Systemic inflammatory response syndromes in the era of interventional cardiology

Management of Systemic Inflammatory Response Syndrome After Cardiovascular Interventions. Diagnostic, Prognostic, and Therapeutic Implications

A substantial number of patients may experience systemic inflammatory response syndrome (SIRS) and related adverse events after transcatheter aortic valve implantation and endovascular aortic aneurysm repair. Although a clear etiology has not been established, endothelial disruption and tissue-ischemic response secondary to the foreign material may represent the trigger events. A latency period (0 to 48 hours) may occur between the initial injury and onset of symptoms mirroring an initial local response followed by a systemic response. Clinical presentation can be mild or severe depending on external triggers and characteristics of the patient. Diagnosis is challenging because it simulates an infection, but lack of response to antibiotics, negative cultures are supportive of SIRS. Increased in-hospital stay, readmissions, major cardiovascular events, and reduced durability of the device used are the main complications. Treatment includes non-steroidal anti-inflammatory drugs or corticosteroids. In conclusion, further studies are warranted to fully explore pathophysiologic mechanisms underpinning SIRS and the possibility of enhancing device material immune compatibility to reduce the inflammatory reaction of the host tissue.

Outcomes of post-implantation syndrome after endovascular repair for Stanford type B aortic dissection

OBJECTIVE

The aim of this study was to investigate the correlation between post-implantation syndrome (PIS) and long-term prognosis in patients with Stanford type B aortic dissection (TBAD) undergoing thoracic endovascular aortic repair (TEVAR).

METHODS

This retrospective study included 547 consecutive patients diagnosed with TBAD who underwent TEVAR at our institution between January 2014 and December 2019. Patients were categorized into two groups: the PIS group (patients with post-TEVAR PIS) and the non-PIS group (patients without post-TEVAR PIS). In-hospital and follow-up data were analyzed.

RESULTS

The incidence of PIS was 28.9% (158/547 patients). No baseline differences were observed between the PIS (n = 158) and the non-PIS (n = 389) groups. The proportion of emergency surgery in the PIS group was higher than that in the non-PIS group (44.9% vs 26.0%; P < .001), the operation time was longer (median, 65.0; interquartile range [IQR], 56.0-75.0 minutes vs 56.0; IQR, 45.0-66.0 minutes; P < .001), the volume of contrast medium used (median, 65.0; IQR, 56.0-75.0 mL vs 56.0; IQR, 45.0-66.0 mL; P < .001), and the average number of trunk stents (1.85 ± 0.4 vs 1.34 ± 0.5 pieces; P < .001) and branch stents (0.7 ± 0.7 vs 0.2 ± 0.5 pieces; P < .001) used were more in the PIS group than in the non-PIS group. The incidence of supra-aortic branch procedures was higher in the PIS group than in the non-PIS group. There was no significant difference in device-related complications (DRCs) or 30-day mortality between the two groups (2.5% vs 4.4%; P = .442 and 1.3% vs 1.3%; P = .688, respectively). Univariate and multivariable logistic regression analysis showed that emergency surgery, number of trunk stents >1, operation time >58.5 minutes, and contrast medium volume >75 mL were risk factors for PIS, and the odds ratios of emergency operation, number of trunk stents >1 piece, operation time >58.5 minutes, and contrast medium volume >75 mL were 2.526 (95% confidence interval [CI], 1.530-4.173), 4.651 (95% CI, 2.838-7.624), 3.577 (95% CI, 2.201-5.815), and 7.356 (95% CI, 4.111-13.160), respectively. Follow-up was completed in 98.5% (532/540) of the patients, with a median follow-up of 67 months (IQR, 50-86 months). There was no significant difference in survival between the PIS and non-PIS groups (12.4% vs 10.3%; P = .476) during follow-up. The incidences of DRCs (7.8% vs 11.6%; P = .200) and aortic false lumen thrombosis (75.8% vs 79.2%; P = .399) were comparable between the PIS and non-PIS groups. Univariate logistic regression analysis showed that PIS had no effect on long-term follow-up mortality, DRCs, entry flow, or aortic false lumen thrombosis rate.

CONCLUSIONS

PIS is relatively common after TEVAR and emergency surgery; number of trunk stents >1, operation time >58.5 minutes, and contrast medium volume >75 mL are of high predictive value for the assessment of PIS after TEVAR. However, PIS had little effect on early and late postoperative mortality or DRCs.

