vdocuments.mx/reader038/viewer/2022102803/5a7a54027f8b9a0d098c09b6/html5/thumbnails/13.jpg)
• TNF α è stato localizzato nella placca ateromasica con capacità di contribuire allaprogressione della placca stessa;
• Altera l’omeostasi lipidica;• Aumenta la resistenza insulinica;• Promuove direttamente la
disfunzione endoteliale;
![Page 14: Anti-TNF, scompenso cardiaco e cardiopatia · PDF fileAnti-TNF, scompenso cardiaco e cardiopatia ischemica : “Controversie e raccomandazioni” Alberto Moggi Pignone SOD Medicina](https://reader038.vdocuments.mx/reader038/viewer/2022102803/5a7a54027f8b9a0d098c09b6/html5/thumbnails/14.jpg)
![Page 15: Anti-TNF, scompenso cardiaco e cardiopatia · PDF fileAnti-TNF, scompenso cardiaco e cardiopatia ischemica : “Controversie e raccomandazioni” Alberto Moggi Pignone SOD Medicina](https://reader038.vdocuments.mx/reader038/viewer/2022102803/5a7a54027f8b9a0d098c09b6/html5/thumbnails/15.jpg)
The balance betweenPro-and anti-inflammatory
Cytokines is associated withPlatelet aggregability in acutecoronary syndrome patients
Gori AM, Abbate R.
Atherosclerosis 2008
![Page 16: Anti-TNF, scompenso cardiaco e cardiopatia · PDF fileAnti-TNF, scompenso cardiaco e cardiopatia ischemica : “Controversie e raccomandazioni” Alberto Moggi Pignone SOD Medicina](https://reader038.vdocuments.mx/reader038/viewer/2022102803/5a7a54027f8b9a0d098c09b6/html5/thumbnails/16.jpg)
………………………La logica conseguenza sarebbe che le terapie
con anti-TNF comportinouna riduzione del rischio
CV
![Page 17: Anti-TNF, scompenso cardiaco e cardiopatia · PDF fileAnti-TNF, scompenso cardiaco e cardiopatia ischemica : “Controversie e raccomandazioni” Alberto Moggi Pignone SOD Medicina](https://reader038.vdocuments.mx/reader038/viewer/2022102803/5a7a54027f8b9a0d098c09b6/html5/thumbnails/17.jpg)
Bozkurt B et al: Results of a Targeted anti tumor necrosis
Factor therapy with etanercept(Embrel) in patients (47) with
Advanced heart failure. Circulation 2001
![Page 18: Anti-TNF, scompenso cardiaco e cardiopatia · PDF fileAnti-TNF, scompenso cardiaco e cardiopatia ischemica : “Controversie e raccomandazioni” Alberto Moggi Pignone SOD Medicina](https://reader038.vdocuments.mx/reader038/viewer/2022102803/5a7a54027f8b9a0d098c09b6/html5/thumbnails/18.jpg)
Inhibition of TNF α reducesMyocardial injury and
Proinflammatory pathwaysFollowing ischemia-reperfusion
In the dog.Quiping Gu et al; J Card Pharm 2006
![Page 19: Anti-TNF, scompenso cardiaco e cardiopatia · PDF fileAnti-TNF, scompenso cardiaco e cardiopatia ischemica : “Controversie e raccomandazioni” Alberto Moggi Pignone SOD Medicina](https://reader038.vdocuments.mx/reader038/viewer/2022102803/5a7a54027f8b9a0d098c09b6/html5/thumbnails/19.jpg)
Anti-inflammation role forMesenchimal stem cells
Transplantation in Myocardial infarction
Guo J et al; Inflammation 2007
![Page 20: Anti-TNF, scompenso cardiaco e cardiopatia · PDF fileAnti-TNF, scompenso cardiaco e cardiopatia ischemica : “Controversie e raccomandazioni” Alberto Moggi Pignone SOD Medicina](https://reader038.vdocuments.mx/reader038/viewer/2022102803/5a7a54027f8b9a0d098c09b6/html5/thumbnails/20.jpg)
Effects of traditional chineseMedicine Shu-Mai-Tang onAttenuating TNF α inducedMyocardial fibrosis in rats.
