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

Cilliers A, Manyemba J, Saloojee H

Published Online:

October 7, 2009

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.

Abstract (click to read)

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 strategy:

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.

This record should be cited as:

Cilliers A, Manyemba J, Saloojee H. Anti-inflammatory treatment for carditis in acute rheumatic fever. Cochrane Database of Systematic Reviews 2003, Issue 2. Art. No.: CD003176. DOI: 10.1002/14651858.CD003176

Assessed as up to date:

July 22, 2009

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Primary Review Group:

Heart Group

Health topics:

Heart & circulation > Rheumatic fever

Infectious disease > Rheumatic fever

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Independent high-quality evidence for health care decision making

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

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