Cardiovascular risk in rheumatoid arthritis: comparing TNF-α blockade with nonbiologic DMARDs.
Cardiovascular risk in rheumatoid arthritis: comparing TNF-α blockade with nonbiologic DMARDs.
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DOI：
10.1016/j.amjmed.2013.02.016
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发表时间：
2013-08
期刊：
影响因子：
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通讯作者：
Rassen JA
中科院分区：
文献类型：
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作者：
Solomon DH;Curtis JR;Saag KG;Lii J;Chen L;Harrold LR;Herrinton LJ;Graham DJ;Kowal MK;Kuriya B;Liu L;Griffin MR;Lewis JD;Rassen JA
肿瘤坏死因子α升高可能是类风湿性关节炎患者心血管风险增加的原因之一。我们比较了类风湿性关节炎患者开始使用肿瘤坏死因子α阻滞剂和非生物修饰的抗风湿药物(NBDMARD)的心血管风险。在1998-2007年间参加了几个不同美国保险计划的类风湿性关节炎患者接受了甲氨蝶呤治疗，符合条件。在COX回归模型中，将加入肿瘤坏死因子α阻滞剂的受试者与加入NBDMARD的受试者进行比较，按倾向评分进行分层，并根据口服糖皮质激素剂量进行调整。我们在6个月后检查了心肌梗死、中风或冠状动脉再血管化的复合心血管终点。我们比较了8,656名使用NBDMARD的新用户和11,587名使用具有相似基线协变量的肿瘤坏死因子α阻滞剂的新用户。复合心血管终点的每百人年发病率nbDMARDS为3.05(95%可信区间2.54-3.65)，肿瘤坏死因子α阻滞剂为2.52(95%可信区间2.12-2.98)。肿瘤坏死因子α阻滞剂与首次暴露的nbDMARD相比，危险比(HR)为0.80(95%CI 0.6 2~1.0 4)，而AS分析的HR为0.71(95%CI 0.5 2~0.97)。在65岁的患者中，肿瘤坏死因子α阻滞剂对心血管的潜在益处最大(HR0.52，95%CI0.34-0.77；相互作用时p=0.075)。在类风湿性关节炎患者中，与nbDMARD相比，肿瘤坏死因子α阻滞剂可能与心血管事件的风险降低有关。应该考虑进行随机对照临床试验来检验这一假设。
Elevated TNFα likely contributes to the excess cardiovascular risk observed in rheumatoid arthritis. We compared the cardiovascular risk in rheumatoid arthritis patients starting a TNFα blocking agent versus a non-biologic disease-modifying anti-rheumatic drug (nbDMARD). Subjects with rheumatoid arthritis participating in several different US insurance programs between 1998-2007 who received methotrexate were eligible. Those who added a TNFα blocking agent were compared with subjects who added a nbDMARD in Cox regression models stratified by propensity score decile and adjusted for oral glucocorticoid dosage. We examined the composite cardiovascular endpoint of myocardial infarction, stroke, or coronary re-vascularization after six months. We compared 8,656 new users of a nbDMARD with 11,587 new users of a TNFα blocking agent with similar baseline covariates. Incidence rates per 100 person-years for the composite cardiovascular endpoint were 3.05 (95% CI 2.54 – 3.65) for nbDMARDs and 2.52 (95% CI 2.12-2.98) for TNFα blocking agents. The hazard ratio (HR) for the TNFα blocking agent compared with nbDMARD carrying the first exposure forward was 0.80 (95% CI 0.62 - 1.04), while the HR for the as-treated analysis was 0.71 (95% CI 0.52 - 0.97). The potential cardiovascular benefit of TNFα blocking agents was strongest among persons ≥ 65 years of age (HR 0.52, 95% CI 0.34 – 0.77; p for interaction = 0.075). Among subjects with rheumatoid arthritis, TNFα blocking agents may be associated with a reduced risk of cardiovascular events compared to a nbDMARD. Randomized controlled clinical trials should be considered to test this hypothesis.