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The nonspecific anti-inflammatory therapy with methotrexate for patients with chronic heart failure
The nonspecific anti-inflammatory therapy with methotrexate for patients with chronic heart failure Kaizheng Gong, MD,a Zhengang Zhang, MD, PhD,b Xiaonin Sun, MD,a Xin Zhang, MD,a Aihua Li, MD,a Junfeng Yan, MD,a Qiuping Luo, MD,a Yang Gao, MD,a and Yiliang Feng, MDa Yangzhou, China
Background Inflammatory mediators play an important role in the pathogenesis of chronic heart failure (CHF). Methotrexate (MTX) is used in the treatment of inflammatory-mediated diseases (eg, rheumatoid arthritis) because it modulates the expression of numerous inflammatory cytokines. However, no studies have assessed the effects of MTX on plasma levels of inflammatory mediators in patients with CHF. Methods
In a prospective, randomized, placebo-controlled, single-blind study, 71 patients receiving conventional treatment were randomly allocated to either MTX group (7.5 mg once a week, n = 35) or placebo group (n = 36) with a follow-up of 12 weeks. The effects of MTX on plasma cytokine expression, left ventricular ejection fraction, left ventricular end-diastolic dimension, New York Heart Association (NYHA) functional class, 6-minute walk test distance, and quality of life (QOL) were determined in patients with CHF.
Results Sixty-two patients completed the study. The circulating levels of inflammatory mediators in patients with CHF were markedly elevated compared with healthy controls ( P V .002). Methotrexate (n = 30) reduced plasma levels of tumor necrosis factor a (15.6%, P b .05), interleukin 6 (21.8%, P b .01), monocyte chemoattractant protein-1 (22.6%, P b .01), soluble intercellular adhesion molecule-1 (19.2%, P b .05), and C-reactive protein (27.2%, P b .01) compared with baseline. Furthermore, interleukin 10 (15.8 %, P b .05) and soluble IL-1 receptor antagonist (36.1%, P b .01) expression was increased, whereas improvements in NYHA classification, 6-minute walk test distance, and QOL were found compared with baseline. Monocyte chemoattractant protein-1 expression was lower and soluble IL-1 receptor antagonist expression higher in the MTX than placebo group (n = 32). Furthermore, the left ventricular ejection fraction, left ventricular end-diastolic dimension, and incidence of main adverse cardiac events between the 2 groups were similar. Conclusion These results suggest that the addition of MTX to conventional therapy for CHF has significant antiinflammatory effects and improves NYHA functional class, 6-minute walk test distance, and QOL. (Am Heart J 2006;151:62-8.) Since the original description of increased circulating levels of tumor necrosis factor a (TNF-a) in patients with chronic heart failure (CHF) in 1990,1 a great deal of evidence has shown that immunologic responses mediated by proinflammatory cytokines may play an important pathogenic role in the development and progression of CHF.2 The growing importance of the pathophysiological consequences of a sustained proinflammatory response in experimental and clinical heart failure has resulted in 2 large-scale clinical trials using Etanercept and Infliximab to antagonize TNF-a.3,4 Although the outcomes of these trials have been rather
disappointing, they evoke great interest in exploring other therapies targeting the inflammatory response in patients with heart failure. It is clear that proinflammatory and anti-inflammatory cytokines have a major role in the initiation and perpetuation of the chronic inflammatory response in rheumatoid arthritis. Methotrexate (MTX) elicits a potent anti-inflammatory response in patients with rheumatoid arthritis5; however, there are no data regarding its effects on circulating inflammatory mediators in patients with CHF. The aims of the present study were to determine the effect of MTX on plasma cytokine expression in patients with CHF and to assess its effects on clinical indices.
From the aDepartment of Cardiology, The First People’s Hospital of Yangzhou, Yangzhou, China, and bDepartment of Clinics, Medical School of Yangzhou University, Yangzhou, China. Submitted May 25, 2004; accepted February 21, 2005. Reprint requests: Kaizheng Gong, MD, Department of Cardiology, The First People’s Hospital of Yangzhou, 45 Taizhou Road, Yangzhou 225001, China. E-mail: [email protected] 0002-8703/$ - see front matter n 2005, Mosby, Inc. All rights reserved. doi:10.1016/j.ahj.2005.02.040
Methods Study design and patients The study was a prospective, randomized, placebo-controlled, single-blind trial approved by the Medicine Institutional Review Board. Seventy-one consecutive patients with CHF attending outpatients were recruited from the First
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People’s Hospital of Yangzhou. CHF was diagnosed according to Framingham criterion.6 All patients provided written informed consent. Patient inclusion criteria were the following: (1) age range 18 to 75 years, (2) New York Heart Association (NYHA) functional class II to IV, (3) high-quality echocardiographic images could be obtained, (4) left ventricular ejection fraction (LVEF) b0.45 and left ventricular end-diastolic dimension (LVEDD) N55 mm by echocardiography, and (5) the etiology of CHF was from ischemia (n = 29, confirmed by history of angina pectoris and/or old myocardial infraction or coronary artery angiography [n = 11]), hypertension (n = 26), or idiopathic dilated cardiomyopathy (n = 16). Patients were excluded if they had any clinical or laboratory evidence of chronic obstructive pulmonary disease, rheumatoid arthritis, an infectious disease, connective tissue disease, neoplasm, severe liver or renal dysfunction, anemia, acute myocardial infarction within 6 weeks, or unstable angina pectoris. The control group consisted of 18 healthy, age-matched volunteers (10 men and 8 women, mean age 62.3 F 10.5 years, range 20 -74 years). All patients were optimally treated with diuretics (76.1%), digoxin (67.6%), angiotensin-converting enzyme inhibitor (94.0%), and h-blockers (45.1%). Patients were randomized to receive a low dose of MTX (ie, 7.5 mg once a week) or placebo for the 12-week study duration.
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Table I. Baseline characteristics of patients with CHF Characteristics Sex (male/female) Age (y) Blood pressure (mm Hg) Systolic Diastolic Cause (CHD/HHD/IDC) NYHA classification (II/III/IV) Body mass index alanine transaminase (IU/L) Creatinine (mmol/L) Blood urea nitrogen (mmol/L) Medication (%) Diuretics Digoxin Angiotensin-converting enzyme inhibitors h-Blockers
MTX group (n = 30)
Placebo group (n = 32)
P
18/12 61.2 F 8.3
19/13 63.5 F 9.3
NS NS
116.1 F 18.7 75.2 F 12.4 11/13/6 12/9/9
126.9 F 23.8 77.5 F 16.0 14/10/8 13/11/8
NS NS NS NS
22.9 F 3.6 44.2 F 18.3
24.4 F 3.0 38.1 F 15.5
NS NS
95.8 F 26.7 7.0 F 2.2
91.3 F 29.9 6.9 F 2.2
NS NS
22 (73.3) 21 (70.0) 28 (93.3)
26 (81.3) 21 (65.6) 30 (93.8)
NS NS NS
13 (43.3)
15 (46.9)
NS
Values are presented as mean F SD or n (%) or otherwise indicated. CHD, Coronary heart disease; HHD, hypertension heart disease; IDC, idiopathic dilated cardiomyopathy.
