Cilliers Antoinette, Manyemba Juliet, Adler Alma J, Saloojee Haroon
Department of Paediatric Cardiology, Chris Hani Baragwanath Hospital, Johannesburg, South
Cochrane Database Syst Rev. 2012 Jun 13(6):CD003176. doi: 10.1002/14651858.CD003176.pub2.
Rheumatic heart disease remains an 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. This is an update of a review published in 2003 and previously updated in 2009.
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.
We searched the Cochrane Central Register of Controlled Trials on The Cochrane Library (Issue 3, 2011), MEDLINE (1966 to Aug 2011), EMBASE (1998 to Sept 2011), LILACS (1982 to Sept 2011), Index Medicus (1950 to April 2001) and references lists of identified studies. No language restrictions were applied.
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 adults and children 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.
Two reviewers independently extracted data. Risk of bias was assessed using methodology outlined in the Cochrane handbook.
No new studies were included in this update. Eight randomised controlled trials involving 996 people were included. Several steroidal agents corticotrophin, 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, one study was done in 1990, and the final study was published in 2001. Overall there was no significant difference in the risk of cardiac disease at one year between the corticosteroid-treated and aspirin-treated groups (six studies, 907 participants, relative risk 0.87, 95% confidence interval 0.66 to 1.15). Similarly, use of prednisone (two studies, 212 participants, relative risk 1.13, 95% confidence interval 0.52 to 2.45) compared to aspirin did not reduce the risk of developing heart disease after one year. Adverse events were not reported in five studies. The three studies reporting on adverse events all reported substantial adverse events. However, all results should be interpreted with caution due to the age of the studies and to substantial risk of bias.
AUTHORS' CONCLUSIONS: There is little evidence of benefit from 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. Additionally there was substantial risk of bias, so results should be viewed with caution. New randomised controlled trials in patients with acute rheumatic fever to assess the effects of corticosteroids such as oral prednisone and intravenous methylprednisolone, and other new anti-inflammatory agents are warranted. Advances in echocardiography will allow for more objective and precise assessments of cardiac outcomes.
在发展中国家，风湿性心脏病仍然是后天性心脏病的一个重要病因。尽管风湿热的预防和复发的管理已经很成熟，但活动性风湿性心脏炎的最佳管理仍不明确。这是对2003年发表并于2009年更新过的一篇综述的更新。
评估阿司匹林、皮质类固醇、免疫球蛋白和己酮可可碱等抗炎药对预防或减少急性风湿热患者进一步心脏瓣膜损害的效果。
我们检索了Cochrane图书馆（2011年第3期）中的Cochrane对照试验中心注册库、MEDLINE（1966年至2011年8月）、EMBASE（1998年至2011年9月）、LILACS（1982年至2011年9月）、医学索引（1950年至2001年4月）以及已识别研究的参考文献列表。未设语言限制。
根据琼斯标准或改良琼斯标准诊断为急性风湿热的成人和儿童中，比较抗炎药（如阿司匹林、类固醇、免疫球蛋白、己酮可可碱）与安慰剂或对照，或比较任何一种抗炎药之间的随机对照试验。治疗一年后心脏病的存在情况是选定的主要结局标准。
两名评价员独立提取数据。使用Cochrane手册中概述的方法评估偏倚风险。
本次更新未纳入新的研究。纳入了八项涉及996人的随机对照试验。在各项研究中，将几种甾体药物促肾上腺皮质激素、可的松、氢化可的松、地塞米松和泼尼松以及静脉注射免疫球蛋白与阿司匹林、安慰剂或不治疗进行了比较。其中六项试验在1950年至1965年之间进行，一项研究于1990年开展，最后一项研究于2001年发表。总体而言，皮质类固醇治疗组和阿司匹林治疗组在一年时患心脏病的风险没有显著差异（六项研究，907名参与者，相对风险0.87，95%置信区间0.66至1.15）。同样，与阿司匹林相比，使用泼尼松（两项研究，212名参与者，相对风险1.13，95%置信区间0.52至2.45）并没有降低一年后患心脏病的风险。五项研究未报告不良事件。报告不良事件的三项研究均报告了大量不良事件。然而，由于研究年代久远以及存在较大的偏倚风险，所有结果都应谨慎解读。
几乎没有证据表明使用皮质类固醇或静脉注射免疫球蛋白可降低急性风湿热患者心脏瓣膜病变的风险。大多数试验年代久远，限制了对数据进行充分的统计分析以及按照当前标准对临床结局进行可接受的评估。此外，存在较大的偏倚风险，因此结果应谨慎看待。有必要开展新的随机对照试验，以评估口服泼尼松和静脉注射甲泼尼龙等皮质类固醇以及其他新型抗炎药对急性风湿热患者的影响。超声心动图的进展将使对心脏结局进行更客观、精确的评估成为可能。
