Kongkiat Chaikriangkrai

Impact of pre-operative coronary artery disease on cardiovascular events following lung transplantation

BACKGROUNDnThis study examined the correlation between pre-operative coronary artery disease (CAD) and post-operative cardiovascular events in lung transplant recipients.nnnMETHODSnConsecutive isolated lung transplant recipients from 2007 to 2013 in our institution were identified and categorized as having significant CAD (≥ 50% coronary stenosis in at least 1 artery or history of coronary revascularization) or no-mild CAD. Patient records and death index data were analyzed for a median of 2 years for death or cardiovascular events, including coronary, cerebrovascular, and peripheral artery events.nnnRESULTSnThe study comprised 280 patients (62% male) with mean age of 60 ± 10 years. Cardiovascular events occurred in 5.7% (16 of 280) of the entire cohort. Patients with significant CAD had a higher annualized rate of cardiovascular events than those with no-mild CAD (11.9% vs 0.6%; p < 0.001). Significant CAD was an independent predictor of cardiovascular events (hazard ratio, 20.32; 95% confidence interval, 5.79-71.26; p < 0.001) but not all-cause mortality (log-rank p = 0.66). Adding significant CAD to clinical risk factors gave incremental prognostic performance compared with clinical risk factors alone (p < 0.001 for increase in global chi-square).nnnCONCLUSIONnSelected lung transplant candidates with significant CAD can undergo transplantation with equal mortality risk to those without CAD but are at a higher risk of non-fatal cardiovascular events. These data support the current practice of accepting a selected group of patients with CAD for lung transplantation and suggest that they should be monitored early and treated to prevent cardiovascular complications.

Sex‐Specific Associations of Oral Anticoagulant Use and Cardiovascular Outcomes in Patients With Atrial Fibrillation

Background Sex‐specific effectiveness of rivaroxaban (RIVA), dabigatran (DABI), and warfarin in reducing myocardial infarction (MI), heart failure (HF), and all‐cause mortality among patients with atrial fibrillation are not known. We assessed sex‐specific associations of RIVA, DABI, or warfarin use with the risk of MI, HF, and all‐cause mortality among patients with atrial fibrillation. Methods and Results Medicare beneficiaries (men: 65 734 [44.8%], women: 81 135 [55.2%]) with atrial fibrillation who initiated oral anticoagulants formed the study cohort. Inpatient admissions for MI, HF, and all‐cause mortality were compared between the 3 drugs separately for men and women using 3‐way propensity‐matched samples. In men, RIVA use was associated with a reduced risk of MI admissions compared with warfarin use (hazard ratio [95% confidence interval (CI): 0.59 [0.38–0.91]), with a trend towards reduced risk compared with DABI use (0.67 [0.44–1.01]). In women, there were no significant differences in the risk of MI admissions across all 3 anticoagulants. In both sexes, RIVA use and DABI use were associated with reduced risk of HF admissions (men: RIVA; 0.75 [0.63–0.89], DABI; 0.81 [0.69–0.96]) (women: RIVA; 0.64 [0.56–0.74], DABI; 0.73 [0.63–0.83]) and all‐cause mortality (men: RIVA; 0.66 [0.53–0.81], DABI; 0.75 [0.61–0.93]) (women: RIVA; 0.76 [0.63–0.91], DABI; 0.77 [0.64–0.93]) compared with warfarin use. Conclusions RIVA use and DABI use when compared with warfarin use was associated with a reduced risk of HF admissions and all‐cause mortality in both sexes. However, reduced risk of MI admissions noted with RIVA use appears to be limited to men.

Gender Differences in the Trends of Hospitalizations for Acute Stroke Among Patients With Atrial Fibrillation in the United States: 2005 to 2014

Female gender was included in stroke prediction algorithms in an attempt to improve anticoagulation rates in women with atrial fibrillation (AF). It is unclear if these efforts reduced stroke burden in women with AF. To bridge this literature gap, using the Nationwide Inpatient Sample, we assessed gender differences in the trends of hospitalizations for stroke among patients with AF in the United States in 2005 to 2014. International classification of diseases, 9th revision, clinical modification codes were used to abstract AF and stroke diagnoses. From 2005 to 2014, 18,413,291 hospitalizations of women with AF and 18,035,866 hospitalizations of men with AF were reported. Of these, 740,635 hospitalizations in women and 595,730 hospitalizations in men had stroke as the primary diagnosis. Age-adjusted stroke hospitalizations increased in women (443 per million in 2005 to 495 per million in 2014) as well as in men (351 per million in 2005 to 453 per million in 2014) (p trendu2009<u20090.001). Further, anticoagulation rates increased in women (11.5% in 2005 to 24.0% in 2014) as well as in men (11.7% in 2005 to 24.9% in 2014). Stroke hospitalizations involving anticoagulated patients with AF decreased in women (411 per million in 2005 to 347 per million in 2014) as well as in men (402 per million in 2005 to 311 per million in 2014) (p trendu2009<u20090.001). In conclusion, although we noted an increasing trend of stroke hospitalizations in both genders, it is reassuring to note that stroke hospitalizations involving anticoagulated patients with AF is decreasing in both genders and in particular among women.