Remote ischaemic preconditioning for transcatheter aortic valve replacement: a protocol for a systematic review with meta-analysis and trial sequential analysis

INTRODUCTION

Transcatheter aortic valve replacement (TAVR) has become an important treatment in patients with aortic valve disease with the continuous advancement of technology and the improvement of outcomes. However, TAVR-related complications still increase patient morbidity and mortality. Remote ischaemic preconditioning (RIPC) is a simple procedure that provides perioperative protection for many vital organs. However, the efficiency of RIPC on TAVR remains unclear based on inconsistent conclusions from different clinical studies. Therefore, we will perform a protocol for a systematic review and meta-analysis to identify the efficiency of RIPC on TAVR.

METHODS AND ANALYSIS

English databases (PubMed, Web of Science, Ovid Medline, Embase and Cochrane Library), Chinese electronic databases (Wanfang Database, VIP Database and China National Knowledge Infrastructure) and trial registry databases will be searched from inception to December 2023 to identify randomised controlled trials of RIPC on TAVR. We will calculate mean differences or standardised mean differences with 95% CIs for continuous data, and the risk ratio (RR) with 95% CIs for dichotomous data by Review Manager version 5.4. Fixed-effects model or random-effects model will be used according to the degree of statistical heterogeneity assessed by the I-square test. We will evaluate the risk of bias using the Cochrane risk-of-bias tool 2 and assess the evidence quality of each outcome by the Grading of Recommendations Assessment, Development and Evaluation. The robustness of outcomes will be evaluated by trial sequential analysis. In addition, we will evaluate the publication bias of outcomes by Funnel plots and Egger's regression test.

ETHICS AND DISSEMINATION

Ethical approval was not required for this systematic review protocol. The results will be disseminated through peer-reviewed publications.

PROSPERO REGISTRATION NUMBER

CRD42023462926.

Immune response following transcatheter aortic valve procedure

Aortic valve stenosis is the most common type of heart valve disease in the United States and Europe and calcific aortic stenosis (AS) affects 2-7% of people aged 65 years and older. Aortic valve replacement (AVR) is the only effective treatment for individuals with this condition. Transcatheter Aortic Valve Replacement (TAVR) has been widely accepted as a minimally invasive therapeutic approach for addressing symptomatic AS in patients who are considered to have a high risk for traditional surgical intervention. TAVR procedure may have a paradoxical effect on the immune system and inflammatory status. A major portion of these immune responses is regulated by activating or inhibiting inflammatory monocytes and the complement system with subsequent changes in inflammatory cytokines. TAVR has the potential to induce various concurrent exposures, including disruption of the native valve, hemodynamic changes, antigenicity of the bioprosthesis, and vascular damage, which finally lead to the development of inflammation. On the other hand, it is important to acknowledge that TAVR may also have anti-inflammatory effects by helping in the resolution of stenosis.The inflammation and immune response following TAVR are complex processes that significantly impact procedural outcomes and patient well-being. Understanding the underlying mechanisms, identifying biomarkers of inflammation, and exploring therapeutic interventions to modulate these responses are crucial for optimizing TAVR outcomes. Further research is warranted to elucidate the precise immunological dynamics and develop tailored strategies to attenuate inflammation and enhance post-TAVR healing while minimizing complications.

Analysis of risk factors for systemic inflammatory response syndrome in patients after transcatheter aortic valve replacement

OBJECTIVE

Our aim was to determine the risk factors of postoperative systemic inflammatory response syndrome (SIRS) in patients with transcatheter aortic valve replacement (TAVR), identify those with a high risk of SIRS, and help reduce SIRS occurrence.

METHODS

A retrospective cohort study was conducted to collect the clinical data of patients who underwent TAVR from January 2014 to December 2019 at a tertiary hospital in Zhejiang Province. The study included 156 men and 94 women. Patients were divided into SIRS and non-SIRS groups. The pre-, intra-, and postoperative indices of the two groups were recorded. The data of the two groups were compared, and univariate analysis was performed. All statistically significant factors were assessed using binary logistic regression analysis to clarify the risk factors of SIRS after TAVR.