J. Ethnopharmacol 2008
![Page 21: Anti-TNF, scompenso cardiaco e cardiopatia · PDF fileAnti-TNF, scompenso cardiaco e cardiopatia ischemica : “Controversie e raccomandazioni” Alberto Moggi Pignone SOD Medicina](https://reader038.vdocuments.mx/reader038/viewer/2022102803/5a7a54027f8b9a0d098c09b6/html5/thumbnails/21.jpg)
Dalla letteratura successivaarrivano segnalazioni che
negano una efficacia effettivadi terapie anti TNFα
nello scompenso cardiaco
![Page 22: Anti-TNF, scompenso cardiaco e cardiopatia · PDF fileAnti-TNF, scompenso cardiaco e cardiopatia ischemica : “Controversie e raccomandazioni” Alberto Moggi Pignone SOD Medicina](https://reader038.vdocuments.mx/reader038/viewer/2022102803/5a7a54027f8b9a0d098c09b6/html5/thumbnails/22.jpg)
…………. Ma anzi ipotizzano
un peggioramento delloscompenso cardiaco in
corso di terapie con anti-TNF
![Page 23: Anti-TNF, scompenso cardiaco e cardiopatia · PDF fileAnti-TNF, scompenso cardiaco e cardiopatia ischemica : “Controversie e raccomandazioni” Alberto Moggi Pignone SOD Medicina](https://reader038.vdocuments.mx/reader038/viewer/2022102803/5a7a54027f8b9a0d098c09b6/html5/thumbnails/23.jpg)
Anker SD et al: How toRECOVER from RENAISSANCE?
The significance of the resultsof RECOVER, RENAISSANCE,
RENEWAL and ATTACH.Int J Cardiol 2004
Grandi trials multicentrici:
![Page 24: Anti-TNF, scompenso cardiaco e cardiopatia · PDF fileAnti-TNF, scompenso cardiaco e cardiopatia ischemica : “Controversie e raccomandazioni” Alberto Moggi Pignone SOD Medicina](https://reader038.vdocuments.mx/reader038/viewer/2022102803/5a7a54027f8b9a0d098c09b6/html5/thumbnails/24.jpg)
Quali ipotesi ????• Il Blocco del TNF potrebbe interferire
con alcune funzioni omeostatiche della citochina, che si esplicano a basse concentrazioni, inibite dalblocco recettoriale
Endogenous TNF protects the adultcardiac myocyrte against ischemic-induced apoptosis in a murine modelOf acute myocardial infarction.
PNAS 2000
![Page 25: Anti-TNF, scompenso cardiaco e cardiopatia · PDF fileAnti-TNF, scompenso cardiaco e cardiopatia ischemica : “Controversie e raccomandazioni” Alberto Moggi Pignone SOD Medicina](https://reader038.vdocuments.mx/reader038/viewer/2022102803/5a7a54027f8b9a0d098c09b6/html5/thumbnails/25.jpg)
•La proteina contiene unPolimorfismo che può
determinare una diversa risposta alla terapia mirata
(responders/non responders)
![Page 26: Anti-TNF, scompenso cardiaco e cardiopatia · PDF fileAnti-TNF, scompenso cardiaco e cardiopatia ischemica : “Controversie e raccomandazioni” Alberto Moggi Pignone SOD Medicina](https://reader038.vdocuments.mx/reader038/viewer/2022102803/5a7a54027f8b9a0d098c09b6/html5/thumbnails/26.jpg)
Genetic polymorphisms ofInflammatory cytokines (IL1-6-10-TNF α-CD14r- TLR4) andMyocardial infarction in the Elderly.Olivieri F et al, 2007
New therapeuticStrategies !!!!!!!
