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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/cdn\/css\/http\/css_Xg7z6oCTVgud_Q0huYz9x9iiD5H_2YPSJ5z2ZViSWdY.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EIt is well known that patients with rheumatoid arthritis (RA) have an increased risk of fatal and non-fatal acute myocardial infarction (AMI). Endothelial dysfunction is part of the RA disease process and is mediated by TNF-alpha [Hurlimann D et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2002]. Localized inflammatory responses in the intimal layer of the arterial wall have been shown to be responsible for many aspects of intimal thickening and plaque disruption, leading to acute cardiovascular events. TNF inhibitors may reduce the risk of AMI in RA patients because their strong anti-inflammatory effect improves endothelial function [Bacon PA et al. \u003Cem\u003EInt Rev Immunol\u003C\/em\u003E 2002].\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \n         \u003Cp id=\u0022p-2\u0022\u003EIt is well known that patients with rheumatoid arthritis (RA) have an increased risk of fatal and non-fatal acute myocardial infarction (AMI). Endothelial dysfunction is part of the RA disease process and is mediated by TNF-alpha [Hurlimann D et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2002]. Localized inflammatory responses in the intimal layer of the arterial wall have been shown to be responsible for many aspects of intimal thickening and plaque disruption, leading to acute cardiovascular events. TNF inhibitors may reduce the risk of AMI in RA patients because their strong anti-inflammatory effect improves endothelial function [Bacon PA et al. \u003Cem\u003EInt Rev Immunol\u003C\/em\u003E 2002].\u003C\/p\u003E\n         \u003Cp id=\u0022p-3\u0022\u003EThe risk of AMI with TNF-inhibitor therapy, methotrexate (MTX), and other DMARDs was studied by Gurkirpal Singh, MD, Standford University School of Medicine, in a large population (MediCal, the Medicaid program for California) of patients with RA, many of whom were on concomitant aspirin therapy.\u003C\/p\u003E\n         \u003Cp id=\u0022p-4\u0022\u003ECases of acute myocardial infarction (AMI) were risk-set matched with 4 controls for age, gender, and date of AMI. All analyses were adjusted for 38 confounding risk factors (including surrogate variables for smoking and dyslipidemias) as well as concomitant aspirin and NSAID treatment (prescription or over-the-counter use).\u003C\/p\u003E\n         \u003Cp id=\u0022p-5\u0022\u003EA total of 19,233 RA patients (mean age 54.7 years, 79.4% women) were identified. Of these, 13,383 patients took MTX, 14,958 took other DMARDs, and 4,943 took TNF inhibitors. Treatment groups included TNF inhibitors (monotherapy), TNF inhibitors plus MTX, TNF inhibitors plus non-MTX DMARDS, non-MTX DMARDs alone, and MTX plus non-TNF DMARDs.\u003C\/p\u003E\n         \u003Cp id=\u0022p-6\u0022\u003EDuring 74,006 person-years of follow-up, 441 cases of AMI were identified, of which 8% were fatal. Treatment with TNF inhibitors plus MTX significantly reduced the risk of AMI vs MTX monotherapy (multivariate-adjusted relative risk 0.20 (95% CI 0.05 \u2212 0.88, p\u0026lt;0.03; \u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E). No statistical difference was seen with TNF-inhibitor monotherapy (RR 1.17, 95% CI 0.50\u20132.75), TNF-inhibitor with other DMARDs (RR 1.78, 95% CI 0.60\u20135.27), other DMARD therapies without MTX (RR 0.88, 95% CI 0.60\u20131.31) or a combination of DMARDs and MTX (RR 0.93, 95% CI 0.54\u20131.62) vs MTX monotherapy. Systemic corticosteroid use was an independent risk factor which significantly increased the risk of AMI (adjusted RR 1.37, 95% CI 1.07\u20131.75, p\u0026lt;0.01).\u003C\/p\u003E\n         \u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/7\/4\/15\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Adjusted Relative Risk of AMI, Compared to MTX Monotherapy.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-1468810238\u0022 data-figure-caption=\u0022Adjusted Relative Risk of AMI, Compared to MTX Monotherapy.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/7\/4\/15\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/7\/4\/15\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/7\/4\/15\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/11158\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n               \u003Cp id=\u0022p-7\u0022 class=\u0022first-child\u0022\u003EAdjusted Relative Risk of AMI, Compared to MTX Monotherapy.\u003C\/p\u003E\n            \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-8\u0022\u003EThese results indicate that combination therapy using a TNF-inhibitor plus MTX is associated with a reduction in the risk of acute myocardial infarction by 80% vs MTX monotherapy in patients with RA. Such a dramatic effect enhances the therapeutic gains of TNF-inhibitor therapy in patients with RA and should be seriously considered, particularly in high-risk patients.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2007 MD Conference Express\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/7\/4\/15.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzm9je\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzm9je\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}