Clinical evaluation All patients underwent transthoracic echocardiography (Hewlett-Packard Sonos 5500 echocardiograph equipped with a 3.5-MHz transducer, MA, USA) at baseline and after receiving MTX or placebo for 12 weeks. All studies were recorded on videotape and performed by the same operator. Left ventricular end-diastolic dimension was measured by M-mode echocardiography in accordance with the American Society of Echocardiography guidelines.7 The LVEF was determined using Teichholz methods. Functional class was assessed according to the standard of the NYHA and a minimum of three 6 -minute walk tests.8 Quality of life (QOL) was assessed with the Chinese edition SF-36 as previously described.9 All assessments were undertaken by investigators blinded to the laboratory data and treatment assigned.
Measurements of inflammatory mediators Twenty milliliters of antecubital vein blood was collected into prechilled evacuated tubes containing EDTA-2Na at baseline and after 12 weeks of treatment with MTX or placebo. Plasma samples were prepared by centrifugation at 2500 rpm for 10 minutes and stored at 708C. Complement component 3 (C3) and C-reactive protein (CRP) were measured by using a routine turbidimetry assay. Tumor necrosis factor a, interleukin (IL)-1h, IL-6, IL-8, and IL-10 were measured using commercially available radioimmunoassay kits (Radioimmuno Tech Institute of PLA General Hospital, Beijing, China). Monocyte chemoattractant protein-1 (MCP-1), soluble IL-1 receptor antagonist (sIL-1Ra), and soluble intercellular adhesion molecule-1 (sICAM-1) were measured using commercially available enzyme-linked immunosorbent assay kits (LIFEKEY Bio Med Tech Corp, NJ, USA). All analyses were performed in duplicate and staff were blinded to the treatment groups.
Follow-up The baseline evaluation consisted of history and vital signs, routine laboratory tests, patient functional classification, echocardiographic measurement, 6 -minute walk test, and QOL assessment. For safety purpose, patients were followed up at 2 weekly intervals over the 12-week study period. Each visit consisted of a physical examination and assessment of adverse effects and blood and urine samples collected for routine analysis. Repeated evaluations of LVEDD, LVEF, NYHA functional class, 6 -minute walk test, and QOL were performed, and main cardiac adverse events including death, rehospitalization, worsening heart failure, acute myocardial infarction, and stroke were statistically evaluated after 12 weeks. Patients could withdraw from the study due to onset of significant adverse events or unwillingness to continue.
Statistical analysis All continuous variables are presented as mean F SD and data were analyzed using SPSSPC (version 11.0 for Windows, SPSS Inc, Chicago, IL). Differences in the levels of inflammatory markers and changes in the indices of clinical condition between groups were analyzed nonparametrically (Mann-Whitney U test for unpaired data). Changes from baseline within each group were analyzed by Wilcoxon matched pairs test. Differences in proportions between groups were analyzed by Fisher exact test (2-sided). A value of P b .05 was taken to indicate statistical significance. Based upon preliminary data from 20 patients with CHF (NYHA II-IV), circulating levels of TNF- a and IL- 6 are 3.21 F 1.09 pg/mL and 162.6 F 48.4 pg/mL, respectively. Anticipating a 15% decrease in their expression levels and a 10% dropout rate, a sample size of 71 patients would be sufficient to
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Table II. Effects of MTX on plasma levels of inflammatory mediators in CHF Placebo group (n = 32) Baseline TNF-a (ng/mL) IL-1h (ng/mL) IL-6 (pg/mL) IL-8 (ng/mL) MCP-1 (pg/mL) IL-10 (ng/mL) sIL-1Ra (pg/mL) sICAM-1 (ng/mL) C3 (mg/L) CRP (Ag/L)
3.10 0.57 155.3 1.33 73.9 40.2 70.4 77.1 0.49 0.72
F F F F F F F F F F
0.80 0.17 62.6 0.38 25.3 10.0 23.5 31.1 0.20 0.35
12 wk 3.23 0.49 134.0 1.29 60.4 45.6 78.2 71.0 0.40 0.61
F F F F F F F F F F
0.89 0.19 35.5 0.37 17.7 14.6 15.5 23.0 0.17 0.29
MTX group (n = 30) #% 7.4 14.0 10.9 1.5 19.6y 15.7 10.7 3.0 14.3 13.9
Baseline 3.33 0.56 159.5 1.29 64.3 44.2 68.2 85.0 0.41 0.81
F F F F F F F F F F
0.84 0.20 49.8 0.33 21.5 11.2 24.1 32.9 0.20 0.30
12 wk 2.81 0.48 124.8 1.15 49.9 51.2 92.7 68.7 0.43 0.59
F F F F F F F F F F
0.83 0.16 39.6 0.40 20.9 13.2 22.0 27.9 0.15 0.28
#%
Differences in 12 wk between groups
15.6T 14.3 21.8y 10.9 22.6y 15.8T 36.1y 19.2T 4.9 27.2y
.064 .927 .220 .217 .037 .068 .004 .622 .303 .652
Data are expressed as mean F SD. There were no significant differences between the groups at baseline. D%, Percent of changes from baseline. TP b .05 versus baseline. yP b .01 versus baseline.
detect such changes, with a power of 80% at the 5% level of significance.
Results Of the 71 patients enrolled, 36 were randomized to the placebo and 35 to the MTX group. The study was discontinued prematurely in 4 (11.1%) patients receiving placebo and 5 (14.3%) patients receiving MTX (Fisher exact test, 2-sided P = .735). Of these patients, 2 were withdrawn due to onsets of nausea and vomit, 4 were due to migration to remote areas, and 3 were unwilling to continue with the study without any definite reason. Patients failing to complete the study were excluded from the final analysis of biochemical and clinical variables. However, their patient global self-assessment was followed up by telephone and included in the analysis. Of those excluded, there was 1 death, 1 reported feeling worse, and 1 reported no change for each treatment group. In addition, 2 in the MTX group and 1 in the placebo group reported an improvement. In total, 62 patients finished the study. There were no statistical differences in baseline characteristics of patients in the 2 groups after exclusion of the 9 patients (Table I).
