784-3 Prognostic Significance of Intimal Thickening Detected by Intracoronary Ultrasound in Heart Transplant Recipients

Intracoronary ultrasound (ICUS) is a sensitive tool for the detection of intimal thickening in coronary arteries of heart transplants recipients. However, the prognostic significance of this intimal thickening has not been proven.During a one year period, 90 transplant recipients had ICUS examination at the time of their annual angiogram. For each ICUS study an intimal index (II), defined as the ratio of the plaque area to the area within the media, was measured for the most diseased segment imaged. The angiogram at the time of ICUS was reviewed for the presence of visually apparent coronary artery disease (V-CADI· Those patients (n=19) with V-CAD present at the time of ICUS were excluded from the study. The time since transplantation for the 71 pts without V-CAD ranged from 1 to 15 yrs, with a mean of 4.2 yrs and median of 3.9 yrs. The subsequent annual follow-up angiograms of the 71 patients without V-CAD at the time of ICUS were reviewed for the development of V-CAD. Mean duration of angiographic follow-up was 2.0 yrs (range 1–3 yrs).V-CAD developed on follow-up angiograms in 13 of the 71 pts. Mean time to development of V-CAD was 1.5 yrs. Forty-six patients had II<0.3, 4 (9%) of whom subsequently developed V-CAD. Twenty-five patients had II ≥0.3, 9 (36%) of whom developed V-CAD. Odds ratio for future V-CAD between pts with II<0.3 and II 2: 0.3 was 5.9 (95% CI 1.8 to 19.0, difference significant at p<0.01 by Fisher's Exact test).In a subgroup of 22 patients more than 5 years post transplantation at the time of ICUS, 12 had II<0.3 and 10 had II 2≥0.3. In this subgroup none of the 12 pts with II<0.3 developed V-CAD and only 1 of the 10 with II >0.3 developed V-CAD (difference not significant).Conclusion — Among patients more than 1 year and less than 5 years post-transplantation without visually apparent angiographic coronary artery disease, the presence of moderate to severe intimal thickening by ICUS is predictive of the future development of angiographically apparent CAD. Intimal thickening as detected by ICUS is of prognostic significance in patients with angiographically silent transplant coronary artery disease

Accelerated coronary vascular disease in the heart transplant patient: Coronary arteriographic findings

AbstractAnnual coronary arteriograms have been obtained from all heart transplant recipients at Stanford University Medical Center since 1969. Angiographic lesions in 81 transplant patients exhibiting coronary vascular disease were classified into three categories: type A, discrete or tubular stenoses; type B, diffuse concentric narrowing; and type C, narrowed irregular vessels with occluded branches. The 81 arteriograms showing transplant coronary vascular disease were contrasted with 32 from nontransplant patients with coronary artery disease analyzed in a similar fashion.The nontransplant angiograms showed 178 lesions, all of type A (discrete or tubular) morphology, 75% of which were located in primary epicardial coronary vessels and 25% in secondary branch vessels. In the patients with transplant coronary vascular disease, 349 (76%) of 461 lesions were type A: 57% in primary vessels, 42% in secondary branches and 1.4% in tertiary branches. Of the 112 type B and C lesions (diffuse narrowing, tapering and obliteration), 25% were in primary vessels, 44% in secondary vessels and 31% in tertiary branches (p < 0.05 for patients with transplant coronary vascular disease versus patients with nontransplant coronary artery disease). Total vessel occlusion was found in proximal or middle vessel segments in 96% and distally in 4% of patients with “ordinary” coronary artery disease versus 49% distally in patients with transplant coronary disease (p < 0.002). In the presence of total vessel occlusion, collateral vessels were poor or absent in 92% of transplant versus 7% of nontransplant patients with coronary disease (p < 0.002).Therefore, coronary artery disease in transplant patients represents a mixture of typical atheromatous lesions and unique transplant-related progressive distal obliterative disease that occurs without collateral vessel development

Early development of accelerated graft coronary artery disease: Risk factors and course

AbstractObjectives. This study assessed the time of first appearance of angiographic graft coronary artery disease in relation to clinical and laboratory variables and clinical events in heart transplant recipients.Background. Graft coronary artery disease is the main factor limiting long-term survival after heart transplantation, and it is important to understand its natural history.Methods. One hundred thirty-nine consecutive patients who developed angiographic coronary artery disease after heart transplantation were classified according to early (≤2 years) versus late (>2 years) posttransplantation initial detection of coronary artery disease. These subgroups were analyzed for differences in clinical and laboratory demographics, incidence of progression to ischemic events and incidence of antecedent cytomegalovirus infection.Results. The early-onset group (64 patients) had more rapid progression to ischemic events than the late-onset group (75 patients), with 59% of the late group and only 35% of the early group free from ischemic events by 5 years after initial detection (p = 0.02), but there were no significantly correlated clinical or laboratory predictors of ischemic events. The early group had a significantly higher incidence of antecedent cytomegalovirus infection.Conclusions. We conclude that 1) accelerated graft coronary artery disease develops at variable times after heart transplantation; 2) the early appearance of graft coronary artery disease may be a marker of intrinsically more aggressive disease; 3) cytomegalovirus infection is associated with earlier onset of graft coronary artery disease. Patients with early development of graft coronary artery disease should potentially be given priority for interventional strategies as they are developed

Measuring What Works: An Impact Evaluation of Women's Groups on Maternal Health Uptake in Rural Nepal.

