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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Concerns of adverse cardiovascular events with the use of tofacitinib have been raised&#44; but no case of cardiomyopathy has been reported so far&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We describe a rare case of Takotsubo cardiomyopathy &#40;TKM&#41; in a rheumatoid arthritis &#40;RA&#41; patient treated with tofacitinib&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinical observation</span><p id="par0015" class="elsevierStylePara elsevierViewall">A 57-year-old white woman was diagnosed with a seropositive for anti-citrullinated protein antibody RA 5 years ago&#46; She was treated with tofacitinib 10<span class="elsevierStyleHsp" style=""></span>mg daily &#40;started one year ago&#41; and prednisolone 5<span class="elsevierStyleHsp" style=""></span>mg daily&#46; Initially&#44; the patient experienced adverse events with the first 2 attempted csDMARDs &#40;liver toxicity under methotrexate and hypertension with leflunomide&#41; and was refractory to multiple biologic agents &#40;etanercept&#44; golimumab and tocilizumab&#44; were consecutively tried&#41; and her disease was refractory to multiple biologic agents &#40;etanercept&#44; golimumab and tocilizumab&#41;&#46; She had no other cardiovascular risk factors&#46; Previous electrocardiogram &#40;ECG&#41; was unremarkable&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">She presented to the emergency department with an acute onset tight squeezing chest pain lasting for 7<span class="elsevierStyleHsp" style=""></span>h&#46; Upon admission&#44; we observed the following vital signs&#58; blood pressure of 110&#47;60<span class="elsevierStyleHsp" style=""></span>mmHg&#44; heart rate of 90 beats per minute&#44; respiratory rate of 18 breaths per minute and oxygen saturation of 98&#37; on room air with a pulse oximeter&#46; Her heart sounds were regular with no murmurs and lung examination was normal&#46; Her cardiac enzymes were elevated&#44; presenting with a creatine phosphokinase-MB of 5&#46;7<span class="elsevierStyleHsp" style=""></span>ng&#47;mL &#40;normal<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&#41; and a troponin <span class="elsevierStyleSmallCaps">I</span> of 1&#46;16<span class="elsevierStyleHsp" style=""></span>ng&#47;mL &#40;normal<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;04<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&#41;&#46; She had a normal complete blood count&#46; Thyroid function and cortisol levels were normal&#46; ECG showed pathologic Q-waves in leads V1-V3 and a negative T-waves in lead V4&#46; Cardiac catheterization was performed&#44; demonstrating normal coronary arteries&#44; circumferential akinesia of the apex and a poor left ventricular systolic function &#40;LVEF&#41; &#40;of approximately 40&#37;&#93;&#44; consistent with the diagnosis of TKM&#46; Myocardial perfusion scintigraphy performed on day 6 showed no alterations&#59; LVEF was estimated at 38&#37;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The patient received supportive care and had an uneventful hospital stay with complete resolution of symptoms and normalization of cardiac enzymes in 48<span class="elsevierStyleHsp" style=""></span>h&#46; Three days after&#44; prior to hospital discharge&#44; she performed an echocardiogram that revealed a preserved LVEF &#40;estimated at 55&#37;&#41;&#44; with normal wall thickness and absence of wall motion abnormalities&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Treatment with tofacitinib was stopped and the patient started abatacept&#46; One year later&#44; the patient was reassessed with a cardiac magnetic resonance&#44; showing no abnormalities in segmental motility&#47;contractility or areas of late gadolinium enhancement&#44; estimating LVEF at 58&#37;&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0035" class="elsevierStylePara elsevierViewall">The diagnosis of TKM was made in this patient once all four Mayo Clinic diagnostic criteria were present&#58; transient left ventricular systolic dysfunction&#44; absence of obstructive coronary disease&#44; new electrocardiographic abnormalities and absence of pheochromocytoma&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Several pathophysiological mechanisms have been proposed for TKM&#44; but one of the most unanimous is a catecholamine surge&#44; supported by a number of features&#44; including its