Changes of the circulating levels of inflammatory mediators The circulating levels of TNF-a (3.21 F 0.82 vs 2.14 F 0.50 pg/mL, P b .000), IL-1h (0.57 F 0.18 vs 0.23 F 0.09 ng/mL, P b .000), IL-6 (157.3 F 56.3 vs 98.4 F 26.3 pg/mL, P b .000), IL-8 (1.31 F 0.36 vs 0.90 F 0.21 ng/mL, P b .000), MCP-1 (69.3 F 23.8 vs 30.9 F 7.8 pg/mL, P b .000), sICAM-1 (80.9 F 31.9 vs 45.8 F 14.2 ng/mL, P b .000), C3 (0.45 F 0.20 vs 0.29 F 0.10 mg/mL, P = .002), CRP (0.76 F 0.33 vs 0.49 F 0.18 Ag/mL, P = .001), IL-10 (42.1 F 10.7 vs
32.7 F 6.0 ng/mL, P b .000), and sIL-1Ra (69.3 F 23.6 vs 39.0 F 17.9 pg/mL, P b .000) were significantly higher in patients with CHF (n = 62) than in healthy controls (n = 18). At baseline, plasma levels of the inflammatory mediators were similar between groups (Table II). After 12 weeks of treatment with MTX, there was a significant reduction in the circulating levels of TNF-a (3.33 F 0.84 vs 2.81 F 0.83 pg/mL, 15.6%, P b .05), IL-6 (159.5 F 49.8 vs 124.8 F 39.6 pg/mL, 21.8%, P b .01), MCP-1 (64.3 F 21.5 vs 49.9 F 20.9 pg/mL, 22.6%, P b .01), sICAM-1 (85.0 F 32.9 vs 68.7 F 27.9 ng/mL, 19.2%, P b .05), and CRP (0.81 F 0.30 vs 0.59 F 0.28 Ag/mL, 27.2%, P b .01). However, levels of IL-10 (44.2 F 11.2 vs 51.2 F 13.2 ng/mL, 15.8%, P b .05) and sIL-1Ra (68.2 F 24.1 vs 92.7 F 22.0 pg/mL, 36.1%, P b .01) were significantly higher compared with baseline values. Furthermore, MCP-1 (49.9 F 20.9 vs 60.4 F 17.7 pg/mL, P = .037) was remarkably lower and sIL-1Ra higher (92.7 F 22.0 vs 78.2 F 15.5 pg/mL, P = .004) in the MTX group than in the placebo group. Administration of MTX did not alter circulating levels of IL-1h, IL-8, and C3. In the placebo group, the 12-week MCP-1 levels were dramatically decreased compared with baseline (60.4 F 17.7 vs 73.9 F 25.3 pg/mL, 19.6%, P b .01).
Impact of MTX on the clinical condition in patients with CHF Significant improvements in NYHA functional class (2.9 F 0.8 vs 2.4 F 0.9, 17.2%, P b .01), 6 -minute walk test distance (296.5 F 68.6 vs 361.4 F 75.3 m, 21.9%, P b .01) (Figure 1), and QOL general scores (82.4 F 15.1 vs 92.0 F 13.8, 11.7%, P b .01) as well as physical health scores (43.1 F 13.7 vs 52.8 F 15.0, 22.5%, P b .01) (Figure 2) were observed in the MTX group at 12 weeks compared with baseline. Furthermore, the 6 -minute
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Figure 1
Changes of NYHA functional class, 6-minute walk distance, LVEF, and LVEDD after 12 weeks of treatment with MTX (n = 30) or placebo (n = 32) in patients with CHF. Values are expressed as mean F SD. yP b .05 12 weeks versus baseline, zP b .05 12 weeks versus baseline, #P b .05 MTX versus placebo.
walk test distance (361.4 F 75.3 vs 321.8 F 83.9 m, P b .05), QOL general scores (92.0 F 13.8 vs 80.1 F 17.8, P b .01), and physical health scores (52.8 F 15.0 vs 43.6 F 14.3, P b .05) were better in those receiving MTX compared with placebo. There were no changes in LVEF, LVEDD, and the mental health scores of QOL in the MTX group at 12 weeks compared with baseline. In contrast, improvements in NYHA functional class (Figure 1) and 6 -minute walk test distance (Figure 2) were observed in the placebo group after 12 weeks ( P b .05).
Incidences of the main cardiac adverse events with MTX therapy During the 12-week follow-up, the incidences of death (1 [2.9%] patient in MTX group, 1 [2.7%] patient in placebo group, Fisher exact test, 2-sided P = 1.000), rehospitalization (14 person times for 8 [23.5%] patients in MTX group, 12 person times for 7 [18.9%]
patients in placebo group, Fisher exact test, 2-sided P = .771), and worsening heart failure (8 person times for 4 [11.8%] patients in MTX group, 10 person times for 6 [16.2%] patients in placebo group, Fisher exact test, 2-sided P = .737) were similar between the 2 groups (N = 71). No patient experienced sudden cardiac death, acute myocardial infarction, or stroke in either group.
Safety of MTX During the follow-up, 2 patients in the MTX group and 2 patients in the placebo group experienced nausea (5.7% and 5.6%, respectively, Fisher exact test, 2-sided P = 1.000) and 2 patients in MTX group experienced vomit (5.7%, Fisher exact test, 2-sided P = .239). Of the 4 patients in the MTX group, 2 happened only after the first dosing and without reoccurrence and the other 2 patients dropped out the study. There
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Figure 2
Changes of general scores of QOL, physical health scores, and mental health scores after 12 weeks of treatment with MTX (n = 30) or placebo (n = 32) in patients with CHF. Values are expressed as mean F SD. yP b .05 12 weeks versus baseline, #P b .05 MTX versus placebo.
are 2 patients with mild alanine transaminase increase (5.7%, Fisher exact test, 2-sided P = .239) and 1 patient with renal function deterioration (2.9%, Fisher exact test, 2-sided P = .493) in MTX group. But the 3 patients got well gradually after stopping the treatment with MTX within 1 week and continued the treatment until the end of the study. No patient suffered from gout, the abnormality in hematology and malignancy during the follow-up. The incidences of these adverse effects between the 2 groups showed no statistical difference.
Discussion This is the first study to show that the addition of MTX to conventional therapy in patients with CHF exerts a significant anti-inflammatory effect and improves several indices of functional status. In particular, improvements in NYHA class, 6-minute walk test distance, QOL general scores, and physical health scores are accompanied by down-regulation of
circulating levels of TNF- a, IL- 6, MCP-1, sICAM-1, and CRP, as well as up-regulation of the anti-inflammatory cytokines IL-10 and sIL-1Ra. Recently, a number of clinical studies have demonstrated that patients with CHF express excessive inflammatory mediators in plasma and failing myocardium.10-12 Inflammatory mediators are capable of modulating cardiovascular functions by a variety of mechanisms. Tumor necrosis factor a has been shown to depress myocardial contractility13 and induce cardiomyocyte hypertrophy,14 apoptosis,15 necrosis, and interstitial remodeling.16 Interestingly, Wolfe and Michaud17 recently reported that heart failure was more common among patients with rheumatoid arthritis (3.9%) than in those with osteoarthritis (2.3%) and that the increased risk of heart failure in patients with rheumatoid arthritis may be reduced by anti-TNF therapies. Similarly, Choi et al18 confirmed that MTX treatment in rheumatoid arthritis provides a substantial survival benefit, largely by reducing cardiovascular mortality.
