title: Biologic drugs and arrhythmic risk in chronic inflammatory arthritis: the good and the bad.
abstract: Increasing evidence indicates that patients with chronic inflammatory arthritis (CIA), including rheumatoid arthritis and spondyloarthropathies, have an increased risk of arrhythmic events, significantly contributing to the higher cardiovascular disease (CVD) morbidity and mortality observed in these subjects compared to the general population. Although the mechanisms accounting for such an arrhythmogenic substrate are not fully understood, the main role is probably played by chronic systemic inflammation, able to accelerate the development of structural CVD, as well as to directly affect cardiac electrophysiology. In the past decade, biologic therapies have revolutionized the treatment of CIA by highly enhancing the probability to effectively control disease activity and its systemic consequences, including cardiovascular involvement. Accordingly, accumulating data demonstrated that by potently inhibiting systemic inflammation, biologic drugs can reduce CVD progression and ameliorate arrhythmic risk parameters, with a putative beneficial impact on arrhythmia incidence. Nevertheless, a significant number of reports from clinical trials and postmarketing experience suggest that some of these medications, particularly TNF inhibitor monoclonal antibodies and rituximab, may in some circumstances precipitate arrhythmia occurrence, probably by acutely amplifying myocardial electric instability intrinsically associated with these diseases. In this review, we analyze the intricate link between biologic drugs and arrhythmias in CIA in the effort to identify which factors are involved in the fine-tuning of antiarrhythmic/pro-arrhythmic balance, and understand how this knowledge should be translated in the clinical practice to obtain the most favorable benefit-to-risk profile when biologic drugs are used in these patients.
authors.affiliation: Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Policlinico "Le Scotte", Viale Bracci, Siena, Italy. lazzerini7@unisi.it.
authors.forename: Pietro Enea
authors.initials: PE
authors.lastname: Lazzerini
authors.affiliation: Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Policlinico "Le Scotte", Viale Bracci, Siena, Italy.
authors.forename: Pier Leopoldo
authors.initials: PL
authors.lastname: Capecchi
authors.affiliation: Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Policlinico "Le Scotte", Viale Bracci, Siena, Italy.
authors.forename: Mauro
authors.initials: M
authors.lastname: Galeazzi
authors.affiliation: Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Policlinico "Le Scotte", Viale Bracci, Siena, Italy.
authors.forename: Franco
authors.initials: F
authors.lastname: Laghi-Pasini
mesh_terms: D000889:Anti-Arrhythmia Agents / Q000627:therapeutic use; D001145:Arrhythmias, Cardiac / Q000139:chemically induced / Q000188:drug therapy; D001168:Arthritis / Q000188:drug therapy* / Q000503:physiopathology; D001688:Biological Products / Q000009:adverse effects / Q000627:therapeutic use; D002908:Chronic Disease; D006801:Humans; D012306:Risk
chemical_list: D000889:Anti-Arrhythmia Agents; D001688:Biological Products
keywords: Arrhythmic risk; Atrial fibrillation; Biologic drugs; Rituximab; Sudden cardiac death; Systemic inflammation; TNF inhibitors