Prognostic value of myocardial perfusion scintigraphy in diabetic patients and without coronary lesion. / Valor pronóstico de la gammagrafía de perfusión miocárdica en pacientes diabéticos sin lesiones coronarias.

OBJECTIVE: To determine the prognostic value of myocardial perfusion scintigraphy-gated SPECT in patients with diabetes mellitus and without obstructive coronary artery disease. MATERIALS AND METHODS: This retrospective study included consecutive patients undergoing adenosine stress-rest myocardial perfusion imaging (MPI) by 99mTc-tetrofosmin between 2009 and 2011. The patients had diabetes mellitus and coronary angiography without significant coronary lesions. In total, 37 diabetic patients (female/male: 20/17; mean age: 65.2 (range: 40-78). 29 non-diabetic patients were included wich are matched with the group of diabetic patients with positive MPI. The group of non-diabetic patients had scintigraphy with myocardial ischemia and without angiographic lesions. A 36-month clinical follow-up was performed, and major cardiac events were recorded. RESULTS: In 78.3% (29/37) of diabetic patients the scintigraphic study showed myocardial ischemia, while it was negative in the 21.7%. The cardiac event rate in both groups was 6%. In diabetics with a myocardial perfusion study with myocardial ischemia, there were 3 major cardiac events. In diabetic patients with negative study had no cardiac event. In the non-diabetic control group the cardiac events rate was 3.4% (1/29). CONCLUSION: In diabetic patients without obstructive coronary disease, myocardial perfusion study can be predictor of cardiac events. A negative study can be an indicator of a better cardiovascular prognosis.

Early mortality after cardiac transplantation: comparison of demographic, clinical, biological and surgical variables.

Cardiac transplantation is the last alternative for those patients in terminal heart failure. However, its mortality is high, and approximately 20% of patients die in the first month after cardiac transplantation. We retrospectively reviewed 116 patients transplanted at our center in the last 6 years. Data about clinical, biological and surgical variables were collected. We undertook a multivariate analysis in order to find differences between those patients who died in the first month and those who survived. We found statistically significant differences in total ischemia time (P = .036) and extracorporeal circulation time (P = .001), with those patients that died in the first month having longer times. We also found a statistically significant difference in the weight of the recipient, with those recipients that died in the first month having a higher weight (P = .03). No statistically significant differences were found in the other variables. Of particular interest was the absence of a significant association in both groups (survival <1 month vs survival >1 month) in the variables related to pulmonary hypertension (pulmonary half-time pressure, pulmonary systolic pressure, vascular pulmonary resistances).

Survival after cardiac transplantation: influence of the previous cardiopathy in the recipient.

INTRODUCTION: Data from cardiac transplantation registries have demonstrated a gradual improvement in patient survival over the last decades. Nevertheless, 5-years mortality rates may reflect the multitude of physiologic processes. Registries offer valuable information regarding predictors of mortality that may help us to improve therapeutic strategies. OBJECTIVES: To determine the influence on long term recipient survival of the type of prior cardiopathy that led to cardiac transplantation. METHODS: Analysis of a 316 patient cohort who underwent heart transplantation since 1991 at a single center. RESULTS: We analyzed the main clinical variables among a cohort with a mean follow-up of 7.2 years (standard deviation [SD], 4.8). There were 84.2% men and the overall mean age of 50.06 years (SD 12.29) at the time of transplantation. We identified 11 cardiopathies as the leading causes for transplantation: severe ischemic cardiopathy (55.3%), dilated cardiomyopathy (29.1%), terminal valvular cardiopathy (5.4%), alcoholic cardiopathy (2.5%), congenital cardiopathy (1.6%), acute myocarditis (1.6%), hypertrophic cardiomyopathy (1.6%), endomyocardial fibrosis (1.3%), anthracyclin-related dilated cardiopathy (0.9%), peripartum cardiomyopathy (0.3%), and vascular allograft disease (0.3%). The mean global survival of the cohort was 4.1 years, which showed a significant increase in the recent 8 compared with the first 11 years (P=.03). Multivariate analysis only demonstrated worse survival rate among those with chronic ischemic compared with the other cardiopathies (HR 2.17; 1.21-6.2; P=.003). Nevertheless, the signification disappeared after adjusting the analysis for the presence of ≥2 classical cardiovascular risk factors. CONCLUSION: Patients with chronic ischemic cardiopathy showed the leading cause for a lower survival after cardiac transplantation compared with other cardiopathies, which seemed to be related to the cardiovascular risk factors that produced the cardiopathy.

Impact of overweight on survival and primary graft failure after heart transplantation.