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Given the important role of inflammatory mediators in the pathogenesis of CHF, therapeutic modulation targeting inflammatory mediators might be a new and promising strategy for treating CHF. However, the results of 2 large-scale clinical trials targeting TNF-a (ENBREL and ATTACH) did not provide any evidence of benefit.3,4 As far as our understanding of the mechanisms of immune activation in CHF is concerned, we consider that activated inflammatory mediators in CHF form a complex network. Therefore, the benefit of antagonizing a single factor in this network may be diminished by the interaction of other factors in the network. We assume that a more generalized approach targeting this network may produce certain beneficial effects in patients with CHF. Recent clinical data support this. Pentoxifylline, a xanthine derivative, inhibits expression of various inflammatory cytokines including TNF-a, IL-1h, and interferon g.19 Furthermore, the addition of pentoxifylline to standard heart failure therapy reduces plasma TNF-a levels and improves clinical status and LVEF in patients with idiopathic dilated cardiomyopathy and ischemic cardiomyopathy.20 Treatment with intravenous immunoglobulin is also of benefit in a wide range of immune-mediated disorders including Kawasaki syndrome and acute inflammatory cardiomyopathy. Their proposed mechanism of action involves neutralization of pathogens, attenuation of complement-mediated tissue damage, and suppression of T-cell proliferation. Gullestad et al21 showed that immunoglobulin treatment significantly increases LVEF in heart failure of ischemic or idiopathic etiology while increasing plasma levels of IL-10, IL-1Ra, and sTNF-a receptors; TNF-a levels were unaffected. A number of clinical studies show that MTX, a folate analogue, not only inhibits inflammatory cell proliferation through action on dihydrofolate reductase but also inhibits the conversion of 5-aminoimidazole-4-carboxamide ribonucleotide to 5-formyl-5-aminoimidazole-4-carboxamide ribonucleotide, thus increasing intracellular and extracellular levels of adenosine-5V-phosphate and adenosine.22,23 Several studies have demonstrated that binding of adenosine to the A2 receptor inhibits lymphocyte proliferation and production of TNF, IL-8, and IL-12, as well as increases secretion of IL-10.24 Methotrexate has been successfully used in the treatment of many immune- or inflammatory-mediated diseases (eg, rheumatoid arthritis) by causing generalized immunomodulation. Furthermore, adenosine receptors are expressed on various cells and implicated in cellular protection against ischemic, anoxia, and heat stress. We conjecture that MTX might provide additional benefit for patients with CHF in addition to its anti-inflammatory effects. Our present study demonstrates that not only the circulating levels of several proinflammatory mediators (eg, TNF-a, IL-1h, IL-6, IL-8, MCP-1, sICAM-1, C3, and
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CRP) but also the anti-inflammatory mediators IL-10 and sIL-1Ra are dramatically increased in the CHF group compared with the control group. This indicates that the activation of inflammatory mediators may be a common pathophysiological characteristic in CHF. Furthermore, MTX decreases the levels of the proinflammatory mediators TNF-a, IL- 6, MCP-1, sICAM-1, and CRP, but increased the levels of anti-inflammatory mediators IL-10 and sIL-1Ra. In contrast, no changes in the circulating levels of inflammatory mediators other than MCP-1 were observed in the placebo group. In addition, MTX produced a further modulating effect on MCP-1 and sIL-1Ra compared with placebo. These results showed that the addition of MTX to conventional heart failure treatment globally regulate levels of circulating inflammatory mediators culminating in a net anti-inflammatory effect. In addition to the anti-inflammatory effect, significant improvements in the NYHA classification, 6 -minute walk test distance, and QOL scores in patients treated with MTX were observed compared with placebo group. Although the anti-inflammatory effect of MTX was not translated into improvement in the LVEF and LVEDD or a reduction in the incidence of main adverse cardiac events (death, rehospitalization, or worsening heart failure), it is well known that LVEF or LVEDD might not be a unique decisive factor of NYHA class, 6 -minute walk test distance, and QOL. Excessive activation of inflammatory mediators in CHF may exert influence on various systems of the body. For example, TNF - a not only acts on cardiac cells and induces cardiac cachexia by promoting metabolic dysfunction, but it also causes myasthenia and dysfunction of the endothelium.25 Therefore, MTX administration could also be beneficial because of modulation of a variety of humoral factors in patients with CHF through its anti-inflammatory effects. Moreover, as mentioned above, MTX can confer cellular protection by increasing extracellular and intracellular adenosine levels. Accordingly, the possibility cannot be excluded that MTX might exert other benefits on patients with CHF apart from immunomodulating effects. Noticeably, the relatively small population size and short therapy duration in this study may limit the ability to detect changes for LVEF, LVEDD, and the reduction in the incidence of main adverse cardiac events. Some studies suggested that the adverse effects of long-term MTX therapy are increased when the accumulated dosage is N2000 mg.26 In this study, the average dosage was 82.5 F 15.8 mg. The main adverse effect associated with MTX was symptoms of gastrointestinal disturbance; there were no reported instances of severe toxicity (eg, bone marrow suppression or alopecia).Therefore, our results indicate that MTX might be fully accepted with good effect/toxicity for short-term treatment.
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In conclusion, our data suggest that the addition of low-dosage MTX to conventional therapy for CHF might have a significant anti-inflammatory effect along with improvements of NYHA functional class, 6 -minute walk test distance, and QOL scores. Methotrexate could be a beneficial adjunct to conventional therapy for patients with CHF. We thank Zhifeng Dong, MD, for preparing the manuscript; Prof Ning Zu and Prof Shunrong Cao for revision of the manuscript; Da Gao, MD, and Xiaopeng Ji, MB, for technical assistance; and Liping Sun, MD, and Prof Cheng Wang for their help with the statistical analysis.