association with emotional stress and with the exposure to supratherapeutic doses of catecholamines&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">4&#8211;6</span></a> In a 2017 article&#44; reviewing all the 157 drug-induced TKM cases published in the literature until then&#44; the authors conclude that over two-thirds of drug-induced TKM cases were due to catecholamine stimulation&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">7</span></a> Moreover&#44; a recent study in rats&#44; who were given tofacitinib&#44; evaluated the relationship between cardiovascular hemodynamics and plasma norepinephrine &#40;NE&#41; levels&#44; showing a dose-dependent increase in circulating NE levels&#44; which was maintained during 14 days of tofacitinib administration&#46; However&#44; this increase in plasma NE concentrations presumably reflects a reflex response to direct vasodilation&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">8</span></a> Further studies in humans&#44; are needed to clarify this finding&#46; It may represent the link between tofacitinib and TKM&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">This is&#44; to our knowledge&#44; the first report of a case of TKM in a patient taking tofacitinib&#46; A cause cannot be clarified with certainty&#44; however the association with tofacitinib should be considered given the etiopathogenic rationale and the absence of any other identifiable cause&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflict of interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">None&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">We describe a case of a 57-year-old white woman treated for rheumatoid arthritis &#40;RA&#41; with tofacitinib 10<span class="elsevierStyleHsp" style=""></span>mg daily &#40;started one year ago&#41; and prednisolone 5<span class="elsevierStyleHsp" style=""></span>mg daily&#46; She presented to the emergency department with a tight squeezing chest pain and shortness of breath for 7<span class="elsevierStyleHsp" style=""></span>h and the clinical evaluation revealed regional systolic dysfunction of the left ventricle&#44; mimicking a myocardial infarction&#44; in the absence of angiographic evidence of obstructive coronary artery disease or acute plaque rupture&#46; All changes were transient and resolved completely within 4 days&#46; The diagnosis of Takotsubo cardiomyopathy &#40;TKM&#41; was established&#46; This is&#44; as far as we know&#44; the first report of a case of TKM in a RA patient taking tofacitinib&#46; Although the association has not been previously described and the precise cause cannot be identified in this patient&#44; the association with tofacitinib should be considered given the etiopathogenic rationale and the absence of any other identifiable cause&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Describimos el caso de una mujer blanca de 57 a&#241;os tratada por artritis reumatoide &#40;AR&#41; con tofacitinib 10<span class="elsevierStyleHsp" style=""></span>mg al d&#237;a &#40;iniciado hace un a&#241;o&#41; y prednisolona 5<span class="elsevierStyleHsp" style=""></span>mg al d&#237;a&#46; Acudi&#243; al servicio de Urgencias con dolor tor&#225;cico opresivo y dificultad para respirar durante 7 h y la evaluaci&#243;n cl&#237;nica revel&#243; disfunci&#243;n sist&#243;lica regional del ventr&#237;culo izquierdo&#44; simulando un infarto de miocardio&#44; en ausencia de evidencia angiogr&#225;fica de enfermedad arterial coronaria obstructiva o aguda&#46; rotura de placa&#46; Todos los cambios fueron transitorios y se resolvieron por completo en 4 d&#237;as&#46; Se estableci&#243; el diagn&#243;stico de miocardiopat&#237;a de takotsubo &#40;TKM&#41;&#46; Este es&#44; hasta donde sabemos&#44; el primer informe de un caso de TKM en un paciente con AR que toma tofacitinib&#46; Aunque la asociaci&#243;n no se ha descrito previamente y no se puede identificar la causa precisa en este paciente&#44; la asociaci&#243;n con tofacitinib debe considerarse dada la justificaci&#243;n etiopatog&#233;nica y la ausencia de cualquier otra causa identificable&#46;</p></span>"
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Case report
Takotsubo Syndrome in a Rheumatoid Arthritis Patient Under Tofacitinib: A Case Report
Síndrome de takotsubo en un paciente con artritis reumatoide tomando tofacitinib: reporte de un caso
Salomé Garciaa,
Autor para correspondencia
salomefernandesgarcia@gmail.com

Corresponding author.