![Page 27: Anti-TNF, scompenso cardiaco e cardiopatia · PDF fileAnti-TNF, scompenso cardiaco e cardiopatia ischemica : “Controversie e raccomandazioni” Alberto Moggi Pignone SOD Medicina](https://reader038.vdocuments.mx/reader038/viewer/2022102803/5a7a54027f8b9a0d098c09b6/html5/thumbnails/27.jpg)
•Il sesso e la razza Possono giuocare
un ruolo importanteNella risposta alla terapia?
Suffredini AF et al.J Immunol 1995
![Page 28: Anti-TNF, scompenso cardiaco e cardiopatia · PDF fileAnti-TNF, scompenso cardiaco e cardiopatia ischemica : “Controversie e raccomandazioni” Alberto Moggi Pignone SOD Medicina](https://reader038.vdocuments.mx/reader038/viewer/2022102803/5a7a54027f8b9a0d098c09b6/html5/thumbnails/28.jpg)
•Gli agenti biologiciutilizzati hanno uneffetto tossico direttosu endotelio e miocellulacardiaca?
Lecour S et al. J Mol Cell Card 2002
![Page 29: Anti-TNF, scompenso cardiaco e cardiopatia · PDF fileAnti-TNF, scompenso cardiaco e cardiopatia ischemica : “Controversie e raccomandazioni” Alberto Moggi Pignone SOD Medicina](https://reader038.vdocuments.mx/reader038/viewer/2022102803/5a7a54027f8b9a0d098c09b6/html5/thumbnails/29.jpg)
•E’ ipotizzabile unainterazione farmacologicacon altri farmaci utilizzatiper l’HF?
Kubota et al; Circulation 1998
![Page 30: Anti-TNF, scompenso cardiaco e cardiopatia · PDF fileAnti-TNF, scompenso cardiaco e cardiopatia ischemica : “Controversie e raccomandazioni” Alberto Moggi Pignone SOD Medicina](https://reader038.vdocuments.mx/reader038/viewer/2022102803/5a7a54027f8b9a0d098c09b6/html5/thumbnails/30.jpg)
•I pazienti studiatinei grandi trials
Multicentrici sono statiArruolati in maniera
Davvero appropriata??
![Page 31: Anti-TNF, scompenso cardiaco e cardiopatia · PDF fileAnti-TNF, scompenso cardiaco e cardiopatia ischemica : “Controversie e raccomandazioni” Alberto Moggi Pignone SOD Medicina](https://reader038.vdocuments.mx/reader038/viewer/2022102803/5a7a54027f8b9a0d098c09b6/html5/thumbnails/31.jpg)
E nelle patologie
Reumatiche ??
![Page 32: Anti-TNF, scompenso cardiaco e cardiopatia · PDF fileAnti-TNF, scompenso cardiaco e cardiopatia ischemica : “Controversie e raccomandazioni” Alberto Moggi Pignone SOD Medicina](https://reader038.vdocuments.mx/reader038/viewer/2022102803/5a7a54027f8b9a0d098c09b6/html5/thumbnails/32.jpg)
C’è ormai grande evidenza chein molte malattie Reumatiche
caratterizzate da flogosi cronica
Ci sia un aumento del rischio cardiovascolare
![Page 33: Anti-TNF, scompenso cardiaco e cardiopatia · PDF fileAnti-TNF, scompenso cardiaco e cardiopatia ischemica : “Controversie e raccomandazioni” Alberto Moggi Pignone SOD Medicina](https://reader038.vdocuments.mx/reader038/viewer/2022102803/5a7a54027f8b9a0d098c09b6/html5/thumbnails/33.jpg)
Deborah Deborah SymmonsSymmons
Cardiovascular mortality was Cardiovascular mortality was increased in men and womenincreased in men and women. When
adjusted for age and gender, RF-positive patients were 37% more patients were 37% more likely to die from CVD than RFlikely to die from CVD than RF--
negative patients.negative patients.