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11. Damas JK, Eiken HG, Oie E, et al. Myocardial expression of CC- and CXC-chemokines and their receptors in human end-stage heart failure. Cardiovasc Res 2000;47:778 - 87. 12. Kubota T, Miyagishima M, Alvarez RJ, et al. Expression of proinflammatory cytokines in the failing human heart: comparison of recent-onset and end-stage congestive heart failure. J Heart Lung Transplant 2000;19:819 - 24. 13. Finkel MS, Oddis CV, Jacob TD, et al. Negative inotropic effects of cytokines on the heart mediated by nitric oxide. Science 1992;257: 387 - 9. 14. Yokoyama T, Nakano M, Bednarczyk JL, et al. Tumor necrosis factor-alpha provokes a hypertrophic growth response in adult cardiac myocytes. Circulation 1997;95:1247 - 52. 15. Ing DJ, Zang J, Dzau VJ, et al. Modulation of cytokine-induced cardiac myocyte apoptosis by nitric oxide, Bak and Bcl-x. Circ Res 1999;84:21 - 33. 16. Siwik DA, Chang DL, Colucci WS. Interleukin-1beta and tumor necrosis factor-alpha decrease collagen synthesis and increase matrix metalloproteinase activity in cardiac fibroblasts in vitro. Circ Res 2000;86:1259 - 65. 17. Wolfe F, Michaud K. Heart failure in rheumatoid arthritis: rates, predictors, and the effect of anti-tumor necrosis factor therapy. Am J Med 2004;116:305 - 11. 18. Choi HK, Hernan MA, Seeger JD, et al. Methotrexate and mortality in patients with rheumatoid arthritis: a prospective study. Lancet 2002;359:1173 - 7. 19. Takehana H, Inomata T, Niwano H, et al. Immunomodulatory effect of pentoxifylline in suppressing experimental autoimmune myocarditis. Circ J 2002;66:499 - 504. 20. Sliwa K, Woodiwiss A, Kone VN, et al. Therapy of ischemic cardiomyopathy with the immunomodulating agent pentoxifylline. Circulation 2004;109:750 - 5. 21. Gullestad L, Aass H, Fjeld JG, et al. Immunomodulating therapy with intravenous immunoglobulin in patients with chronic heart failure. Circulation 2001;103:220 - 5. 22. Hornung N, Stengaard-Pedersen K, Ehrnrooth E, et al. The effects of low-dose methotrexate on thymidylate synthase activity in human peripheral blood mononuclear cells. Clin Exp Rheumatol 2000;18: 691 - 8. 23. Morabito L, Montesinos MC, Schreibman DM, et al. Methotrexate and sulfasalazine promote adenosine release by a mechanism that requires ecto-5V-nucleotidase-mediated conversion of adenine nucleotides. J Clin Invest 1998;101:295 - 300. 24. Cutolo M, Sulli A, Pizzorni C, et al. Anti-inflammatory mechanisms of methotrexate in rheumatoid arthritis. Ann Rheum Dis 2001;60: 729 - 35. 25. Fichtlscherer S, Rossig L, Breuer S, et al. Tumor necrosis factor antagonism with Etanercept improves systemic endothelial vasoreactivity in patients with advanced heart failure. Circulation 2001; 104:3023 - 5. 26. Papadopoulos NG, Alamanos Y, Papadopoulos IA, et al. Disease modifying antirheumatic drugs in early rheumatoid arthritis: a longterm observational study. J Rheumatol 2002;29:261 - 6.
Background Inflammatory mediators play an important role in the pathogenesis of chronic heart failure (CHF). Methotrexate (MTX) is used in the treatment of inflammatory-mediated diseases (eg, rheumatoid arthritis) because it modulates the expression of numerous inflammatory cytokines. However, no studies have assessed the effects of MTX on plasma levels of inflammatory mediators in patients with CHF. Methods
In a prospective, randomized, placebo-controlled, single-blind study, 71 patients receiving conventional treatment were randomly allocated to either MTX group (7.5 mg once a week, n = 35) or placebo group (n = 36) with a follow-up of 12 weeks. The effects of MTX on plasma cytokine expression, left ventricular ejection fraction, left ventricular end-diastolic dimension, New York Heart Association (NYHA) functional class, 6-minute walk test distance, and quality of life (QOL) were determined in patients with CHF.
Results Sixty-two patients completed the study. The circulating levels of inflammatory mediators in patients with CHF were markedly elevated compared with healthy controls ( P V .002). Methotrexate (n = 30) reduced plasma levels of tumor necrosis factor a (15.6%, P b .05), interleukin 6 (21.8%, P b .01), monocyte chemoattractant protein-1 (22.6%, P b .01), soluble intercellular adhesion molecule-1 (19.2%, P b .05), and C-reactive protein (27.2%, P b .01) compared with baseline. Furthermore, interleukin 10 (15.8 %, P b .05) and soluble IL-1 receptor antagonist (36.1%, P b .01) expression was increased, whereas improvements in NYHA classification, 6-minute walk test distance, and QOL were found compared with baseline. Monocyte chemoattractant protein-1 expression was lower and soluble IL-1 receptor antagonist expression higher in the MTX than placebo group (n = 32). Furthermore, the left ventricular ejection fraction, left ventricular end-diastolic dimension, and incidence of main adverse cardiac events between the 2 groups were similar. Conclusion These results suggest that the addition of MTX to conventional therapy for CHF has significant antiinflammatory effects and improves NYHA functional class, 6-minute walk test distance, and QOL. (Am Heart J 2006;151:62-8.) Since the original description of increased circulating levels of tumor necrosis factor a (TNF-a) in patients with chronic heart failure (CHF) in 1990,1 a great deal of evidence has shown that immunologic responses mediated by proinflammatory cytokines may play an important pathogenic role in the development and progression of CHF.2 The growing importance of the pathophysiological consequences of a sustained proinflammatory response in experimental and clinical heart failure has resulted in 2 large-scale clinical trials using Etanercept and Infliximab to antagonize TNF-a.3,4 Although the outcomes of these trials have been rather
disappointing, they evoke great interest in exploring other therapies targeting the inflammatory response in patients with heart failure. It is clear that proinflammatory and anti-inflammatory cytokines have a major role in the initiation and perpetuation of the chronic inflammatory response in rheumatoid arthritis. Methotrexate (MTX) elicits a potent anti-inflammatory response in patients with rheumatoid arthritis5; however, there are no data regarding its effects on circulating inflammatory mediators in patients with CHF. The aims of the present study were to determine the effect of MTX on plasma cytokine expression in patients with CHF and to assess its effects on clinical indices.
From the aDepartment of Cardiology, The First People’s Hospital of Yangzhou, Yangzhou, China, and bDepartment of Clinics, Medical School of Yangzhou University, Yangzhou, China. Submitted May 25, 2004; accepted February 21, 2005. Reprint requests: Kaizheng Gong, MD, Department of Cardiology, The First People’s Hospital of Yangzhou, 45 Taizhou Road, Yangzhou 225001, China. E-mail: [email protected] 0002-8703/$ - see front matter n 2005, Mosby, Inc. All rights reserved. doi:10.1016/j.ahj.2005.02.040
Methods Study design and patients The study was a prospective, randomized, placebo-controlled, single-blind trial approved by the Medicine Institutional Review Board. Seventy-one consecutive patients with CHF attending outpatients were recruited from the First
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People’s Hospital of Yangzhou. CHF was diagnosed according to Framingham criterion.6 All patients provided written informed consent. Patient inclusion criteria were the following: (1) age range 18 to 75 years, (2) New York Heart Association (NYHA) functional class II to IV, (3) high-quality echocardiographic images could be obtained, (4) left ventricular ejection fraction (LVEF) b0.45 and left ventricular end-diastolic dimension (LVEDD) N55 mm by echocardiography, and (5) the etiology of CHF was from ischemia (n = 29, confirmed by history of angina pectoris and/or old myocardial infraction or coronary artery angiography [n = 11]), hypertension (n = 26), or idiopathic dilated cardiomyopathy (n = 16). Patients were excluded if they had any clinical or laboratory evidence of chronic obstructive pulmonary disease, rheumatoid arthritis, an infectious disease, connective tissue disease, neoplasm, severe liver or renal dysfunction, anemia, acute myocardial infarction within 6 weeks, or unstable angina pectoris. The control group consisted of 18 healthy, age-matched volunteers (10 men and 8 women, mean age 62.3 F 10.5 years, range 20 -74 years). All patients were optimally treated with diuretics (76.1%), digoxin (67.6%), angiotensin-converting enzyme inhibitor (94.0%), and h-blockers (45.1%). Patients were randomized to receive a low dose of MTX (ie, 7.5 mg once a week) or placebo for the 12-week study duration.