RESULTS

Overall, 30 patients developed SIRS after TAVR, with an incidence rate of 12%, an odds ratio (OR) of 0.571, and a 95% confidence interval (CI) of 0.469-0.694 (p = 0.000). There was a significant correlation between SIRS and glucose (OR: 0.823, 95% CI: 0.678-1.000, p = 0.049), albumin (OR: 0.938, 95% CI: 0.881-0.998, p = 0.044), brain natriuretic peptide (OR: 1.000, 95% CI: 1.000-1.000, p = 0.010), sex (OR: 0.412, 95% CI: 0.190-0.892, p = 0.025), and history of hypertension (OR: 0.375, 95% CI: 0.169-0.819, p = 0.014). Multivariate regression analysis demonstrated that age (OR: 1.190, 95%CI: 1.073-1.319, p = 0.001) and body mass index (BMI; OR: 0.559, 95% CI: 0.447-0.698, p = 0.000) were independent risk factors for postoperative SIRS in patients with TAVR.

CONCLUSION

The incidence of SIRS after TAVR was 12%. There was a significant correlation between SIRS and albumin, glucose, and hypertension. The independent risk factors for SIRS after TAVR were age and BMI.

Aortic Stenosis Phenotypes and Precision Transcatheter Aortic Valve Implantation

Patients with a clinical indication for aortic valve replacement can either undergo surgical aortic valve replacement (SAVR) or Transcatheter Aortic Valve Implantation (TAVI). There are many different factors that go into determining which type of replacement to undergo, including age, life expectancy, comorbidities, frailty, and patient preference. While both options offer significant benefits to patients in terms of clinical outcomes and quality of life, there is growing interest in expanding the indications for TAVI due to its minimally invasive approach. However, it is worth noting that there are several discrepancies in TAVI outcomes in regards to various endpoints, including death, stroke, and major cardiovascular events. It is unclear why these discrepancies exist, but potential explanations include the diversity of etiologies for aortic stenosis, complex patient comorbidities, and ongoing advancements in both medical therapies and devices. Of these possibilities, we propose that phenotypic variation of aortic stenosis has the most significant impact on post-TAVI clinical outcomes. Such variability in phenotypes is often due to a complex interplay between underlying comorbidities and environmental and inherent patient risk factors. However, there is growing evidence to suggest that patient genetics may also play a role in aortic stenosis pathology. As such, we propose that the selection and management of TAVI patients should emphasize a precision medicine approach.

Carbon dioxide flushing versus saline flushing of thoracic aortic stents (INTERCEPTevar): protocol for a multicentre pilot randomised controlled trial

INTRODUCTION

Thoracic endovascular aortic repair (TEVAR) carries a 3%-6.1% stroke risk, including risk of 'silent' cerebral infarction (SCI). Stent-grafts are manufactured in room air and retain air. Instructions for use recommend saline flushing to 'de-air' the system prior to insertion, but substantial amounts of air are released when deploying them, potentially leading to downstream neuronal injury and SCI. Carbon dioxide (CO2) is more dense and more soluble in blood than air, without risk of bubble formation, so could be used in addition to saline to de-air stents. This pilot trial aims to assess the feasibility of a full-scale randomised controlled trial (RCT) investigating the neuroprotective benefit against SCI with the use of CO2-flushed aortic stent-grafts.

METHODS AND ANALYSIS

This is a multicentre pilot RCT, which is taking place in vascular centres in the UK, USA and New Zealand. Patients identified for TEVAR will be enrolled after informed written consent. 120 participants will be randomised (1:1) to TEVAR-CO2 or TEVAR-saline, stratified according to TEVAR landing zone. Participants will undergo preoperative neurocognitive tests and quality of life assessments, which will be repeated at 6 weeks, or first outpatient appointment, and 6 months. Inpatient neurological testing will be performed within 48 hours of return to level 1 care for clinical stroke or delirium. Diffusion-weighted MRI will be undertaken within 72 hours postoperatively (1-7 days) and at 6 months to look for evidence and persistence of SCI. Feasibility will be assessed via measures of recruitment and retention, informing the design of a full-scale trial.

ETHICS AND DISSEMINATION

The study coordination centre has obtained approval from the London Fulham Research Ethics Committee (19/LO/0836) and Southern Health and Disability Ethics Committee (NZ) and UK's Health Regulator Authority (HRA). The study has received ethical approval for recruitment in the UK (Fulham REC, 19/LO/0836), New Zealand (21/STH/192) and the USA (IRB 019-264, Ref 378630). Consent for entering into the study will be taken using standardised consent forms by the local study team, led by a local PI. The results of the trial will be submitted for publication in an open access journal.