, Georgina Terrosoa, Elisabete Martinsb, Sofia Pimentaa, Lúcia Costaa, Miguel Bernardesa
a Rheumatology Department, Centro Hospitalar de São João, Porto, Portugal
b Cardiology Department, Centro Hospitalar de São João, Porto, Portugal
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Concerns of adverse cardiovascular events with the use of tofacitinib have been raised&#44; but no case of cardiomyopathy has been reported so far&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We describe a rare case of Takotsubo cardiomyopathy &#40;TKM&#41; in a rheumatoid arthritis &#40;RA&#41; patient treated with tofacitinib&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinical observation</span><p id="par0015" class="elsevierStylePara elsevierViewall">A 57-year-old white woman was diagnosed with a seropositive for anti-citrullinated protein antibody RA 5 years ago&#46; She was treated with tofacitinib 10<span class="elsevierStyleHsp" style=""></span>mg daily &#40;started one year ago&#41; and prednisolone 5<span class="elsevierStyleHsp" style=""></span>mg daily&#46; Initially&#44; the patient experienced adverse events with the first 2 attempted csDMARDs &#40;liver toxicity under methotrexate and hypertension with leflunomide&#41; and was refractory to multiple biologic agents &#40;etanercept&#44; golimumab and tocilizumab&#44; were consecutively tried&#41; and her disease was refractory to multiple biologic agents &#40;etanercept&#44; golimumab and tocilizumab&#41;&#46; She had no other cardiovascular risk factors&#46; Previous electrocardiogram &#40;ECG&#41; was unremarkable&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">She presented to the emergency department with an acute onset tight squeezing chest pain lasting for 7<span class="elsevierStyleHsp" style=""></span>h&#46; Upon admission&#44; we observed the following vital signs&#58; blood pressure of 110&#47;60<span class="elsevierStyleHsp" style=""></span>mmHg&#44; heart rate of 90 beats per minute&#44; respiratory rate of 18 breaths per minute and oxygen saturation of 98&#37; on room air with a pulse oximeter&#46; Her heart sounds were regular with no murmurs and lung examination was normal&#46; Her cardiac enzymes were elevated&#44; presenting with a creatine phosphokinase-MB of 5&#46;7<span class="elsevierStyleHsp" style=""></span>ng&#47;mL &#40;normal<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&#41; and a troponin <span class="elsevierStyleSmallCaps">I</span> of 1&#46;16<span class="elsevierStyleHsp" style=""></span>ng&#47;mL &#40;normal<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;04<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&#41;&#46; She had a normal complete blood count&#46; Thyroid function and cortisol levels were normal&#46; ECG showed pathologic Q-waves in leads V1-V3 and a negative T-waves in lead V4&#46; Cardiac catheterization was performed&#44; demonstrating normal coronary arteries&#44; circumferential akinesia of the apex and a poor left ventricular systolic function &#40;LVEF&#41; &#40;of approximately 40&#37;&#93;&#44; consistent with the diagnosis of TKM&#46; Myocardial perfusion scintigraphy performed on day 6 showed no alterations&#59; LVEF was estimated at 38&#37;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The patient received supportive care and had an uneventful hospital stay with complete resolution of symptoms and normalization of cardiac enzymes in 48<span class="elsevierStyleHsp" style=""></span>h&#46; Three days after&#44; prior to hospital discharge&#44; she performed an echocardiogram that revealed a preserved LVEF &#40;estimated at 55&#37;&#41;&#44; with normal wall thickness and absence of wall motion abnormalities&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Treatment with tofacitinib was stopped and the patient started abatacept&#46; One year later&#44; the patient was reassessed with a cardiac magnetic resonance&#44; showing no abnormalities in segmental motility&#47;contractility or areas of late gadolinium enhancement&#44; estimating LVEF at 58&#37;&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0035" class="elsevierStylePara elsevierViewall">The diagnosis of TKM was made in this patient once all four Mayo Clinic diagnostic criteria were present&#58; transient left ventricular systolic dysfunction&#44; absence of obstructive coronary disease&#44; new electrocardiographic abnormalities and absence of pheochromocytoma&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Several pathophysiological mechanisms have been proposed for TKM&#44; but one of the most unanimous is a catecholamine surge&#44; supported by a number of features&#44; including its association with emotional stress and