Fibro-fatty Degeneration in Hypertrophic Cardiomyopathy

A 44-year-old woman with hypertrophic cardiomyopathy (HCM) (TNNI-3 mutation) presented with palpitations. She did not have history of syncope or family history of sudden cardiac death. Further investigations did not show any evidence of ventricular tachycardia. Cardiovascular magnetic resonance (CMR) imaging was performed for further xadevaluationxad andxad riskxad stratification.xad CMRxad demonstratedxad asymmetric septal hypertrophy (maximal thickness 2.1 cm) and apical hypertrophy (maximal thickness 2 cm) with the left ventricular ejection fraction of 64%. Steady-state free precession imaging (Fig. 1A) also demonstrated hyperintense midmyocardial lesions in the basal-to-mid anteroseptal wall (solid arrowheads) and mid-to-apical inferior wall (blank arrowheads) myocardium. The lesions were bright on double-inversion recovery sequences (Fig. 1B), and became hypointense with fat suppression protocol (Fig. 1C) suggesting fatty deposits. Late gadolinium images (Fig. 1D and 1E) revealed extensive lesions with hyper-enhancement consistent with scar in the adjacent regions. To the best of our knowledge, fatty degeneration of the myocardium in HCM has never been described in the literature. Fatty deposition along with scar tissue have been reported following myocardial infarction secondary to epicardial coronary artery disease (typically subendocardium in the territory of diseased coronary artery), dilated cardiomyopathy (typically midmyocardium) and arrhythmogenic right ventricular cardiomyopathy (typically right ventricular subepicardium or left ventricular free wall).1 In HCM, we hypothesize that fibro-fattyxad degenerationxad occursxad afterxad myocardialxad infarctionxad secondary to supply/demand mismatch and/or remodeling of the intramyocardial blood vessels. In contrast to late gadolinium enhancement imaging, which may provide xadfurtherxad riskxadstratificationxad information,2,3 it is unclear at this timexad ifxad fibro-fattyxad degenerationxad inxad HCMxad representsxad anxad additional risk factor for sudden cardiac death.

CORONARY ARTERY CALCIUM SCORE AS A PREDICTOR FOR INCIDENT ISCHEMIC STROKE: SYSTEMATIC REVIEW AND META-ANALYSIS

The objective of this study was to investigate the predictive value of CACS obtained by noncontrast electrocardiogram-gated CT for incident ischemic stroke.nnWe search Pubmed, Embase, Cochrane databases for prospective longitudinal studies of CACS which reported the incidence of ischemic stroke.

Tu1108 Pre-Transplant Proton Pump Inhibitor Is Not Associated With Improved Survival of Lung Allografts

Background Gastroesophageal reflux disease (GERD) has been identified as a possible contributor of aspiration after lung transplantation that leads to graft failure and increased mortality. This study was designed to investigate whether the usage of proton pump inhibitor (PPI) pre-transplant is associated with decreased posttransplant mortality and/or retransplant. Methods A total of 324 consecutive patients who underwent lung transplant from January 2009 to June 2012 were retrospectively reviewed. Demographic information and baseline clinical characteristics of lung transplant recipients were collected. Clinical variables were compared between patients with and without clinical events determined as all-cause mortality and/or re-transplant. Usage of PPI were analyzed between recipients with clinical events (n= 78) and those without events (n= 246). Perioperative events were defined as events that occurred within 30 days after transplant. Results The cohort comprised of 58.3% male (189 of 324) with mean age (SD) of 58(13). Majority of patients had double lung transplant (62.8%; 203 of 324). Mean (SD) follow up interval was 2.0 (1.2) year. Idiopathic pulmonary fibrosis was the leading primary lung pathology (46.9%), followed by COPD (23.1%) and cystic fibrosis (6.5%). Prevalence of GERD prior to transplant was 42% (137 of 324). Clinical events occurred in 25% (78 of 324) of the cohort (66 death and 12 retransplants). Of those, 29.5% (23 of 78) were perioperative. There was no statistically significant difference in percentage use of PPI between patients with and without events (54.7% VS 53.0% respectively; p 0.927). Subgroup analysis in patients with diagnosis of GERD pre-transplant also demonstrated no significant difference in PPI use in the two groups (78.8% VS 83.7%; p 0.522). Kaplan Meier survival analysis revealed no significant difference in both mortality (p 0.874) and overall graft survival (p 0.806) as shown in Figure 1. Conclusion Use of proton pump inhibitors prior to transplantation is not associated with increased allografts survival in lung transplant recipients. Baseline characteristics and study variables categorized by clinical events.