TRIAL REGISTRATION NUMBER

NCT03886675.

Relation of Preprocedure Platelet-to-Lymphocyte Ratio and Major Adverse Cardiovascular Events Following Transcatheter Aortic Valve Implantation for Aortic Stenosis

The platelet-to-lymphocyte ratio (PLR) is a novel inflammatory biomarker that has prognostic value in patients presenting with acute coronary syndrome. Transcatheter aortic valve implantation (TAVI) treats the inflammatory disease of aortic stenosis. However, the utility of preprocedure PLR in predicting major adverse cardiovascular events (MACE) after TAVI is not clear. Our study population included 470 patients who underwent TAVI at The Alfred Hospital in Melbourne, Australia from August 2008, to January 2019. Patients were divided into 4 groups based on PLR quartiles. The incidence of 30-day MACE (a composite of stroke, myocardial infarction, and death) was then compared. Outcomes were reported according to the Valve Academic Research Consortium-2 criteria. Of 470 patients, median age 84 years, 54% men, and median Society of Thoracic Surgeons score of 3.5%, 14 (3%) suffered a MACE within 30 days. Rates of MACE were low in all 4 groups (1.7%, 2.5%, 2.6%, 5.1%, respectively) with no statistically significant difference in the different PLR groups (p = 0.46). This nonsignificant association was supported by univariate logistic regression analysis of PLR as a continuous variable (odds ratio 1.01, p = 0.55). Using multivariable logistic regression analysis accounting for age, gender, self-expanding valve, and procedural risk, a higher PLR did not correlate with MACE (odds ratio 1.01, p = 0.60). In this study of a large cohort of TAVI patients, elevated preprocedure PLR was not independently associated with MACE after TAVI. This is a novel finding in comparison with previous studies.

Prevalence, Predictors, and Clinical Presentation of Acute Pericardial Effusion Following Percutaneous Coronary Intervention

Background: Iatrogenic pericardial effusion (PE) has been demonstrated to lead to cardiac injury as a sign of systemic inflammatory response. Objectives: This study sought to determine the anatomical characteristics and clinical presentation associated with PE after percutaneous coronary intervention (PCI) by using echocardiography. Methods: The clinical outcomes of all patients with coronary artery disease who underwent PCI from July 2014 to December 2018 were evaluated. The quantitative and qualitative analyses of PE were performed. The associations between the presence of PE and procedural factors were also evaluated. Results: A total of 882 patients were enrolled. PE was found in 144 patients (16.3%) and was mostly located in the anterior pericardium at low amounts. The serum levels of high-sensitive C-reaction protein before PCI and troponin T in the group with PE after PCI were significantly higher than those in the group without PE (p < 0.0001). The presence of PE was associated with the procedural time (OR = 1.02, p = 0.035) and the degree of interventional complexity (multiple vessels OR = 1.89, p = 0.014; chronic total occlusion OR = 2.04, p = 0.005; and PCI with rotational atherectomy OR = 1.15, p = 0.011) independent of the number of culprit vessels and stents. During 1-year follow-up, a significantly higher number of cardiac deaths (3) and myocardial infarctions (8) occurred in patients with PE than in patients without PE (P < 0.05). Conclusion: Post-PCI acute PE was frequent, generally mild, mainly asymptomatic, and independently associated with procedural time and complexity. This effusion, which is considered as a cardiac damage marker, could be a predominant clinical sign for long-term prognosis.

A New Era of Diagnosis and Therapy in Acute Aortic Syndromes: The Mainz-Essen Experience (Part II)-Management and Outcomes

Over the years, the cardiovascular department of Johannes Gutenberg University in Mainz-West-German Heart Centre in Essen (Germany) designed and implemented the hybrid operating room (2003) along with advanced endovascular and surgical procedures, including the frozen elephant trunk technique. For the study purpose, the Mainz-Essen experience on acute aortic syndromes was summarized by considering original articles from single-center or multicenter studies performed at West German Heart Centre, Essen, Germany, or at the cardiovascular department of Johannes Gutenberg University, Mainz, Germany. We present the 35-year-long Mainz-Essen research, education, and patient management journey in creating an integrated multidisciplinary "Aortic Center" in the heart of Europe.

