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Dobutamine stress echocardiography is predictive of events after heart transplantation
S174
Abstracts
The Journal of Heart and Lung Transplantation January 2003
309 IMPACT OF NEW THERAPIES ON THE PREVALENCE OF CORONARY ARTERY DISEASE IN HEART TRANSPLANT SURVIVORS: STANFORD EXPERIENCE S.-Z. Gao, M. Perlroth, S. Hunt, J. Schreoder, Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA Background: The major cause of late graft failure is coronary artery disease (CAD). Evolution of post-transplantation (Tx) therapy has added calcium channel blockers (CCB) and statins (STN) in addition to new immunosuppressives. Annual coronary angiograms permitted identification of the onset and severity of CAD and correlation with new treatments. Methods: 647 patients(pts) underwent heart Tx between 11/80-12/97 at Stanford. Patients who survived I year and had at least 1 follow-up(F/U) angiogram were included in the study(n ⫽ 473). Three cohorts were identified: (A) 11/80-07/86 received cyclosporine, azathioprine, prednisone, (n ⫽ 151); (B) 07/86-12/93, same as A plus CCB; OKT3, ganciclovir(n ⫽ 219); (C) 01/94-12/97, same as B plus statin, tacrolimus, Mycophenolate mofetil(n ⫽ 103). F/U was 5 years. Results: Over all prevalence of TxCAD: Table 1 shows the initial appearance of TxCAD between 3 cohorts (p ⫽ 0.002). 50% stenosis of TxCAD is shown in table 2 (p ⫽ 0,001).The incidence of any CAD was 38%, 26% and 27%; and of 50% CAD was 21%, 12%, and 13% incohort A, B and C at 5 years post-Tx respectively. Comparisons of incidence of CAD between cohorts: cohort A vs B p ⫽ 0.05; A vs C P ⫽ 0.06; B vs C p ⫽ 0.7. Similarly, the incidence of 50% CAD in cohort A vs B p ⫽ 0.01; A vs C P ⫽ 0.06; B vs C p ⫽ 0.8. Conclusion: The introduction of CCB, statin and new immunosuppressives and steroid-sparing regimens have reduced the incidence and progression of post-transplant CAD. Freedom from initial appearance of TxCAD p ⴝ 0.002 (MantalHaenszel log-rank test) Cohort/Yr
0
1
2
3
4
5
A % (n) B C
100 (51) 100 (219) 100 (103)
93 (141) 96 (211) 96 (99)
76 (115) 85 (187) 87 (90)
62 (95) 78 (172) 79 (82)
52 (81) 67 (145) 72 (74)
46 (70) 59 (125) 53 (54)
Freedom from 50% stenosis of TxCAD p ⴝ 0.001 Cohort/Yr
0
1
2
3
4
5
A % (n) B C
100 (151) 100 (219) 100 (103)
97 (147) 99 (215) 100 (103)
87 (131) 91 (198) 92 (95)
76 (115) 88 (191) 85 (88)
63 (96) 82 (177) 82 (84)
59 (89) 75 (163) 63 (65)
310 UTILITY OF B-TYPE NATRIURETIC PEPTIDE IN CARDIAC TRANSPLANT EVALUATION G. Bhat,1,2 A. Jevans,2 1Division of Cardiology, University of Louisville, Louisville, KY; 2Heart Failure/Cardiac Transplant Center, Jewish Hospital, Louisville, KY Our goal was to determine if B-type natriuretic peptide (BNP) could aid in the risk stratification of patients (pts) referred for cardiac transplantation (CT), when evaluated in the heart failure (HF) clinic. Methods: BNP was measured (Triage威 BNP test) prospectively in 189 consecutive pts referred for CT. The pts were divided into two groups based on clinical assessment by the HF physician blinded to the BNP levels. Group 1: 166 pts (mean age 49 years, 71% male, 44 % ischemic) were considered stable and underwent outpatient CT evaluation with cardiopulmonary exercise testing. Group 2: 23 pts (mean age 48 years,
77 % male, 51 % ischemic) were judged to have significant HF requiring emergent CT listing and 20 of 23 pts were hospitalized. Results: Comparison of the two groups are shown: VARIABLE
Group 1 (n ⴝ 166)
Group 2 (n ⴝ 23)
mean NYHA class mean LVEF (%) mean BNP (pg/ml)
2.5 ⫾ 0.1 23.0 ⫾ 1.0 254.6 ⫾ 22.7
3.5 ⫾ 0.1* 19.7 ⫾ 1.5 951.2 ⫾ 64.7*
*Pⱕ0.05
At mean follow-up of 12 months, 155 pts in Group 1 remained stable on medical therapy and CT listing was deferred (mean peak oxygen consumption (PV02) of 16.7 ⫾ 0.5 ml/kg/min, mean BNP 246.1 ⫾ 23.6 pg/ml). Only 11 of 166 pts underwent outpatient CT listing (mean PV02 13.3 ⫾ 0.6 ml/kg/min, mean BNP 374.2 ⫾ 74.0 pg/ml). 12 of 23 pts in Group 2 deteriorated while hospitalized and received left ventricular assist device at a mean of 2 weeks after admission. 8 of 23 pts in Group 2 were stabilized and discharged on continuous intravenous milrinone therapy. Conclusion: In addition to physician assessment, rapidly performed BNP in the clinic may predict short-term prognosis of patients referred for CT. This would help risk stratify advanced HF pts and lead to cost effective CT evaluation and decrease the need for more expensive prognostic workup. 