BACKGROUND: There is a need for studies evaluating maternal health interventions in low-income countries. This paper evaluates one such intervention designed to promote maternal health among rural women in Nepal. METHODS AND RESULTS: This was a five-year controlled, non-randomised, repeated cross-sectional study (2007, 2010, 2012) of a participatory community-based maternal health promotion intervention focusing on women's groups to improve maternal health services uptake. In total 1,236 women of childbearing age, who had their last child ≤ two years ago, were interviewed. Difference-in-Difference estimation assessed the effects of the intervention on selected outcome variables while controlling for a constructed wealth index and women's characteristics. In the first three years (from 2007 to the 2010), the intervention increased women's likelihood of attending for antenatal care at least once during pregnancy by seven times [OR = 7.0, 95%CI (2.3; 21.4)], of taking iron and folic acid by three times [OR = 3.0, 95%CI (1.2; 7.8)], and of seeking four or more antenatal care visits of two times, although not significantly [OR = 2.2, 95%CI (1.0; 4.7)]. Over five years, women were more likely to seek antenatal care at least once [OR = 3.0, 95%CI (1.5; 5.2)], to take iron/folic acid [OR = 1.9, [95% CI (1.1; 3.2)], and to attend postnatal care [OR = 1.5, [95% CI (1.1; 2.2)]. No improvement was found on attending antenatal care in the first trimester, birthing at an institution or with a skilled birth attendant. CONCLUSION: Community-based health promotion has a much stronger effect on the uptake of antenatal care and less on delivery care. Other factors not easily resolved through health promotion interventions may influence these outcomes, such as costs or geographical constraints. The evaluation has implications for policy and practice in public health, especially maternal health promotion

Development of new coronary atherosclerotic lesions during a 4-year multifactor risk reduction program: The stanford coronary risk intervention project (SCRIP)

AbstractObjectives. This study attempted to determine whether an intensive multifactor risk reduction program conducted over 4 years would reduce the rate of development of new coronary artery lesions.Background. Recent angiographic trials have generally demonstrated that normalization of plasma lipoprotein profiles reduces the rate of progression of established coronary lesions, but limited data exist on how these treatments influence the development of new lesions.Methods. Three hundred men and women with coronary artery disease were randomized to multifactor risk reduction or usual care. Highly significant improvements in risk factors were achieved by the risk reduction group compared with minimal changes by the usual care group. Quantitative coronary angiography was performed on entry and after 4 years under identical conditions. A decrement in the minimal diameter of visually normal segments >0.2 mm was considered to indicate new lesion formation.Results. A total of 1,605 segments, representing 257 patients, were considered normal at baseline, with 804 and 801 disease-free segments in the usual care and risk reduction groups, respectively. Ninety-nine segments (6.1%) were identified by follow-up quantitative angiography and two angiographic observers as having new lesion formation (usual care 7.6%, risk reduction 4.7%, p = 0.05). New lesion formation was observed in 41 (31%) of 131 patients in the usual care group and in 29 (23%) of 126 patients in the risk reduction group (p = 0.16), with a mean number of new lesions/patient of 0.47 in the usual care group and 0.30 in the risk reduction group (p = 0.06). Multiple regression analysis identified on-study dietary fat intake as the best correlate with new lesion formation.Conclusions. These data indicate that intensive multifactor risk reduction tends to diminish the frequency of new coronary lesion formation

Breast Reconstruction Practices in North America: Current Trends and Future Priorities

The Women's Health and Cancer Rights Act (WHCRA) became federal law on January 1, 1999, mandating health care payer coverage for postmastectomy breast reconstruction. Despite passage of this legislation, breast reconstruction rates in the United States remain low. The Surveillance, Epidemiology and End Results (SEER) database for mastectomy patients in 11 regions across the United States show overall rates for immediate and early delayed reconstruction (performed within 4 months of mastectomy) of 15.4% for 1998 and 18.0% for 2000. Reconstruction rates vary significantly by region as well as by patient age, race, and income. The paper examines potential etiologies for low utilization of breast reconstruction and outlines possible remedies