BACKGROUND: Overweight influence on prognosis after heart transplantation remains controversial. The objective of this study was to determine the relationship between overweight and survival in this setting. METHODS: We evaluated 271 cardiac transplant recipients engrafted from 1991 to 2009 whose age was 50.3±12.1 (mean; SD) years. Their body mass index (BMI) was 25.7±3.9 kg/m2. Regarding gender, 85.2% were males. Patients were classified by pretransplantation BMI into group A (>25 kg/m2) and group B (<25 kg/m2). We analyzed the differences in mortality and related factors. RESULTS: One hundred fifty Group A patients (55.4%) showed a slightly lower median survival (7.35 vs 8.62 years; P=.152). Group A patients were at higher risk of death within 1 year of follow-up (HR, 1.71; confidence interval [CI], 0.996-2.939; P=.051). Overweight was associated with increased mortality at 1 year after adjustment for age, recipient gender, hypertension, diabetes mellitus, hypercholesterolemia, coronary artery disease, and donor-recipient heart size mismatch. The incidence of primary graft failure was also significantly increased in group A (HR, 2.74; CI, 1.17-6.40; P=.017) after adjustment for the same variables. There were no significant differences between the groups concerning surgical ischemic time, number of acute rejection episodes, and infections during the first year. CONCLUSION: In our sample, overweight was associated with increased mortality and an increased incidence of primary graft failure within 1 year after cardiac transplantation.

Safety and effectiveness of ivabradine after cardiac transplantation.

BACKGROUND: Heart denervation is the primary cause of sinus tachycardia in transplant recipients. Drugs are usually needed to treat associated symptoms. OBJECTIVE: To evaluate the safety and effectiveness of the novel I(f) channel antagonist ivabradine to control heart rate after transplantation. METHODS: Of 316 heart transplant recipients at a single center since 1991, ivabradine was administered in 15 patients, in addition to ß-blockers in 4 patients and contraindication to use of ß-blocker therapy in the others. A prospective follow-up study was conducted to identify possible adverse effects, tolerance, and drug effects on heart rate and control of symptoms. RESULTS: Of the 15 patients, 13 were men; overall mean (SD) patient age was 46 (4.6) years. In all patients, treatment was begun after verification of basal heart rate greater than 100 bpm and after other causes of sinus tachycardia had been ruled out. During follow-up of 1.13 (0.3) years, no substantial adverse effects were observed. It was possible to reach the maximum drug dosage in all patients, achieving a reduction in basal heart rate of 33 (6.2) bpm. All patients reported substantial clinical improvement, and demonstrated an increase in functional class. CONCLUSION: Ivabradine is safe, well tolerated, and effective in heart transplant recipients.

Incidence and importance of de novo diabetes mellitus after heart transplantation.

INTRODUCTION: Diabetes mellitus is one of the main metabolic complications after heart transplantation. The aims of our study were to determine the incidence and factors that determine the appearance of posttransplantation diabetes mellitus (PTDM) and its prognostic value. MATERIALS AND METHODS: We performed a retrospective study of all heart transplant recipients in our hospital from January 1993 to December 2005, including 116 patients with prolonged monitoring with 59-month median follow-up. We divided the patients into two groups, according to whether they had de novo diabetes (group 1) or no diabetes (group 2). RESULTS: Patients with PTDM were significantly older, with a median difference (MD) of 5.4 years (95% confidence interval [CI], 1.53-9.28) and a greater body mass index (MD, 3.37 kg/m(2); 95% CI, 1.68-5.06). Moreover, a greater percentage of patients in group 1 had ischemia compared to other etiologies. However, no significant differences were observed regarding other cardiovascular risk factors. PTDM was associated with a greater incidence of posttransplant hypertension (51.6% in group 1 vs 48.4% in group 2, P = .08) and posttransplant renal failure (59.5% in group 1 vs 40.5% in group 2, P = .001). However, no differences were observed in overall survival. CONCLUSIONS: Age, overweight, and ischemic origin of cardiopathy were the main risk factors for the development of PTDM in our population. Although no differences were observed in survival rates, PTDM was associated with a greater incidence of hypertension and renal insufficiency, which may have long-term influences on patient survival.

Safety and efficacy of ezetimibe in a sample of cardiac transplant patients.

OBJECTIVE: To evaluate the safety and efficacy of ezetimibe in a sample of transplanted cardiac patients. MATERIALS AND METHODS: We undertook a descriptive retrospective observational study of 19 transplanted cardiac patients in whom treatment with ezetimibe was initiated at doses of 10 mg/d between 2004 and 2006, assessing tolerability and changes in lipid levels (total cholesterol and triglycerides), doses of immunosuppressive drugs, and the hepatic profile after 12 months of treatment. RESULTS: There was no effect on the doses required of any immunosuppressive drugs. We observed a reduction in cholesterol levels, with a normal distribution (mean +/- standard deviation 26.84 +/- 14 mg/dL) among patients with ezetimibe addition, despite no change in the statin doses. There were no changes in the levels of triglycerides, transaminases, or bilirubin, and no cases of rhabdomyolysis or myalgia. All patients continued to take the drug after 1 year of treatment. CONCLUSIONS: In our sample, the administration of ezetimibe to transplanted cardiac patients for 1 year was associated with a reduction in cholesterol levels by 26.8%. No substantial changes in the doses of immunosuppressive drugs could be attributed to the use of ezetimibe. Tolerance was good, with no need for drug withdrawal in any case.