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Table I. Baseline characteristics of patients with CHF Characteristics Sex (male/female) Age (y) Blood pressure (mm Hg) Systolic Diastolic Cause (CHD/HHD/IDC) NYHA classification (II/III/IV) Body mass index alanine transaminase (IU/L) Creatinine (mmol/L) Blood urea nitrogen (mmol/L) Medication (%) Diuretics Digoxin Angiotensin-converting enzyme inhibitors h-Blockers
MTX group (n = 30)
Placebo group (n = 32)
P
18/12 61.2 F 8.3
19/13 63.5 F 9.3
NS NS
116.1 F 18.7 75.2 F 12.4 11/13/6 12/9/9
126.9 F 23.8 77.5 F 16.0 14/10/8 13/11/8
NS NS NS NS
22.9 F 3.6 44.2 F 18.3
24.4 F 3.0 38.1 F 15.5
NS NS
95.8 F 26.7 7.0 F 2.2
91.3 F 29.9 6.9 F 2.2
NS NS
22 (73.3) 21 (70.0) 28 (93.3)
26 (81.3) 21 (65.6) 30 (93.8)
NS NS NS
13 (43.3)
15 (46.9)
NS
Values are presented as mean F SD or n (%) or otherwise indicated. CHD, Coronary heart disease; HHD, hypertension heart disease; IDC, idiopathic dilated cardiomyopathy.
Clinical evaluation All patients underwent transthoracic echocardiography (Hewlett-Packard Sonos 5500 echocardiograph equipped with a 3.5-MHz transducer, MA, USA) at baseline and after receiving MTX or placebo for 12 weeks. All studies were recorded on videotape and performed by the same operator. Left ventricular end-diastolic dimension was measured by M-mode echocardiography in accordance with the American Society of Echocardiography guidelines.7 The LVEF was determined using Teichholz methods. Functional class was assessed according to the standard of the NYHA and a minimum of three 6 -minute walk tests.8 Quality of life (QOL) was assessed with the Chinese edition SF-36 as previously described.9 All assessments were undertaken by investigators blinded to the laboratory data and treatment assigned.
Measurements of inflammatory mediators Twenty milliliters of antecubital vein blood was collected into prechilled evacuated tubes containing EDTA-2Na at baseline and after 12 weeks of treatment with MTX or placebo. Plasma samples were prepared by centrifugation at 2500 rpm for 10 minutes and stored at 708C. Complement component 3 (C3) and C-reactive protein (CRP) were measured by using a routine turbidimetry assay. Tumor necrosis factor a, interleukin (IL)-1h, IL-6, IL-8, and IL-10 were measured using commercially available radioimmunoassay kits (Radioimmuno Tech Institute of PLA General Hospital, Beijing, China). Monocyte chemoattractant protein-1 (MCP-1), soluble IL-1 receptor antagonist (sIL-1Ra), and soluble intercellular adhesion molecule-1 (sICAM-1) were measured using commercially available enzyme-linked immunosorbent assay kits (LIFEKEY Bio Med Tech Corp, NJ, USA). All analyses were performed in duplicate and staff were blinded to the treatment groups.
Follow-up The baseline evaluation consisted of history and vital signs, routine laboratory tests, patient functional classification, echocardiographic measurement, 6 -minute walk test, and QOL assessment. For safety purpose, patients were followed up at 2 weekly intervals over the 12-week study period. Each visit consisted of a physical examination and assessment of adverse effects and blood and urine samples collected for routine analysis. Repeated evaluations of LVEDD, LVEF, NYHA functional class, 6 -minute walk test, and QOL were performed, and main cardiac adverse events including death, rehospitalization, worsening heart failure, acute myocardial infarction, and stroke were statistically evaluated after 12 weeks. Patients could withdraw from the study due to onset of significant adverse events or unwillingness to continue.
Statistical analysis All continuous variables are presented as mean F SD and data were analyzed using SPSSPC (version 11.0 for Windows, SPSS Inc, Chicago, IL). Differences in the levels of inflammatory markers and changes in the indices of clinical condition between groups were analyzed nonparametrically (Mann-Whitney U test for unpaired data). Changes from baseline within each group were analyzed by Wilcoxon matched pairs test. Differences in proportions between groups were analyzed by Fisher exact test (2-sided). A value of P b .05 was taken to indicate statistical significance. Based upon preliminary data from 20 patients with CHF (NYHA II-IV), circulating levels of TNF- a and IL- 6 are 3.21 F 1.09 pg/mL and 162.6 F 48.4 pg/mL, respectively. Anticipating a 15% decrease in their expression levels and a 10% dropout rate, a sample size of 71 patients would be sufficient to
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Table II. Effects of MTX on plasma levels of inflammatory mediators in CHF Placebo group (n = 32) Baseline TNF-a (ng/mL) IL-1h (ng/mL) IL-6 (pg/mL) IL-8 (ng/mL) MCP-1 (pg/mL) IL-10 (ng/mL) sIL-1Ra (pg/mL) sICAM-1 (ng/mL) C3 (mg/L) CRP (Ag/L)
3.10 0.57 155.3 1.33 73.9 40.2 70.4 77.1 0.49 0.72
F F F F F F F F F F
0.80 0.17 62.6 0.38 25.3 10.0 23.5 31.1 0.20 0.35
12 wk 3.23 0.49 134.0 1.29 60.4 45.6 78.2 71.0 0.40 0.61
F F F F F F F F F F
0.89 0.19 35.5 0.37 17.7 14.6 15.5 23.0 0.17 0.29
MTX group (n = 30) #% 7.4 14.0 10.9 1.5 19.6y 15.7 10.7 3.0 14.3 13.9
Baseline 3.33 0.56 159.5 1.29 64.3 44.2 68.2 85.0 0.41 0.81
F F F F F F F F F F
0.84 0.20 49.8 0.33 21.5 11.2 24.1 32.9 0.20 0.30
12 wk 2.81 0.48 124.8 1.15 49.9 51.2 92.7 68.7 0.43 0.59
F F F F F F F F F F
0.83 0.16 39.6 0.40 20.9 13.2 22.0 27.9 0.15 0.28
#%
Differences in 12 wk between groups
15.6T 14.3 21.8y 10.9 22.6y 15.8T 36.1y 19.2T 4.9 27.2y
.064 .927 .220 .217 .037 .068 .004 .622 .303 .652
Data are expressed as mean F SD. There were no significant differences between the groups at baseline. D%, Percent of changes from baseline. TP b .05 versus baseline. yP b .01 versus baseline.
detect such changes, with a power of 80% at the 5% level of significance.