Ann Rheum Dis 2005;64:1595-601
![Page 34: Anti-TNF, scompenso cardiaco e cardiopatia · PDF fileAnti-TNF, scompenso cardiaco e cardiopatia ischemica : “Controversie e raccomandazioni” Alberto Moggi Pignone SOD Medicina](https://reader038.vdocuments.mx/reader038/viewer/2022102803/5a7a54027f8b9a0d098c09b6/html5/thumbnails/34.jpg)
Atherogenesis in rheumatologyLupus (2006) 15, 117–121
![Page 35: Anti-TNF, scompenso cardiaco e cardiopatia · PDF fileAnti-TNF, scompenso cardiaco e cardiopatia ischemica : “Controversie e raccomandazioni” Alberto Moggi Pignone SOD Medicina](https://reader038.vdocuments.mx/reader038/viewer/2022102803/5a7a54027f8b9a0d098c09b6/html5/thumbnails/35.jpg)
When comparing atherosclerosis to RA, a bone fide autoimmune disease, an interesting pattern of similaritiescan be deduced. both have evidence of activation of macrophages, B cells, T cells, and endothelial cells; alteration in the Th1/Th2 ratio and elevation of inflammatory cytokines
Histopathological specimens depicting similar inflammatory cells in chronic synovitis of RA (right) and in the atherosclerotic vessel (left)
![Page 36: Anti-TNF, scompenso cardiaco e cardiopatia · PDF fileAnti-TNF, scompenso cardiaco e cardiopatia ischemica : “Controversie e raccomandazioni” Alberto Moggi Pignone SOD Medicina](https://reader038.vdocuments.mx/reader038/viewer/2022102803/5a7a54027f8b9a0d098c09b6/html5/thumbnails/36.jpg)
Cardiovascular risk parameters inMen with AS in comparison with
Non-inflammatory control subjects:Relevance of systemic inflammation
Divecha H et al, Clin Science 2005
![Page 37: Anti-TNF, scompenso cardiaco e cardiopatia · PDF fileAnti-TNF, scompenso cardiaco e cardiopatia ischemica : “Controversie e raccomandazioni” Alberto Moggi Pignone SOD Medicina](https://reader038.vdocuments.mx/reader038/viewer/2022102803/5a7a54027f8b9a0d098c09b6/html5/thumbnails/37.jpg)
•Evidence of systemic inflammationAnd estimation of coronary arteryDisease risk: a population perspectiveWilson PW et al• Cardiovacular morbidity and mortalityin RA. Gabriel ES et al
• Subclinical atherosclerosis in RA andSLE. Salmon JE et al
The American J of Medicine 2008
![Page 38: Anti-TNF, scompenso cardiaco e cardiopatia · PDF fileAnti-TNF, scompenso cardiaco e cardiopatia ischemica : “Controversie e raccomandazioni” Alberto Moggi Pignone SOD Medicina](https://reader038.vdocuments.mx/reader038/viewer/2022102803/5a7a54027f8b9a0d098c09b6/html5/thumbnails/38.jpg)
Cardiovascular, rheumatologicand pharmacologic predictorsof stroke in patients with RA:a nested, case-control study.Nadareishvili Z et al.Arthr Rheum 2008
![Page 39: Anti-TNF, scompenso cardiaco e cardiopatia · PDF fileAnti-TNF, scompenso cardiaco e cardiopatia ischemica : “Controversie e raccomandazioni” Alberto Moggi Pignone SOD Medicina](https://reader038.vdocuments.mx/reader038/viewer/2022102803/5a7a54027f8b9a0d098c09b6/html5/thumbnails/39.jpg)
Updated consensus statement on Biologic agents………. For the Treatment of rheumatic diseases.Furst D et al, Ann Rheum Dis 2004
Update on the British Society forRheumatology guidelines forPrescribing TNF α blockers in adultsWith RA. Ledingham J et al.Rheumatology 2005
![Page 40: Anti-TNF, scompenso cardiaco e cardiopatia · PDF fileAnti-TNF, scompenso cardiaco e cardiopatia ischemica : “Controversie e raccomandazioni” Alberto Moggi Pignone SOD Medicina](https://reader038.vdocuments.mx/reader038/viewer/2022102803/5a7a54027f8b9a0d098c09b6/html5/thumbnails/40.jpg)
