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Original Investigation
Journal Club
December 2016

Coronary Artery Complication in Kawasaki Disease and the Importance of Early Intervention A Systematic Review and Meta-analysis

Journal Club PowerPoint Slide Download
Author Affiliations
  • 1Department of Cardiology, Shanghai First People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
  • 2Allgemein öffentliches Krankenhaus Elisabethinen Linz and Department of Cardiology, Elisabethinen University Teaching Hospital of Medical University Innsbruck and Vienna, Linz, Oberösterreich, Austria
  • 3Department of Pediatrics, Children’s Hospital of Fudan University, Shanghai, China
  • 4Hospital e Clínica São Gonçalo, Department of Medicine, Universidade Federal Fluminense, Niteroi, Rio de Janeiro, Brazil
  • 5Humanmedzin, Universität Leipzig, Leipzig University, Freistaat Sachsen, Germany
  • 6Herzzentrum Universität Leipzig, Heart Center Leipzig University, Leipzig, Freistaat Sachsen, Germany
  • 7Department of Cardiology, Second Affiliated Hospital Chongqing Medical University, Chongqing, China
  • 8Department of Cardiology, Ninth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
  • 9Department of Cardiology, Affiliated Hospital of Zunyi Medical College, Zunyi, China
  • 10Department of Medicine and Cardiology, Duke University Medical Center, Durham, North Carolina
  • 11Duke Clinical Research Institute, Durham, North Carolina
JAMA Pediatr. 2016;170(12):1156-1163. doi:10.1001/jamapediatrics.2016.2055
Key Points

Questions  What is the effect of corticosteroid therapy in patients with Kawasaki disease in to prevent coronary artery complications?

Findings  This systematic review and meta-analysis demonstrates that adjunctive corticosteroid therapy was associated with a significantly lower rate of coronary artery complication compared with intravenous immunoglobulin therapy, particularly among high-risk patients. Meta-regression based on known variables demonstrated that the overall efficacy was negatively correlated with the duration of illness before corticosteroids therapy.

Meanings  This study highlights the importance of “timing” in treating Kawasaki disease; high-risk patients with Kawasaki disease benefit greatly from a “timely” adjunctive corticosteroid therapy strategy.

Abstract

Importance  The timing and selection of patients with Kawasaki disease for corticosteroid use to prevent coronary artery complications remain controversial.

Objective  To evaluate the effect of corticosteroid therapy in KD.

Data Sources  Databases of Medline, The Cochrane Library, and the Clinicaltrials.gov website until July 2015. We used the key words [“Kawasaki disease”] and [“steroid” OR “corticosteroid”] to retrieve potentially relevant studies in the databases of Medline, the Cochrane Library, and the Clinicaltrials.gov website until July 2015. Both English and non-English literature was identified. Titles and abstracts were reviewed by 2 authors (S.C. and Y.D.) to determine suitability for inclusion. Relevant articles were reassessed by reviewing the full text. Discrepancies in study inclusion were resolved by consensus (M.G.K.).

Study Selection  Clinical studies that compared corticosteroids plus intravenous immunoglobulin (IVIG) therapy with IVIG therapy alone in treating patients with KD. Studies either using corticosteroids as initial therapy or as rescue therapy were included.

Data Extraction and Synthesis  Investigators independently extracted the data information. Data were quantitatively synthesized using random-effects analysis.

Main Outcomes and Measures  Rate of coronary artery abnormalities.

Results  Sixteen comparative studies characterizing 2746 patients were analyzed. The duration of illness before corticosteroids therapy was significantly shorter in the initial corticosteroids subset than in the rescue corticosteroids subset. The rate of coronary artery abnormalities was significantly lower in adjunctive corticosteroids therapy than in IVIG therapy (odds ratio [OR], 0.424; 95% CI, 0.270-0.665). Meta-regression based on known variables demonstrated that the overall efficacy was negatively correlated with the duration of illness before corticosteroid therapy (P < .001). Subgroup analysis, including studies using corticosteroids plus IVIG as initial therapy, showed a more advantageous effect than IVIG alone regarding coronary artery abnormality prevention (OR, 0.320; 95% CI, 0.183-0.560), whereas this benefit was not found in a subgroup of studies using corticosteroids as rescue therapy. Further analysis found that patients predicted at baseline to be at high risk of IVIG resistance seemed to obtain the greatest benefit from adjunctive corticosteroid therapy regarding coronary artery abnormality prevention (OR, 0.240; 95% CI, 0.123-0.467). The fever duration was significantly reduced in the corticosteroids group. The favorable effects of corticosteroids were conferred without an increased risk of adverse events.

Conclusions and Relevance  This study highlights the importance of timing to prevent coronary artery complication in treating KD. High-risk patients with KD benefit greatly from a timely and potent adjunctive corticosteroid therapy strategy.

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