Results Of the 71 patients enrolled, 36 were randomized to the placebo and 35 to the MTX group. The study was discontinued prematurely in 4 (11.1%) patients receiving placebo and 5 (14.3%) patients receiving MTX (Fisher exact test, 2-sided P = .735). Of these patients, 2 were withdrawn due to onsets of nausea and vomit, 4 were due to migration to remote areas, and 3 were unwilling to continue with the study without any definite reason. Patients failing to complete the study were excluded from the final analysis of biochemical and clinical variables. However, their patient global self-assessment was followed up by telephone and included in the analysis. Of those excluded, there was 1 death, 1 reported feeling worse, and 1 reported no change for each treatment group. In addition, 2 in the MTX group and 1 in the placebo group reported an improvement. In total, 62 patients finished the study. There were no statistical differences in baseline characteristics of patients in the 2 groups after exclusion of the 9 patients (Table I).
Changes of the circulating levels of inflammatory mediators The circulating levels of TNF-a (3.21 F 0.82 vs 2.14 F 0.50 pg/mL, P b .000), IL-1h (0.57 F 0.18 vs 0.23 F 0.09 ng/mL, P b .000), IL-6 (157.3 F 56.3 vs 98.4 F 26.3 pg/mL, P b .000), IL-8 (1.31 F 0.36 vs 0.90 F 0.21 ng/mL, P b .000), MCP-1 (69.3 F 23.8 vs 30.9 F 7.8 pg/mL, P b .000), sICAM-1 (80.9 F 31.9 vs 45.8 F 14.2 ng/mL, P b .000), C3 (0.45 F 0.20 vs 0.29 F 0.10 mg/mL, P = .002), CRP (0.76 F 0.33 vs 0.49 F 0.18 Ag/mL, P = .001), IL-10 (42.1 F 10.7 vs
32.7 F 6.0 ng/mL, P b .000), and sIL-1Ra (69.3 F 23.6 vs 39.0 F 17.9 pg/mL, P b .000) were significantly higher in patients with CHF (n = 62) than in healthy controls (n = 18). At baseline, plasma levels of the inflammatory mediators were similar between groups (Table II). After 12 weeks of treatment with MTX, there was a significant reduction in the circulating levels of TNF-a (3.33 F 0.84 vs 2.81 F 0.83 pg/mL, 15.6%, P b .05), IL-6 (159.5 F 49.8 vs 124.8 F 39.6 pg/mL, 21.8%, P b .01), MCP-1 (64.3 F 21.5 vs 49.9 F 20.9 pg/mL, 22.6%, P b .01), sICAM-1 (85.0 F 32.9 vs 68.7 F 27.9 ng/mL, 19.2%, P b .05), and CRP (0.81 F 0.30 vs 0.59 F 0.28 Ag/mL, 27.2%, P b .01). However, levels of IL-10 (44.2 F 11.2 vs 51.2 F 13.2 ng/mL, 15.8%, P b .05) and sIL-1Ra (68.2 F 24.1 vs 92.7 F 22.0 pg/mL, 36.1%, P b .01) were significantly higher compared with baseline values. Furthermore, MCP-1 (49.9 F 20.9 vs 60.4 F 17.7 pg/mL, P = .037) was remarkably lower and sIL-1Ra higher (92.7 F 22.0 vs 78.2 F 15.5 pg/mL, P = .004) in the MTX group than in the placebo group. Administration of MTX did not alter circulating levels of IL-1h, IL-8, and C3. In the placebo group, the 12-week MCP-1 levels were dramatically decreased compared with baseline (60.4 F 17.7 vs 73.9 F 25.3 pg/mL, 19.6%, P b .01).
Impact of MTX on the clinical condition in patients with CHF Significant improvements in NYHA functional class (2.9 F 0.8 vs 2.4 F 0.9, 17.2%, P b .01), 6 -minute walk test distance (296.5 F 68.6 vs 361.4 F 75.3 m, 21.9%, P b .01) (Figure 1), and QOL general scores (82.4 F 15.1 vs 92.0 F 13.8, 11.7%, P b .01) as well as physical health scores (43.1 F 13.7 vs 52.8 F 15.0, 22.5%, P b .01) (Figure 2) were observed in the MTX group at 12 weeks compared with baseline. Furthermore, the 6 -minute
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Figure 1
Changes of NYHA functional class, 6-minute walk distance, LVEF, and LVEDD after 12 weeks of treatment with MTX (n = 30) or placebo (n = 32) in patients with CHF. Values are expressed as mean F SD. yP b .05 12 weeks versus baseline, zP b .05 12 weeks versus baseline, #P b .05 MTX versus placebo.
walk test distance (361.4 F 75.3 vs 321.8 F 83.9 m, P b .05), QOL general scores (92.0 F 13.8 vs 80.1 F 17.8, P b .01), and physical health scores (52.8 F 15.0 vs 43.6 F 14.3, P b .05) were better in those receiving MTX compared with placebo. There were no changes in LVEF, LVEDD, and the mental health scores of QOL in the MTX group at 12 weeks compared with baseline. In contrast, improvements in NYHA functional class (Figure 1) and 6 -minute walk test distance (Figure 2) were observed in the placebo group after 12 weeks ( P b .05).
Incidences of the main cardiac adverse events with MTX therapy During the 12-week follow-up, the incidences of death (1 [2.9%] patient in MTX group, 1 [2.7%] patient in placebo group, Fisher exact test, 2-sided P = 1.000), rehospitalization (14 person times for 8 [23.5%] patients in MTX group, 12 person times for 7 [18.9%]
patients in placebo group, Fisher exact test, 2-sided P = .771), and worsening heart failure (8 person times for 4 [11.8%] patients in MTX group, 10 person times for 6 [16.2%] patients in placebo group, Fisher exact test, 2-sided P = .737) were similar between the 2 groups (N = 71). No patient experienced sudden cardiac death, acute myocardial infarction, or stroke in either group.
Safety of MTX During the follow-up, 2 patients in the MTX group and 2 patients in the placebo group experienced nausea (5.7% and 5.6%, respectively, Fisher exact test, 2-sided P = 1.000) and 2 patients in MTX group experienced vomit (5.7%, Fisher exact test, 2-sided P = .239). Of the 4 patients in the MTX group, 2 happened only after the first dosing and without reoccurrence and the other 2 patients dropped out the study. There
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Figure 2
Changes of general scores of QOL, physical health scores, and mental health scores after 12 weeks of treatment with MTX (n = 30) or placebo (n = 32) in patients with CHF. Values are expressed as mean F SD. yP b .05 12 weeks versus baseline, #P b .05 MTX versus placebo.
are 2 patients with mild alanine transaminase increase (5.7%, Fisher exact test, 2-sided P = .239) and 1 patient with renal function deterioration (2.9%, Fisher exact test, 2-sided P = .493) in MTX group. But the 3 patients got well gradually after stopping the treatment with MTX within 1 week and continued the treatment until the end of the study. No patient suffered from gout, the abnormality in hematology and malignancy during the follow-up. The incidences of these adverse effects between the 2 groups showed no statistical difference.