Kwon HJ et al. : Case reportsof heart fealure after therapywith a tumor necrosis factorantagonist. Ann Inter Med 2003
![Page 41: Anti-TNF, scompenso cardiaco e cardiopatia · PDF fileAnti-TNF, scompenso cardiaco e cardiopatia ischemica : “Controversie e raccomandazioni” Alberto Moggi Pignone SOD Medicina](https://reader038.vdocuments.mx/reader038/viewer/2022102803/5a7a54027f8b9a0d098c09b6/html5/thumbnails/41.jpg)
“ 47 pazienti affetti da diverse patologie reumatiche che in corso di terapia con anti TNF hanno sviluppato HF di nuova insorgenza e/o peggioramento
di HF già diagnosticato”
Esaminati gli adverse eventsspontanei presenti nel Data Base
Dell’FDA fino al Febbraio 2002
![Page 42: Anti-TNF, scompenso cardiaco e cardiopatia · PDF fileAnti-TNF, scompenso cardiaco e cardiopatia ischemica : “Controversie e raccomandazioni” Alberto Moggi Pignone SOD Medicina](https://reader038.vdocuments.mx/reader038/viewer/2022102803/5a7a54027f8b9a0d098c09b6/html5/thumbnails/42.jpg)
In realtà la prevalenza di HFnella popolazione oggetto dello
studio, confrontata per età eSesso, è sovrapponibile alla
popolazione generale degli US.
La risoluzione e/o il miglioramentodel quadro clinico dopo la
sospensione degli anti TNF e dopo adeguata terapia
“Fa ipotizzare un rapporto causale”
![Page 43: Anti-TNF, scompenso cardiaco e cardiopatia · PDF fileAnti-TNF, scompenso cardiaco e cardiopatia ischemica : “Controversie e raccomandazioni” Alberto Moggi Pignone SOD Medicina](https://reader038.vdocuments.mx/reader038/viewer/2022102803/5a7a54027f8b9a0d098c09b6/html5/thumbnails/43.jpg)
Acute coronary syndrome afterinfliximab therapy in a patientswith Crohn’s disease.Panteris V et al. World J Gastroenterol 2006
Case report che classifica la correlazione tra uso del farmaco ed
evento clinico come “probabile”
![Page 44: Anti-TNF, scompenso cardiaco e cardiopatia · PDF fileAnti-TNF, scompenso cardiaco e cardiopatia ischemica : “Controversie e raccomandazioni” Alberto Moggi Pignone SOD Medicina](https://reader038.vdocuments.mx/reader038/viewer/2022102803/5a7a54027f8b9a0d098c09b6/html5/thumbnails/44.jpg)
Heart fealure in RA: Rates, Predictors, and the effects ofAnti-Tumor Necrosis Factor
Therapy.Wolfe F et al., Am J Med 2004
Studio su circa 16.000 pazienticon AR ed OA che suggerisce un
effetto protettivo delle terapie anti-TNFsulle patologie CV correlate ad AR
E OA
![Page 45: Anti-TNF, scompenso cardiaco e cardiopatia · PDF fileAnti-TNF, scompenso cardiaco e cardiopatia ischemica : “Controversie e raccomandazioni” Alberto Moggi Pignone SOD Medicina](https://reader038.vdocuments.mx/reader038/viewer/2022102803/5a7a54027f8b9a0d098c09b6/html5/thumbnails/45.jpg)
Treatment with TNF blockersIs associated with a lowerIncidence of first CV events
In patients with RA.Jacobsson et al:
J Rheumatol 2005
983 pazienti
![Page 46: Anti-TNF, scompenso cardiaco e cardiopatia · PDF fileAnti-TNF, scompenso cardiaco e cardiopatia ischemica : “Controversie e raccomandazioni” Alberto Moggi Pignone SOD Medicina](https://reader038.vdocuments.mx/reader038/viewer/2022102803/5a7a54027f8b9a0d098c09b6/html5/thumbnails/46.jpg)
Reduction in the incidence ofMI in patients with RA who
respond to anti-TNF α therapy:results from the British Society
for rheumatolgy biologics register.Dixon WG et al:
Arthritis Rheum 2007
Circa 11.000pazienti !!