311 DOBUTAMINE STRESS ECHOCARDIOGRAPHY IS PREDICTIVE OF EVENTS AFTER HEART TRANSPLANTATION M.W. Pincus,1 T. Nguyen,2 A.M. Keogh,1 C.S. Hayward,1 M. Feneley,1 P.S. Macdonald,1 1Cardiac Transplant Department, St Vincent’s Hospital, Sydney, NSW, Australia; 2Garvan Institute of Medical Research, Sydney, NSW, Australia Cardiac allograft vasculopathy (CAV) is the commonest cause of death in patients surviving more than one year after heart transplantation. Dobutamine stress echocardiography (DSE) is a commonly used noninvasive screening tool for CAV. There is little published information on the prognostic value of DSE in transplant recipients, although a study of 109 patients found it to be predictive of cardiac events. The aim of this study was to assess the predictive value of DSE in a larger patient population. A retrospective study was made of 240 heart transplant recipients referred for screening DSE. Dobutamine infusions were started at 5 mcg/kg/min and increased to a maximum of 50 mcg/kg/min or maximum predicted heart rate. The definitions of an abnormal resting and stress study were, respectively, a resting regional wall motion abnormality and a new or worsening regional wall motion abnormality with dobutamine. The primary endpoint was a combination of the following events: death, acute coronary syndrome, heart failure, percutaneous coronary intervention and coronary bypass surgery. Results: 455 DSE examinations were performed with each patient having between 1 and 5. The mean follow-up period was 3.5 years (range 1 month-7 years). 53 patients had a total of 68 events. The odds ratios of an event for any abnormality on DSE, a resting abnormality, and a stress abnormality were 3.1 (95%CI 1.4-7.1), 3.2 (1.3-8.4) and 3.6 (1.4-9.5) respectively. The probability of being event free at 1 year was 95% in those with a normal DSE. The probability of having an event at 2 years was 10% in those with a normal and 32% in those with an abnormal DSE and this was significantly different (p⬍0.05). Conclusions: DSE is predictive of events after heart transplantation. A normal DSE identifies patients at low risk of an event over the subsequent 12 months. In screening for CAV, invasive studies such as angiography could reasonably be restricted to those who have an abnormal DSE.
Abstracts
The Journal of Heart and Lung Transplantation January 2003
309 IMPACT OF NEW THERAPIES ON THE PREVALENCE OF CORONARY ARTERY DISEASE IN HEART TRANSPLANT SURVIVORS: STANFORD EXPERIENCE S.-Z. Gao, M. Perlroth, S. Hunt, J. Schreoder, Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA Background: The major cause of late graft failure is coronary artery disease (CAD). Evolution of post-transplantation (Tx) therapy has added calcium channel blockers (CCB) and statins (STN) in addition to new immunosuppressives. Annual coronary angiograms permitted identification of the onset and severity of CAD and correlation with new treatments. Methods: 647 patients(pts) underwent heart Tx between 11/80-12/97 at Stanford. Patients who survived I year and had at least 1 follow-up(F/U) angiogram were included in the study(n ⫽ 473). Three cohorts were identified: (A) 11/80-07/86 received cyclosporine, azathioprine, prednisone, (n ⫽ 151); (B) 07/86-12/93, same as A plus CCB; OKT3, ganciclovir(n ⫽ 219); (C) 01/94-12/97, same as B plus statin, tacrolimus, Mycophenolate mofetil(n ⫽ 103). F/U was 5 years. Results: Over all prevalence of TxCAD: Table 1 shows the initial appearance of TxCAD between 3 cohorts (p ⫽ 0.002). 50% stenosis of TxCAD is shown in table 2 (p ⫽ 0,001).The incidence of any CAD was 38%, 26% and 27%; and of 50% CAD was 21%, 12%, and 13% incohort A, B and C at 5 years post-Tx respectively. Comparisons of incidence of CAD between cohorts: cohort A vs B p ⫽ 0.05; A vs C P ⫽ 0.06; B vs C p ⫽ 0.7. Similarly, the incidence of 50% CAD in cohort A vs B p ⫽ 0.01; A vs C P ⫽ 0.06; B vs C p ⫽ 0.8. Conclusion: The introduction of CCB, statin and new immunosuppressives and steroid-sparing regimens have reduced the incidence and progression of post-transplant CAD. Freedom from initial appearance of TxCAD p ⴝ 0.002 (MantalHaenszel log-rank test) Cohort/Yr
0
1
2
3
4
5
A % (n) B C
100 (51) 100 (219) 100 (103)
93 (141) 96 (211) 96 (99)
76 (115) 85 (187) 87 (90)
62 (95) 78 (172) 79 (82)
52 (81) 67 (145) 72 (74)
46 (70) 59 (125) 53 (54)
Freedom from 50% stenosis of TxCAD p ⴝ 0.001 Cohort/Yr
0
1
2
3
4
5
A % (n) B C
100 (151) 100 (219) 100 (103)