Discussion This is the first study to show that the addition of MTX to conventional therapy in patients with CHF exerts a significant anti-inflammatory effect and improves several indices of functional status. In particular, improvements in NYHA class, 6-minute walk test distance, QOL general scores, and physical health scores are accompanied by down-regulation of
circulating levels of TNF- a, IL- 6, MCP-1, sICAM-1, and CRP, as well as up-regulation of the anti-inflammatory cytokines IL-10 and sIL-1Ra. Recently, a number of clinical studies have demonstrated that patients with CHF express excessive inflammatory mediators in plasma and failing myocardium.10-12 Inflammatory mediators are capable of modulating cardiovascular functions by a variety of mechanisms. Tumor necrosis factor a has been shown to depress myocardial contractility13 and induce cardiomyocyte hypertrophy,14 apoptosis,15 necrosis, and interstitial remodeling.16 Interestingly, Wolfe and Michaud17 recently reported that heart failure was more common among patients with rheumatoid arthritis (3.9%) than in those with osteoarthritis (2.3%) and that the increased risk of heart failure in patients with rheumatoid arthritis may be reduced by anti-TNF therapies. Similarly, Choi et al18 confirmed that MTX treatment in rheumatoid arthritis provides a substantial survival benefit, largely by reducing cardiovascular mortality.
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Given the important role of inflammatory mediators in the pathogenesis of CHF, therapeutic modulation targeting inflammatory mediators might be a new and promising strategy for treating CHF. However, the results of 2 large-scale clinical trials targeting TNF-a (ENBREL and ATTACH) did not provide any evidence of benefit.3,4 As far as our understanding of the mechanisms of immune activation in CHF is concerned, we consider that activated inflammatory mediators in CHF form a complex network. Therefore, the benefit of antagonizing a single factor in this network may be diminished by the interaction of other factors in the network. We assume that a more generalized approach targeting this network may produce certain beneficial effects in patients with CHF. Recent clinical data support this. Pentoxifylline, a xanthine derivative, inhibits expression of various inflammatory cytokines including TNF-a, IL-1h, and interferon g.19 Furthermore, the addition of pentoxifylline to standard heart failure therapy reduces plasma TNF-a levels and improves clinical status and LVEF in patients with idiopathic dilated cardiomyopathy and ischemic cardiomyopathy.20 Treatment with intravenous immunoglobulin is also of benefit in a wide range of immune-mediated disorders including Kawasaki syndrome and acute inflammatory cardiomyopathy. Their proposed mechanism of action involves neutralization of pathogens, attenuation of complement-mediated tissue damage, and suppression of T-cell proliferation. Gullestad et al21 showed that immunoglobulin treatment significantly increases LVEF in heart failure of ischemic or idiopathic etiology while increasing plasma levels of IL-10, IL-1Ra, and sTNF-a receptors; TNF-a levels were unaffected. A number of clinical studies show that MTX, a folate analogue, not only inhibits inflammatory cell proliferation through action on dihydrofolate reductase but also inhibits the conversion of 5-aminoimidazole-4-carboxamide ribonucleotide to 5-formyl-5-aminoimidazole-4-carboxamide ribonucleotide, thus increasing intracellular and extracellular levels of adenosine-5V-phosphate and adenosine.22,23 Several studies have demonstrated that binding of adenosine to the A2 receptor inhibits lymphocyte proliferation and production of TNF, IL-8, and IL-12, as well as increases secretion of IL-10.24 Methotrexate has been successfully used in the treatment of many immune- or inflammatory-mediated diseases (eg, rheumatoid arthritis) by causing generalized immunomodulation. Furthermore, adenosine receptors are expressed on various cells and implicated in cellular protection against ischemic, anoxia, and heat stress. We conjecture that MTX might provide additional benefit for patients with CHF in addition to its anti-inflammatory effects. Our present study demonstrates that not only the circulating levels of several proinflammatory mediators (eg, TNF-a, IL-1h, IL-6, IL-8, MCP-1, sICAM-1, C3, and
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CRP) but also the anti-inflammatory mediators IL-10 and sIL-1Ra are dramatically increased in the CHF group compared with the control group. This indicates that the activation of inflammatory mediators may be a common pathophysiological characteristic in CHF. Furthermore, MTX decreases the levels of the proinflammatory mediators TNF-a, IL- 6, MCP-1, sICAM-1, and CRP, but increased the levels of anti-inflammatory mediators IL-10 and sIL-1Ra. In contrast, no changes in the circulating levels of inflammatory mediators other than MCP-1 were observed in the placebo group. In addition, MTX produced a further modulating effect on MCP-1 and sIL-1Ra compared with placebo. These results showed that the addition of MTX to conventional heart failure treatment globally regulate levels of circulating inflammatory mediators culminating in a net anti-inflammatory effect. In addition to the anti-inflammatory effect, significant improvements in the NYHA classification, 6 -minute walk test distance, and QOL scores in patients treated with MTX were observed compared with placebo group. Although the anti-inflammatory effect of MTX was not translated into improvement in the LVEF and LVEDD or a reduction in the incidence of main adverse cardiac events (death, rehospitalization, or worsening heart failure), it is well known that LVEF or LVEDD might not be a unique decisive factor of NYHA class, 6 -minute walk test distance, and QOL. Excessive activation of inflammatory mediators in CHF may exert influence on various systems of the body. For example, TNF - a not only acts on cardiac cells and induces cardiac cachexia by promoting metabolic dysfunction, but it also causes myasthenia and dysfunction of the endothelium.25 Therefore, MTX administration could also be beneficial because of modulation of a variety of humoral factors in patients with CHF through its anti-inflammatory effects. Moreover, as mentioned above, MTX can confer cellular protection by increasing extracellular and intracellular adenosine levels. Accordingly, the possibility cannot be excluded that MTX might exert other benefits on patients with CHF apart from immunomodulating effects. Noticeably, the relatively small population size and short therapy duration in this study may limit the ability to detect changes for LVEF, LVEDD, and the reduction in the incidence of main adverse cardiac events. Some studies suggested that the adverse effects of long-term MTX therapy are increased when the accumulated dosage is N2000 mg.26 In this study, the average dosage was 82.5 F 15.8 mg. The main adverse effect associated with MTX was symptoms of gastrointestinal disturbance; there were no reported instances of severe toxicity (eg, bone marrow suppression or alopecia).Therefore, our results indicate that MTX might be fully accepted with good effect/toxicity for short-term treatment.
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In conclusion, our data suggest that the addition of low-dosage MTX to conventional therapy for CHF might have a significant anti-inflammatory effect along with improvements of NYHA functional class, 6 -minute walk test distance, and QOL scores. Methotrexate could be a beneficial adjunct to conventional therapy for patients with CHF. We thank Zhifeng Dong, MD, for preparing the manuscript; Prof Ning Zu and Prof Shunrong Cao for revision of the manuscript; Da Gao, MD, and Xiaopeng Ji, MB, for technical assistance; and Liping Sun, MD, and Prof Cheng Wang for their help with the statistical analysis.
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