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Does TNF-α blockade cause plaque rupture?

      Tumour necrosis factor α (TNF-α) plays a pivotal role in inflammation by potentiating the inflammatory reaction. Recent studies and clinical experience have shown remarkable effects, on inflammatory markers and symptoms, of drugs that block the biologic activity of TNF-α in patients with rheumatoid arthritis (RA). Without being a traditional inflammatory disease, left ventricular dysfunction has recently been characterised by increased expression of TNF-α in the myocardium [
      • Mann D.L.
      Inflammatory mediators and the failing heart. Past, present and the foreseeable future.
      ]. As a result, inhibition of TNF-α has been suggested to be beneficial for patients with heart failure. However, several recent studies of TNF-α blockade in heart failure have shown a lack of improvement of symptoms and an increased risk for death [
      • Coletta A.P.
      • Clark A.L.
      • Banarjee P.
      • Cleland J.G.F.
      Clinical trials update: RENEWAL (RENAISSANCE and RECOVER) and ATTACH.
      ,
      • Chung E.S.
      • Packer M.
      • Lo K.H.
      • Fasanmade A.A.
      • Willerson J.T.
      Anti-TNF therapy against congestive heart failure investigators. Randomized, double-blind, placebo-controlled, pilot trial of infliximab, a chimeric monoclonal antibody to tumor necrosis factor-alpha, in patients with moderate-to-severe heart failure: results of the anti-TNF therapy against congestive heart failure (ATTACH) trial.
      ]. The lack of effect and the possible risk of TNF-α blockade in heart failure is not well understood. The following case reported suggests that TNF-α blockade might aggravate coronary heart disease (CHD) which is the underlying cause of heart failure in many patients.
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