with the exposure to supratherapeutic doses of catecholamines&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">4&#8211;6</span></a> In a 2017 article&#44; reviewing all the 157 drug-induced TKM cases published in the literature until then&#44; the authors conclude that over two-thirds of drug-induced TKM cases were due to catecholamine stimulation&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">7</span></a> Moreover&#44; a recent study in rats&#44; who were given tofacitinib&#44; evaluated the relationship between cardiovascular hemodynamics and plasma norepinephrine &#40;NE&#41; levels&#44; showing a dose-dependent increase in circulating NE levels&#44; which was maintained during 14 days of tofacitinib administration&#46; However&#44; this increase in plasma NE concentrations presumably reflects a reflex response to direct vasodilation&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">8</span></a> Further studies in humans&#44; are needed to clarify this finding&#46; It may represent the link between tofacitinib and TKM&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">This is&#44; to our knowledge&#44; the first report of a case of TKM in a patient taking tofacitinib&#46; A cause cannot be clarified with certainty&#44; however the association with tofacitinib should be considered given the etiopathogenic rationale and the absence of any other identifiable cause&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflict of interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">None&#46;</p></span></span>"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">We describe a case of a 57-year-old white woman treated for rheumatoid arthritis &#40;RA&#41; with tofacitinib 10<span class="elsevierStyleHsp" style=""></span>mg daily &#40;started one year ago&#41; and prednisolone 5<span class="elsevierStyleHsp" style=""></span>mg daily&#46; She presented to the emergency department with a tight squeezing chest pain and shortness of breath for 7<span class="elsevierStyleHsp" style=""></span>h and the clinical evaluation revealed regional systolic dysfunction of the left ventricle&#44; mimicking a myocardial infarction&#44; in the absence of angiographic evidence of obstructive coronary artery disease or acute plaque rupture&#46; All changes were transient and resolved completely within 4 days&#46; The diagnosis of Takotsubo cardiomyopathy &#40;TKM&#41; was established&#46; This is&#44; as far as we know&#44; the first report of a case of TKM in a RA patient taking tofacitinib&#46; Although the association has not been previously described and the precise cause cannot be identified in this patient&#44; the association with tofacitinib should be considered given the etiopathogenic rationale and the absence of any other identifiable cause&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Describimos el caso de una mujer blanca de 57 a&#241;os tratada por artritis reumatoide &#40;AR&#41; con tofacitinib 10<span class="elsevierStyleHsp" style=""></span>mg al d&#237;a &#40;iniciado hace un a&#241;o&#41; y prednisolona 5<span class="elsevierStyleHsp" style=""></span>mg al d&#237;a&#46; Acudi&#243; al servicio de Urgencias con dolor tor&#225;cico opresivo y dificultad para respirar durante 7 h y la evaluaci&#243;n cl&#237;nica revel&#243; disfunci&#243;n sist&#243;lica regional del ventr&#237;culo izquierdo&#44; simulando un infarto de miocardio&#44; en ausencia de evidencia angiogr&#225;fica de enfermedad arterial coronaria obstructiva o aguda&#46; rotura de placa&#46; Todos los cambios fueron transitorios y se resolvieron por completo en 4 d&#237;as&#46; Se estableci&#243; el diagn&#243;stico de miocardiopat&#237;a de takotsubo &#40;TKM&#41;&#46; Este es&#44; hasta donde sabemos&#44; el primer informe de un caso de TKM en un paciente con AR que toma tofacitinib&#46; Aunque la asociaci&#243;n no se ha descrito previamente y no se puede identificar la causa precisa en este paciente&#44; la asociaci&#243;n con tofacitinib debe considerarse dada la justificaci&#243;n etiopatog&#233;nica y la ausencia de cualquier otra causa identificable&#46;</p></span>"
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                      "doi" => "10.1186/s13075-019-1866-2"
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                        "fecha" => "2019"
                        "volumen" => "21"
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                      "titulo" => "Incidence of venous and arterial thromboembolic events reported in the tofacitinib rheumatoid arthritis&#44; psoriasis and psoriatic arthritis development programmes and from real-world data"
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