Updated cardiac concerns with rituximab use: A growing challenge

Autoimmune blistering disorders and cardiovascular risks: A population-based cohort study

BACKGROUND

Autoimmune blistering disorders (ABDs) might elevate cardiovascular risk, but studies are lacking.

OBJECTIVE

The objective of this study was to examine if ABDs elevate the risk of atherosclerotic cardiovascular disease, heart failure, arrhythmia, venous thromboembolism, and cardiovascular death.

METHODS

A population-based cohort of Danish patients with ABD (≥18 years of age) diagnosed during 1996-2021 (n = 3322) was compared with an age- and sex-matched comparison cohort from the general population (n = 33,195).

RESULTS

Compared with the general population, patients with ABDs had higher 1-year risks of atherosclerotic cardiovascular disease (3.4% vs 1.6%), heart failure (1.9% vs 0.7%), arrhythmia (3.8% vs 1.3%), venous thromboembolism (1.9% vs 0.3%), and cardiovascular death (3.3% vs 0.9%). The elevated risk persisted after 10 years for all outcomes but arrhythmia. The hazard ratios associating ABDs with the outcomes during the entire follow-up were 1.24 (1.09-1.40) for atherosclerotic cardiovascular disease, 1.48 (1.24-1.77) for heart failure, 1.16 (1.02-1.32) for arrhythmia, 1.87 (1.50-2.34) for venous thromboembolism, and 2.01 (1.76-2.29) for cardiovascular death. The elevated cardiovascular risk was observed for both pemphigus and pemphigoid.

LIMITATIONS

Our findings might only generalize to patients with ABDs without prevalent cardiovascular diseases.

CONCLUSION

Patients with ABDs had an elevated cardiovascular risk compared with age- and sex-matched controls.

A practical guide to the management of immune thrombocytopenia co-existing with acute coronary syndrome

Introduction

Immune thrombocytopenia (ITP) management with co-existing acute coronary syndrome (ACS) remains challenging as it requires a clinically relevant balance between the risk and outcomes of thrombosis and the risk of bleeding. However, the literature evaluating the treatment approaches in this high-risk population is scarce.

Methods and Results

In this review, we aimed to summarize the available literature on the safety of ITP first- and second-line therapies to provide a practical guide on the management of ITP co-existing with ACS. We recommend holding antithrombotic therapy, including antiplatelet agents and anticoagulation, in severe thrombocytopenia with a platelet count < 30 × 109/L and using a single antiplatelet agent when the platelet count falls between 30 and 50 × 109/L. We provide a stepwise approach according to platelet count and response to initial therapy, starting with corticosteroids, with or without intravenous immunoglobulin (IVIG) with a dose limit of 35 g, followed by thrombopoietin receptor agonists (TPO-RAs) to a target platelet count of 200 × 109/L and then rituximab.

Conclusion

Our review may serve as a practical guide for clinicians in the management of ITP co-existing with ACS.

An Unusual Case of Delayed-Onset Rituximab-Induced Ventricular Tachycardia: A Case Report

Cardiac disease associated with cancer treatment is a common adverse effect that is well-treated with appropriate monitoring. However, some cardiac adverse effects with cancer treatment are not well-understood, in particular rituximab-associated ventricular tachycardia. We present the fourth case of rituximab-associated ventricular tachycardia in a patient who is rituximab-naive and who does not have known cardiac disease history. This patient developed non-sustained polymorphic ventricular tachycardia 14 hours after rituximab was started and 6 hours after it was stopped, and after extensive monitoring including a 30-day event monitor, did not develop further significant runs of ventricular tachycardia.