Elevated Systemic and Intestinal Inflammatory Response Are Associated With Gut Microbiome Disorder After Cardiovascular Surgery

Systemic inflammatory response after cardiovascular surgery is associated with poor prognosis, to which gut barrier impairment is related. To investigate whether perioperative changes of the gut microbiome are associated with systemic and intestinal inflammatory response, we examined changes of the gut microbiome, intestinal homeostasis, and systemic inflammatory response in cardiovascular patients before (Pre) surgery and on the first defecation day [postoperative time 1 (Po1)] or a week [postoperative time 2 (Po2)] postsurgery. Markedly, the enhanced systemic inflammatory response was observed in Po1 and Po2 compared with that in Pre. In line with inflammatory response, impaired gut barrier and elevated gut local inflammation were observed in Po1 and Po2. Microbiome analysis showed a remarkable and steady decline of alpha diversity perioperatively. In addition, microbial composition in the postoperation period was characterized by significant expansion of Enterococcus along with a decrease in anaerobes (Blautia, Faecalibacterium, Bifidobacterium, Roseburia, Gemmiger, [Ruminococcus], and Coprococcus), which were typically health-associated bacteria. Spearman correlation analysis showed microbiome disorder was associated with enhanced systemic inflammatory response and intestinal dysbiosis. These results suggest that microbiome disorder was related to disturbed gut homeostatic and subsequently elevates plasma endotoxin and systemic inflammatory response after cardiovascular surgery. This study not only highlights gut microbiome would be considered in future clinical practice but also proposes a promising perspective of potential diagnostic and therapeutic options for perioperative management of cardiovascular surgery patients.

Innate immunity, inflammation activation and heat-shock protein in COVID-19 pathogenesis

SARS-CoV-2-induced COVID-19 is a serious pandemic of the 21st century, which has caused a devastating loss of lives and a global economic catastrophe. A successful vaccine against SARS-CoV-2 has suffered a delay due to lack of substantial knowledge about its mechanisms of action. Understanding the innate immune system against SARS-CoV-2 and the role of heat shock proteins' (HSP) inhibiting and resolution of inflammatory pathways may provide information to the low SARS-CoV-2 mortality rates in Africa. In addition, bats being a host to different viruses, including SARS-CoV-2 possess a well specialized IFN-innate antiviral inflammatory response, showing no signs of disease or pro-inflammatory cytokine storm. We discuss the molecular pathways in COVID-19 with a focus on innate immunity, inflammation, HSP responses, and suggest appropriate candidates for therapeutic targets and The contribution of the innate immune system to the efficacy of mRNA or vector based Corona immunizations.

The emerging spectrum of cardiopulmonary pathology of the coronavirus disease 2019 (COVID-19): Report of 3 autopsies from Houston, Texas, and review of autopsy findings from other United States cities

This paper collates the pathological findings from initial published autopsy reports on 23 patients with coronavirus disease 2019 (COVID-19) from 5 centers in the United States of America, including 3 cases from Houston, Texas. Findings confirm that COVID-19 is a systemic disease with major involvement of the lungs and heart. Acute COVID-19 pneumonia has features of a distinctive acute interstitial pneumonia with a diffuse alveolar damage component, coupled with microvascular involvement with intra- and extravascular fibrin deposition and intravascular trapping of neutrophils, and, frequently, with formation of microthombi in arterioles. Major pulmonary thromboemboli with pulmonary infarcts and/or hemorrhage occurred in 5 of the 23 patients. Two of the Houston cases had interstitial pneumonia with diffuse alveolar damage pattern. One of the Houston cases had multiple bilateral segmental pulmonary thromboemboli with infarcts and hemorrhages coupled with, in nonhemorrhagic areas, a distinctive interstitial lymphocytic pneumonitis with intra-alveolar fibrin deposits and no hyaline membranes, possibly representing a transition form to acute fibrinous and organizing pneumonia. Multifocal acute injury of cardiac myocytes was frequently observed. Lymphocytic myocarditis was reported in 1 case. In addition to major pulmonary pathology, the 3 Houston cases had evidence of lymphocytic pericarditis, multifocal acute injury of cardiomyocytes without inflammatory cellular infiltrates, depletion of splenic white pulp, focal hepatocellular degeneration and rare glomerular capillary thrombosis. Each had evidence of chronic cardiac disease: hypertensive left ventricular hypertrophy (420 g heart), dilated cardiomyopathy (1070 g heart), and hypertrophic cardiomyopathy (670 g heart). All 3 subjects were obese (BMIs of 33.8, 51.65, and 35.2 Kg/m2). Overall, the autopsy findings support the concept that the pathogenesis of severe COVID-19 disease involves direct viral-induced injury of multiple organs, including heart and lungs, coupled with the consequences of a procoagulant state with coagulopathy.