![Page 47: Anti-TNF, scompenso cardiaco e cardiopatia · PDF fileAnti-TNF, scompenso cardiaco e cardiopatia ischemica : “Controversie e raccomandazioni” Alberto Moggi Pignone SOD Medicina](https://reader038.vdocuments.mx/reader038/viewer/2022102803/5a7a54027f8b9a0d098c09b6/html5/thumbnails/47.jpg)
Biological treatment in rheumaticdiseases: results from a
logitudinal surveillance: adverseevents.
Konttinen L et al. Rheum Int 2006
“284 casi studiati in 5 anni”
![Page 48: Anti-TNF, scompenso cardiaco e cardiopatia · PDF fileAnti-TNF, scompenso cardiaco e cardiopatia ischemica : “Controversie e raccomandazioni” Alberto Moggi Pignone SOD Medicina](https://reader038.vdocuments.mx/reader038/viewer/2022102803/5a7a54027f8b9a0d098c09b6/html5/thumbnails/48.jpg)
All–cause and cause-specificmortality in RA are not greaterthan expected when treatedwith tumor necrosis factorantagonists.Carmona L et al., Ann Rheum Dis 2007
“4459 cases”
![Page 49: Anti-TNF, scompenso cardiaco e cardiopatia · PDF fileAnti-TNF, scompenso cardiaco e cardiopatia ischemica : “Controversie e raccomandazioni” Alberto Moggi Pignone SOD Medicina](https://reader038.vdocuments.mx/reader038/viewer/2022102803/5a7a54027f8b9a0d098c09b6/html5/thumbnails/49.jpg)
Haert Failure among youngerRA and Cronh’s patients
exposed to TNF alpha antagonists
Curtis JR et al, Rheumatology 2007
“4018 pazienti, follow-up 18 mesi”
![Page 50: Anti-TNF, scompenso cardiaco e cardiopatia · PDF fileAnti-TNF, scompenso cardiaco e cardiopatia ischemica : “Controversie e raccomandazioni” Alberto Moggi Pignone SOD Medicina](https://reader038.vdocuments.mx/reader038/viewer/2022102803/5a7a54027f8b9a0d098c09b6/html5/thumbnails/50.jpg)
Does TNFα inhibitionPromote or preventHeart fealure in patientsWith RA ?Listing J et al; Arthritis Rheum 2008
2757 pazient, 1491 controlli, follow-up3 anni:
La terapia con anti TNF α sembra piùprotettiva che dannosa rispetto
al rischio CV
![Page 51: Anti-TNF, scompenso cardiaco e cardiopatia · PDF fileAnti-TNF, scompenso cardiaco e cardiopatia ischemica : “Controversie e raccomandazioni” Alberto Moggi Pignone SOD Medicina](https://reader038.vdocuments.mx/reader038/viewer/2022102803/5a7a54027f8b9a0d098c09b6/html5/thumbnails/51.jpg)
Nessun episodio35I. P (lieve)
Nessun episodio1618Disf. Diast.t.
Nessun episodio35NYHA I-II
Nessun episodio2 pregressi IMA (PTCA + STENT ) senza piùepisodi di angina da almeno 2 anni
4 pregressi IMA (PTCA + STENT) senza piùepisodi di angina da almeno 2 anni
PREGRESSA CAD
1 episodio di lieve oppressione toracica (ECG neg.) risoltasi senza l’interruzione della terapia
2214Ip. Art.
