Interleukin‐receptor antagonist and tumour necrosis factor inhibitors for the primary and secondary prevention of atherosclerotic cardiovascular diseases

Background Atherosclerotic cardiovascular disease (ACVD) is worsened by chronic inflammatory diseases. Interleukin receptor antagonists (IL‐RAs) and tumour necrosis factor‐alpha (TNF) inhibitors have been studied to see if they can prevent cardiovascular events. Objectives The purpose of this study was to assess the clinical benefits and harms of IL‐RAs and TNF inhibitors in the primary and secondary prevention of ACVD. Search methods The Cochrane Heart Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE (including In‐Process & Other Non‐Indexed Citations), Ovid Embase, EBSCO CINAHL plus, and clinical trial registries for ongoing and unpublished studies were searched in February 2024. The reference lists of relevant studies, reviews, meta‐analyses and health technology reports were searched to identify additional studies. No limitations on language, date of publication or study type were set. Selection criteria RCTs that recruited people with and without pre‐existing ACVD, comparing IL‐RAs or TNF inhibitors versus placebo or usual care, were selected. The primary outcomes considered were all‐cause mortality, myocardial infarction, unstable angina, and adverse events. Data collection and analysis Two or more review authors, working independently at each step, selected studies, extracted data, assessed the risk of bias and used GRADE to judge the certainty of evidence. Main results We included 58 RCTs (22,053 participants; 21,308 analysed), comparing medication efficacy with placebo or usual care. Thirty‐four trials focused on primary prevention and 24 on secondary prevention. The interventions included IL‐1 RAs (anakinra, canakinumab), IL‐6 RA (tocilizumab), TNF‐inhibitors (etanercept, infliximab) compared with placebo or usual care. The certainty of evidence was low to very low due to biases and imprecision; all trials had a high risk of bias. Primary prevention: IL‐1 RAs The evidence is very uncertain about the effects of the intervention on all‐cause mortality(RR 0.33, 95% CI 0.01 to 7.58, 1 trial), myocardial infarction (RR 0.71, 95% CI 0.04 to 12.48, I² = 39%, 2 trials), unstable angina (RR 0.24, 95% CI 0.03 to 2.11, I² = 0%, 2 trials), stroke (RR 2.42, 95% CI 0.12 to 50.15; 1 trial), adverse events (RR 0.85, 95% CI 0.59 to 1.22, I² = 54%, 3 trials), or infection (rate ratio 0.84, 95% 0.55 to 1.29, I² = 0%, 4 trials). Evidence is very uncertain about whether anakinra and cankinumab may reduce heart failure