Marked Variations in Serial Coronary Artery Diameter Measures in Kawasaki Disease: A New Indicator of Coronary Involvement
ABSTRACT The long-term risk of patients with Kawasaki disease is not well defined. A great proportion of patients with Kawasaki disease have important variation of their coronary artery (CA) diameters, but the significance of this variation is not known. The aim of this study was to test the hypothesis that patients within the normal range of CA diameters but with important Z-score variation have a stronger inflammatory response and increased resistance to treatment than those without such Z-score variation.
A retrospective study was conducted in 197 patients with Kawasaki disease with serial echocardiograms up to 12 months after diagnosis. Patients with occult CA dilatation (variation > 2 Z-score units but within the normal range) were compared with patients with definite CA dilatation (Z score > 2.5) and with patients with normal CA for resistance to treatment and systemic inflammatory parameters.
A total of 63 patients (32.0%) were identified with Z scores always within the normal range but with important variation of CA diameter during follow-up (occult dilatation). There was a strong statistically significant trend of increasing inflammatory marker levels across patient categories (normal > occult dilatation > definite dilatation). Furthermore, resistance to intravenous immunoglobulin therapy was significantly increased in patients with occult dilatation compared with patients with normal CAs (relative risk, 2.6; 95% confidence interval, 1.21-5.44; P = .006).
The suggested definition of occult CA dilatation identified patients with CA involvement currently unrecognized per the current guidelines. These patients might be at a higher CA risk than previously thought.
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ABSTRACT: Kawasaki disease, the most common cause of acquired heart disease in developed countries, is a self-limited vasculitis that is treated with high doses of intravenous immunoglobulin. Resistance to intravenous immunoglobulin in Kawasaki disease increases the risk of coronary artery aneurysms. We assessed whether the addition of infliximab to standard therapy (intravenous immunoglobulin and aspirin) in acute Kawasaki disease reduces the rate of treatment resistance. We undertook a phase 3, randomised, double-blind, placebo-controlled trial in two children's hospitals in the USA to assess the addition of infliximab (5 mg per kg) to standard therapy. Eligible participants were children aged 4 weeks-17 years who had a fever (temperature ≥38·0°C) for 3-10 days and met American Heart Association criteria for Kawasaki disease. Participants were randomly allocated in 1:1 ratio to two treatment groups: infliximab 5 mg/kg at 1 mg/mL intravenously over 2 h or placebo (normal saline 5 mL/kg, administered intravenously). Randomisation was based on a randomly permuted block design (block sizes 2 and 4), stratified by age, sex, and centre. Patients, treating physicians and staff, study team members, and echocardiographers were all masked to treament assignment. The primary outcome was the difference between the groups in treatment resistance defined as a temperature of 38·0°C or higher at 36 h to 7 days after completion of the infusion of intravenous immunoglobulin. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, NCT00760435. 196 patients were enrolled and randomised: 98 to the infliximab group and 98 to placebo. One patient in the placebo group was withdrawn from the study because of hypotension before receiving treatment. Treatment resistance rate did not differ significantly (11 [11·2%] for infliximab and 11 [11·3%] for placebo; p=0·81). Compared with the placebo group, participants given infliximab had fewer days of fever (median 1 day for infliximab vs 2 days for placebo; p<0·0001). At week 2, infliximab-treated patients had greater mean reductions in erythrocyte sedimentation rate (p=0·009) and a two-fold greater decrease in Z score of the left anterior descending artery (p=0·045) than did those in the placebo group, but this difference was not significant at week 5. Participants in the infliximab group had a greater mean reduction in C-reactive protein concentration (p=0·0003) and in absolute neutrophil count (p=0·024) at 24 h after treatment than did those given placebo, but by week 2 this difference was not significant. At week 5, none of the laboratory values differed significantly compared with baseline. No significant differences were recorded between the two groups at any timepoint in proximal right coronary artery Z scores, age-adjusted haemoglobin values, duration of hospital stay, or any other laboratory markers of inflammation measured. No reactions to intravenous immunoglobulin infusion occurred in patients treated with infliximab compared with 13 (13·4%) patients given placebo (p<0·0001). No serious adverse events were directly attributable to infliximab infusion. The addition of infliximab to primary treatment in acute Kawasaki disease did not reduce treatment resistance. However, it was safe and well tolerated and reduced fever duration, some markers of inflammation, left anterior descending coronary artery Z score, and intravenous immunoglobulin reaction rates. US Food and Drug Administration, Robert Wood Johnson Foundation, and Janssen Biotech.The Lancet 02/2014; 383(9930). DOI:10.1016/S0140-6736(13)62298-9 · 45.22 Impact Factor