Trends and Specific Causes of Cardiovascular Mortality after Kidney Transplantation in Finland.

BACKGROUND: Cardiovascular diseases are an important cause of mortality in patients who have undergone kidney transplantation, but the knowledge on trends of cardiovascular mortality and specific causes of cardiovascular death among these patients is scarce. METHODS: Our aim was to compare the cardiovascular mortality rates after kidney transplantation in Finland between 1990-1999, 2000-2009, and 2010-2019 using data from the Finnish Registry for Kidney Diseases. We analyzed 1-year and long-term cardiovascular mortality rates as well as the specific causes of cardiovascular death and the trends in them. RESULTS: In total, 4946 patients underwent first kidney transplantation in 1990-2019. During the follow-up time (median 8.3 years, interquartile range 4.0-14.5), there were 1392 deaths, of which 582 were cardiovascular deaths. In an unadjusted Cox regression model, the risk of long-term cardiovascular mortality was similar in the different periods. However, when adjusted for age, sex, duration of dialysis, and cause of kidney disease, the long-term cardiovascular mortality risk was significantly lower in 2000-2009 and 2010-2019 (hazard ratio 0.60 [95% confidence interval, 0.49 to 0.73] and hazard ratio 0.51 [95% confidence interval, 0.39 to 0.66], respectively) compared with 1990-1999. The results were similar regarding 1-year cardiovascular mortality. The distribution of different causes of cardiovascular death remained unchanged during the study period, with coronary artery disease accounting for 47% of deaths. During the first year after transplantation, pulmonary embolisms and arrhythmias were more common than in the long term. CONCLUSIONS: Cardiovascular disease remained the most common cause of death in kidney transplant recipients, but adjusted cardiovascular mortality risk has decreased significantly during the past three decades. Coronary artery disease was the most frequent cause of cardiovascular death, and the proportion of coronary artery disease-related cardiovascular deaths increased after the first year after transplantation.

The value of myocardial perfusion imaging in screening coronary artery disease before kidney transplantation.

The value of myocardial single-photon emission computed tomography (SPECT) in pre-transplant evaluation of kidney transplant recipients is controversial. We assessed whether myocardial SPECT predicts major adverse cardiac events (MACE) and determined whether SPECT findings affected transplant recipients' medical and invasive treatment. We analyzed 301 patients referred for myocardial SPECT before kidney transplantation and combined the results with information from patient files and the Transplantation Registry. During the median follow-up time of 96 months (IQR 70.75-118.25 months), the incidence of MACE was higher in patients (n = 37) with severely abnormal SPECT (>10% reversible perfusion defect) than in patients (n = 35) with mildly abnormal or normal SPECT (51.4%, 29.4%, and 27.0%, respectively, P = .011). Severely abnormal SPECT findings predicted long-term MACE in a univariable analysis but not after adjusting for other risk factors. Following SPECT, 29 patients (9.6%) underwent coronary angiography and 14 (4.6%) were revascularized. New antithrombotic or statin medication was prescribed to 7.3% of patients with ischemia in SPECT. Kidney transplantation patients are at high long-term risk of MACE even with normal preoperative myocardial SPECT. Abnormal SPECT did not predict MACE when adjusted for other risk factors. Minority of the patients underwent coronary revascularization or had changes in preventive medication before transplantation.

Even mild reversible myocardial perfusion defects predict mortality in patients evaluated for kidney transplantation.

Aims: The value of single-photon emission tomography (SPECT) in patients with severe chronic kidney disease is controversial, and the implications of SPECT finding with lower level of ischaemia are unknown. We assessed the prognostic value of SPECT in patients evaluated for kidney transplantation. Methods and results: Five hundred and forty-eight patients underwent SPECT as a part of routine evaluation for kidney transplantation. During the median follow-up of 43.7 months (IQR 22.4-68.4 months), 112 patients (20.4%) died, 49 of cardiovascular (CV) causes (8.9%). In comparison to those with no perfusion defects, mild perfusion abnormalities (1%-9.9%) had an adjusted Cox hazard ratio (HR) of 1.80 [95% confidence interval (95% CI) 1.02-3.17, P = 0.041] for all-cause mortality, while large perfusion defects (≥10%) demonstrated an HR of 2.20 (95% CI 1.38-3.50, P = 0.001). A competing risk analysis produced a similar prognostic capacity for CV mortality. SPECT also offered incremental prognostic impact with two reclassification methods. Revascularization was performed clearly more often on patients with severely than mildly abnormal or normal SPECT (28.0%, 4.3%, and 1.3%, respectively, P < 0.001). However, revascularization was not linked with better survival. Patients with a normal SPECT received a kidney transplant more often than patients with a mildly or severely abnormal SPECT (50.5%, 36.2%, and 36.6%, respectively, P = 0.010). Conclusion: Myocardial ischaemia in SPECT is clearly linked with mortality in patients screened for kidney transplantation. Contrary to populations with coronary artery disease, even a mild perfusion defect in SPECT predicts poor prognosis in this patient population. The finding deserves further attention in forthcoming trials.

Trends in treatment delays for patients with acute ST-elevation myocardial infarction treated with primary percutaneous coronary intervention.

BACKGROUND: Treatment delay is an important prognostic factor for patients with acute ST-elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI). We aimed to determine recent trends in these delays and factors associated with longer delays. METHODS: We compared two datasets collected in Helsinki University Central Hospital in 2007-2008 (HUS-STEMI I) and 2011-2012 (HUS-STEMI II), a total of 500 patients treated with primary PCI within 12 hours of the onset of symptoms. RESULTS: Delays of the emergency medical system (EMS) were longer in HUS-STEMI I than II (medians 81 vs. 67 min, respectively, p < 0.001). Although door-to-balloon times were longer in the later dataset (33 vs. 48 min, p < 0.001) most of the patients (75.3% vs. 62.8%, respectively, p = 0.010) were treated within the recommendation (<60 min) of the European Society of Cardiology (ESC). In HUS-STEMI II, patient arrival at the hospital during off-hours was associated with longer door-to-balloon time (40 and 57.5 min, p = 0.001) and system delay (111 and 127 min, p = 0.009). However, in HUS-STEMI I, arrival time did not impact the delays. Longer system delay was associated with higher mortality rates. CONCLUSIONS: Though the delays inside the hospital have increased they are still mostly within the ESC guidelines. Still, only about half of the patients are treated within a system delay of recommended two hours. Albeit our results are good in comparison with previous studies, further efforts for decreasing the delays particularly within the EMS should be established.