Ginsenoside Rg2 attenuates myocardial fibrosis and improves cardiac function after myocardial infarction via AKT signaling pathway

With the popularization of percutaneous coronary intervention technology in clinical applications, the mortality rate of acute myocardial infarction has been significantly reduced. However, ventricular remodeling following myocardial infarction (MI) has attracted extensive attention for that it can cause malignant arrhythmia, heart failure, and even death. We aimed to investigate the effects of ginsenoside Rg2 on cardiac function and myocardial fibrosis after MI and its potential mechanism. The results demonstrated that ginsenoside Rg2 improved cardiac function and inhibited collagen deposition in mice after MI. In addition, ginsenoside Rg2 reduced the levels of fibrosis-associated genes Collagen I (Col 1), Collagen III (Col 3), and alpha-smooth muscle actin (α-SMA) by activating phosphorylated AKT in angiotensin II-induced cardiac fibroblasts. Taken together, ginsenoside Rg2 improves cardiac function and attenuates cardiac fibrosis via the AKT pathway, suggesting that ginsenoside Rg2 may be a promising drug for the prevention of ventricular remodeling after MI. Abbreviations: MI: myocardial infarction; AMI: acute myocardial infarction; LAD: left anterior descending; ECM: extracellular matrix; Col 1: collagen I; Col 3: collagen III; α-SMA: alpha-smooth muscle actin; ROS: reactive oxygen species; SOD: superoxide dismutase; GSH: glutathione; HO-1: heme oxygenase-1; WST8: water-soluble tetrazolium salt 8.

Complication from Desensitization

Sensitization to human leukocyte antigens (HLAs) has been one of the major clinical challenges for successful kidney transplantation. In end-stage renal disease, kidney transplantation provides benefits compared with dialysis in terms of improved patient survival better quality of life, and lower ongoing costs after the first year. Living donor kidney transplantation has an advantage with improved allograft survival, and performed earlier and electively compared with deceased donor transplantation. However sensitized patients are increasing in number on transplant waiting lists, and their prospect of getting a transplant is less than nonsensitized patients due to immunological incompatibility with the donor. Strategy for sensitized patients are listing for a compatible deceased donor transplant or, if they have a living donor, either selecting a kidney exchange program or undergoing a desensitization procedure. Desensitization procedures may be undertaken to increase access to either living or deceased donor transplants, and in some situations may also be employed to facilitate participation in a kidney exchange, in less immunological barrier to be overcome. The question of whether individuals are better off with a desensitization treatment followed by HLA-incompatible living donor transplantation or waiting on the deceased donor kidney transplant list for a compatible transplant has recently been addressed by two large multicenter studies, with conflicting results. A multicenter study from the United States published in the New England Journal of Medicine [365;318 326.2011] concluded that there was a strong survival benefit for sensitized patients undergoing desensitization followed by HLA-incompatible living donor kidney transplant compared with those remaining on the waiting list. Of interest, a second study, published in the Lancet, [389;727 734.2017] found no significant survival advantage for desensitized patients compared with similar patients remaining on the waiting list in the United Kingdom. Controversies still remain regarding how desensitization can be achieved and which techniques are effective and safe.

In this chapter various complications from the desensitization will be dealt with in current use of medications or armamentum.

Anterior ST-elevation myocardial infarction induced by rituximab infusion: A case report and review of the literature

WHAT IS KNOWN AND OBJECTIVES

Rituximab is a chimeric monoclonal anti-CD20 antibody approved for the treatment of some lymphoid malignancies as well as for autoimmune diseases including rheumatoid arthritis (RA), idiopathic thrombocytopenic purpura (ITP) and vasculitis. Generally, rituximab is well tolerated; nevertheless, some patients develop adverse effects including infusion reactions. Albeit rare, these reactions may in some cases be life-threatening conditions. Rituximab cardiovascular side effects include more common effects such as hypertension, oedema and rare cases of arrhythmias and myocardial infarction.

CASE SUMMARY

In this article, we report a case of a 58-year-old man with a history of overlap syndrome including RA and limited scleroderma who was treated with rituximab and developed a dramatic ST-elevation myocardial infarction (STEMI) during the drug administration.

WHAT IS NEW AND CONCLUSION

This report underlines previous published reports emphasizing the awareness of such an association. This communication also warrants the importance of screening for ischaemic heart disease in selected cases of patients treated with rituximab.