1 episodio di modesto rialzo pressorio risoltosi senza l’interruzione della terapia
6045No impegno CV
Eventi avversi CVAr.SieronegAR
![Page 52: Anti-TNF, scompenso cardiaco e cardiopatia · PDF fileAnti-TNF, scompenso cardiaco e cardiopatia ischemica : “Controversie e raccomandazioni” Alberto Moggi Pignone SOD Medicina](https://reader038.vdocuments.mx/reader038/viewer/2022102803/5a7a54027f8b9a0d098c09b6/html5/thumbnails/52.jpg)
E’ evidente che le terapiebiologiche sono ad oggi
uno strumento terapeuticofondamentale in diverse
patologie a carattereinfiammatorio, incluse molte
“malattie reumatiche”
CONCLUSIONI
![Page 53: Anti-TNF, scompenso cardiaco e cardiopatia · PDF fileAnti-TNF, scompenso cardiaco e cardiopatia ischemica : “Controversie e raccomandazioni” Alberto Moggi Pignone SOD Medicina](https://reader038.vdocuments.mx/reader038/viewer/2022102803/5a7a54027f8b9a0d098c09b6/html5/thumbnails/53.jpg)
E’ accettato l’utilizzo di taliterapie in pazienti che non presentino uno scompenso
cardiaco in classe funzionale III-IV
Perché verosimilmenteprivo di conseguenze
sul piano CV
CONCLUSIONI
![Page 54: Anti-TNF, scompenso cardiaco e cardiopatia · PDF fileAnti-TNF, scompenso cardiaco e cardiopatia ischemica : “Controversie e raccomandazioni” Alberto Moggi Pignone SOD Medicina](https://reader038.vdocuments.mx/reader038/viewer/2022102803/5a7a54027f8b9a0d098c09b6/html5/thumbnails/54.jpg)
L’ipotesi più logica è che talifarmaci si debbano utilizzare
quando esiste il massimo“burden citochinico”,
come nei pazienti nelle fasi iniziali del
processo infiammatorio
CONCLUSIONI
![Page 55: Anti-TNF, scompenso cardiaco e cardiopatia · PDF fileAnti-TNF, scompenso cardiaco e cardiopatia ischemica : “Controversie e raccomandazioni” Alberto Moggi Pignone SOD Medicina](https://reader038.vdocuments.mx/reader038/viewer/2022102803/5a7a54027f8b9a0d098c09b6/html5/thumbnails/55.jpg)
E’ quindi anche ipotizzabileche nelle malattie reumatiche
l’uso precoce delle terapiebiologiche possa essere
di aiuto nel prevenirenon solo il danno articolarema anche l’evoluzione del
danno CV
CONCLUSIONI
![Page 56: Anti-TNF, scompenso cardiaco e cardiopatia · PDF fileAnti-TNF, scompenso cardiaco e cardiopatia ischemica : “Controversie e raccomandazioni” Alberto Moggi Pignone SOD Medicina](https://reader038.vdocuments.mx/reader038/viewer/2022102803/5a7a54027f8b9a0d098c09b6/html5/thumbnails/56.jpg)
…… che ovviamenteamplificherebbe molto
l’impatto già così rilevantedelle terapie biologiche
nelle malattie reumatiche
![Page 57: Anti-TNF, scompenso cardiaco e cardiopatia · PDF fileAnti-TNF, scompenso cardiaco e cardiopatia ischemica : “Controversie e raccomandazioni” Alberto Moggi Pignone SOD Medicina](https://reader038.vdocuments.mx/reader038/viewer/2022102803/5a7a54027f8b9a0d098c09b6/html5/thumbnails/57.jpg)
Ne consegue che risultasempre più mandatoria
una diagnostica precoce per poter utilizzare le
migliori strategie terapeutichenelle “early arthritis”
CONCLUSIONI
![Page 58: Anti-TNF, scompenso cardiaco e cardiopatia · PDF fileAnti-TNF, scompenso cardiaco e cardiopatia ischemica : “Controversie e raccomandazioni” Alberto Moggi Pignone SOD Medicina](https://reader038.vdocuments.mx/reader038/viewer/2022102803/5a7a54027f8b9a0d098c09b6/html5/thumbnails/58.jpg)
Ringraziamenti:SOD di Reumatologia(Dir.Prof.M.Matucci Cerinic)Equipe del DH Reumatologico:Dr. G. FioriDr. G. Salvadorini