COVID-19-associated cardiovascular morbidity in older adults: a position paper from the Italian Society of Cardiovascular Researches

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infects host cells following binding with the cell surface ACE2 receptors, thereby leading to coronavirus disease 2019 (COVID-19). SARS-CoV-2 causes viral pneumonia with additional extrapulmonary manifestations and major complications, including acute myocardial injury, arrhythmia, and shock mainly in elderly patients. Furthermore, patients with existing cardiovascular comorbidities, such as hypertension and coronary heart disease, have a worse clinical outcome following contraction of the viral illness. A striking feature of COVID-19 pandemics is the high incidence of fatalities in advanced aged patients: this might be due to the prevalence of frailty and cardiovascular disease increase with age due to endothelial dysfunction and loss of endogenous cardioprotective mechanisms. Although experimental evidence on this topic is still at its infancy, the aim of this position paper is to hypothesize and discuss more suggestive cellular and molecular mechanisms whereby SARS-CoV-2 may lead to detrimental consequences to the cardiovascular system. We will focus on aging, cytokine storm, NLRP3/inflammasome, hypoxemia, and air pollution, which is an emerging cardiovascular risk factor associated with rapid urbanization and globalization. We will finally discuss the impact of clinically available CV drugs on the clinical course of COVID-19 patients. Understanding the role played by SARS-CoV2 on the CV system is indeed mandatory to get further insights into COVID-19 pathogenesis and to design a therapeutic strategy of cardio-protection for frail patients.

Imaging and Biomarkers in Acute Aortic Syndromes: Diagnostic and Prognostic Implications

Acute aortic syndrome (AAS) is an emergency and life-threatening condition including aortic dissection, intramural hematoma, penetrating atherosclerotic ulcer and iatrogenic-traumatic aortic injury. An integrated multiparametric approach (clinical history and examination, electrocardiogram, biomarkers and imaging techniques) is recommended in order to make timely and accurate diagnosis, delineate the prognosis, choose the most appropriate therapeutic interventions tailored for the individual patient. Nowadays the best imaging strategy for diagnosing AAS and its complications is a combination of transthoracic echocardiography and computed tomography angiography (CTA). Transesophageal echocardiography tends to be carried out in complicated cases prior to surgical or endovascular therapy, often in the operating room and under general anesthesia. In this regard, intravascular ultrasound and intraluminal phase array imaging may be implemented during the endovascular procedures depending on operator expertise and cost issues. On the other hand, owing to its intrinsic characteristics, magnetic resonance imaging is an ideal imaging technique for serial measurements in patients at risk of AAS or with chronic dissection. Among biomarkers, D-dimer is the closest to "golden status" (high sensitivity and low negative likelihood ratio). Interestingly, 18fluorodeoxyglucose positron emission tomography/CT is increasingly being used along with specific serologic biomarkers (white blood cells, C-reactive protein, fibrinogen and D-dimer) to detect and monitor vascular inflammation affecting the aorta and systemic arteries. It is expected, in the near future, the development of serologic and imaging biomarkers able to early detect clinically-silent pathologic changes in the aorta wall before (primary prevention) and after (secondary prevention) the acute index event.

Targeting the Immune System for Pulmonary Inflammation and Cardiovascular Complications in COVID-19 Patients

In December 2019, following a cluster of pneumonia cases in China caused by a novel coronavirus (CoV), named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the infection disseminated worldwide and, on March 11th, 2020, the World Health Organization officially declared the pandemic of the relevant disease named coronavirus disease 2019 (COVID-19). In Europe, Italy was the first country facing a true health policy emergency, and, as at 6.00 p.m. on May 2nd, 2020, there have been more than 209,300 confirmed cases of COVID-19. Due to the increasing number of patients experiencing a severe outcome, global scientific efforts are ongoing to find the most appropriate treatment. The usefulness of specific anti-rheumatic drugs came out as a promising treatment option together with antiviral drugs, anticoagulants, and symptomatic and respiratory support. For this reason, we feel a duty to share our experience and our knowledge on the use of these drugs in the immune-rheumatologic field, providing in this review the rationale for their use in the COVID-19 pandemic.