Author + information
- Received March 9, 2020
- Revision received May 15, 2020
- Accepted May 18, 2020
- Published online July 13, 2020.
- Peter Izmirly, MDa,∗ (, )
- Mimi Kim, ScDb,
- Deborah M. Friedman, MDc,
- Nathalie Costedoat-Chalumeau, MD, PhDd,
- Robert Clancy, PhDa,
- Joshua A. Copel, MDe,
- Colin K.L. Phoon, MD, MPhila,
- Bettina F. Cuneo, MDf,
- Rebecca E. Cohen, BAa,
- Kimberly Robins, MSa,
- Mala Masson, BAa,
- Benjamin J. Wainwright, BAa,
- Noel Zahr, PharmD, PhDg,
- Amit Saxena, MDa and
- Jill P. Buyon, MDa@JillBuyonMD
- aNew York University School of Medicine, New York, New York
- bAlbert Einstein College of Medicine, Bronx, New York
- cNew York Medical College, Valhalla, New York
- dAPHP, Hospital Cochin, Paris, France
- eYale School of Medicine, New Haven, Connecticut
- fUniversity of Colorado School of Medicine, Aurora, Colorado
- gPitié-Salpêtrière University Hospital, Paris, France
- ↵∗Address for correspondence:
Dr. Peter Izmirly, NYU Langone Health, Medical Science Building 625, 550 1st Avenue, New York, New York 10016.
Background Experimental and clinical evidence support the role of macrophage Toll-like receptor signaling in maternal anti-SSA/Ro–mediated congenital heart block (CHB).
Objectives Hydroxychloroquine (HCQ), an orally administered Toll-like receptor antagonist widely used in lupus including during pregnancy, was evaluated for efficacy in reducing the historical 18% recurrence rate of CHB.
Methods This multicenter, open-label, single-arm, 2-stage clinical trial was designed using Simon’s optimal approach. Anti-SSA/Ro–positive mothers with a previous pregnancy complicated by CHB were recruited (n = 19 Stage 1; n = 35 Stage 2). Patients received 400 mg daily of HCQ prior to completion of gestational week 10, which was maintained through pregnancy. The primary outcome was 2° or 3° CHB any time during pregnancy, and secondary outcomes included isolated endocardial fibroelastosis, 1° CHB at birth and skin rash.
Results By intention-to-treat (ITT) analysis, 4 of 54 evaluable pregnancies resulted in a primary outcome (7.4%; 90% confidence interval: 3.4% to 15.9%). Because 9 mothers took potentially confounding medications (fluorinated glucocorticoids and/or intravenous immunoglobulin) after enrollment but prior to a primary outcome, to evaluate HCQ alone, 9 additional mothers were recruited and followed the identical protocol. In the per-protocol analysis restricted to pregnancies exposed to HCQ alone, 4 of 54 (7.4%) fetuses developed a primary outcome as in the ITT. Secondary outcomes included mild endocardial fibroelastosis (n = 1) and cutaneous neonatal lupus (n = 4).
Conclusions These prospective data support that HCQ significantly reduces the recurrence of CHB below the historical rate by >50%, suggesting that this drug should be prescribed for secondary prevention of fetal cardiac disease in anti-SSA/Ro-exposed pregnancies. (Preventive Approach to Congenital Heart Block With Hydroxychloroquine [PATCH]; NCT01379573)
This research was supported by the Lupus Foundation of Minnesota, the Lupus Foundation of America (LIFELINE Grant), and the Eunice Kennedy Shriver National Institute of Child Health and Human Development (R03HD069986 and R01HD079951 to Dr. Buyon).
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC author instructions page.
- Received March 9, 2020.
- Revision received May 15, 2020.
- Accepted May 18, 2020.
- 2020 American College of Cardiology Foundation
This article requires a subscription or purchase to view the full text. If you are a subscriber or member, click Login or the Subscribe link (top menu above) to access this article.