97 (147) 99 (215) 100 (103)
87 (131) 91 (198) 92 (95)
76 (115) 88 (191) 85 (88)
63 (96) 82 (177) 82 (84)
59 (89) 75 (163) 63 (65)
310 UTILITY OF B-TYPE NATRIURETIC PEPTIDE IN CARDIAC TRANSPLANT EVALUATION G. Bhat,1,2 A. Jevans,2 1Division of Cardiology, University of Louisville, Louisville, KY; 2Heart Failure/Cardiac Transplant Center, Jewish Hospital, Louisville, KY Our goal was to determine if B-type natriuretic peptide (BNP) could aid in the risk stratification of patients (pts) referred for cardiac transplantation (CT), when evaluated in the heart failure (HF) clinic. Methods: BNP was measured (Triage威 BNP test) prospectively in 189 consecutive pts referred for CT. The pts were divided into two groups based on clinical assessment by the HF physician blinded to the BNP levels. Group 1: 166 pts (mean age 49 years, 71% male, 44 % ischemic) were considered stable and underwent outpatient CT evaluation with cardiopulmonary exercise testing. Group 2: 23 pts (mean age 48 years,
77 % male, 51 % ischemic) were judged to have significant HF requiring emergent CT listing and 20 of 23 pts were hospitalized. Results: Comparison of the two groups are shown: VARIABLE
Group 1 (n ⴝ 166)
Group 2 (n ⴝ 23)
mean NYHA class mean LVEF (%) mean BNP (pg/ml)
2.5 ⫾ 0.1 23.0 ⫾ 1.0 254.6 ⫾ 22.7
3.5 ⫾ 0.1* 19.7 ⫾ 1.5 951.2 ⫾ 64.7*
*Pⱕ0.05
At mean follow-up of 12 months, 155 pts in Group 1 remained stable on medical therapy and CT listing was deferred (mean peak oxygen consumption (PV02) of 16.7 ⫾ 0.5 ml/kg/min, mean BNP 246.1 ⫾ 23.6 pg/ml). Only 11 of 166 pts underwent outpatient CT listing (mean PV02 13.3 ⫾ 0.6 ml/kg/min, mean BNP 374.2 ⫾ 74.0 pg/ml). 12 of 23 pts in Group 2 deteriorated while hospitalized and received left ventricular assist device at a mean of 2 weeks after admission. 8 of 23 pts in Group 2 were stabilized and discharged on continuous intravenous milrinone therapy. Conclusion: In addition to physician assessment, rapidly performed BNP in the clinic may predict short-term prognosis of patients referred for CT. This would help risk stratify advanced HF pts and lead to cost effective CT evaluation and decrease the need for more expensive prognostic workup. 311 DOBUTAMINE STRESS ECHOCARDIOGRAPHY IS PREDICTIVE OF EVENTS AFTER HEART TRANSPLANTATION M.W. Pincus,1 T. Nguyen,2 A.M. Keogh,1 C.S. Hayward,1 M. Feneley,1 P.S. Macdonald,1 1Cardiac Transplant Department, St Vincent’s Hospital, Sydney, NSW, Australia; 2Garvan Institute of Medical Research, Sydney, NSW, Australia Cardiac allograft vasculopathy (CAV) is the commonest cause of death in patients surviving more than one year after heart transplantation. Dobutamine stress echocardiography (DSE) is a commonly used noninvasive screening tool for CAV. There is little published information on the prognostic value of DSE in transplant recipients, although a study of 109 patients found it to be predictive of cardiac events. The aim of this study was to assess the predictive value of DSE in a larger patient population. A retrospective study was made of 240 heart transplant recipients referred for screening DSE. Dobutamine infusions were started at 5 mcg/kg/min and increased to a maximum of 50 mcg/kg/min or maximum predicted heart rate. The definitions of an abnormal resting and stress study were, respectively, a resting regional wall motion abnormality and a new or worsening regional wall motion abnormality with dobutamine. The primary endpoint was a combination of the following events: death, acute coronary syndrome, heart failure, percutaneous coronary intervention and coronary bypass surgery. Results: 455 DSE examinations were performed with each patient having between 1 and 5. The mean follow-up period was 3.5 years (range 1 month-7 years). 53 patients had a total of 68 events. The odds ratios of an event for any abnormality on DSE, a resting abnormality, and a stress abnormality were 3.1 (95%CI 1.4-7.1), 3.2 (1.3-8.4) and 3.6 (1.4-9.5) respectively. The probability of being event free at 1 year was 95% in those with a normal DSE. The probability of having an event at 2 years was 10% in those with a normal and 32% in those with an abnormal DSE and this was significantly different (p⬍0.05). Conclusions: DSE is predictive of events after heart transplantation. A normal DSE identifies patients at low risk of an event over the subsequent 12 months. In screening for CAV, invasive studies such as angiography could reasonably be restricted to those who have an abnormal DSE.