Progression of endothelial dysfunction, atherosclerosis, and arterial stiffness in stable kidney transplant patients: a pilot study.

BACKGROUND: Kidney transplant patients suffer from vascular abnormalities and high cardiovascular event rates, despite initial improvements post-transplantation. The nature of the progression of vascular abnormalities in the longer term is unknown. This pilot study investigated changes in vascular abnormalities over time in stable kidney transplant patients long after transplantation. METHODS: Brachial artery flow-mediated dilation (FMD), nitroglycerin-mediated dilation, carotid-femoral pulse wave velocity (cf-PWV), ankle-brachial pressure index, and common carotid artery intima-media thickness (CCA-IMT) were assessed in 18 kidney transplant patients and 17 controls at baseline and 3-6 months after. RESULTS: There was no difference in age (51 ± 13 vs. 46 ± 11; P = 0.19), body mass index (26 ± 5 vs. 25 ± 3; P = 0.49), serum cholesterol (4.54 ± 0.96 vs. 5.14 ± 1.13; P = 0.10), systolic blood pressure (BP) (132 ± 12 vs. 126 ± 12; P = 0.13), diastolic BP (82 ± 9 vs. 77 ± 8; P = 0.10), or diabetes status (3 vs. 0; P = 0.08) between transplant patients and controls. No difference existed in vascular markers between patients and controls at baseline. In transplant patients, FMD decreased (- 1.52 ± 2.74; P = 0.03), cf-PWV increased (0.62 ± 1.06; P = 0.03), and CCA-IMT increased (0.35 ± 0.53; P = 0.02). No changes were observed in controls. CONCLUSION: Markers of vascular structure and function worsen in the post-transplant period on long-term follow-up, which may explain the continued high cardiovascular event rates in this population

Procedural and Clinical Outcomes of Transitioning to High Power Short Duration Guided Ablation for Atrial Fibrillation

Introduction: High-power short-duration (HPSD; 50W for up to 15s) ablation is a novel way to use a contact force-sensing catheter optimized for power-controlled radiofrequency ablation of atrial fibrillation (AF). Our goal was to compare the procedural and clinical outcomes of AF ablation with HPSD to previous ablation methods used, including standard-power standard duration (SPSD; 20-25W, up to 60s) and temperature-controlled non-contact (TCNC; 20-40W, up to 60s). Methods: Procedural and clinical data was from consecutive cases of patients with paroxysmal or persistent AF undergoing pulmonary vein isolation with HPSD, TCNC and SPSD between 7/1/13 to 11/1/19. A total of 171 patients were studied (76 HPSD, 44 TCNC, 51 SPSD). Results: There was no difference in age, sex, or AF type between groups. Radiofrequency ablation time was shorter when comparing HPSD to SPSD (71 vs 101min; p\u3c0.01), HPSD to TCNC (71 vs 146min; p\u3c0.01), and SPSD to TCNC groups (101 vs 146min; p\u3c0.01). There was no difference in sinus rhythm maintenance after 3 or 12-months between groups overall, and when stratified by AF type, left atrial volume, CHA2DS2-VASc score, or left ventricular EF. There was a numerical difference in safety with no adverse events in HPSD (0/76 in HPSD vs 1/51 in SPSD vs 3/44 in TCNC; p=0.06). Discussion: AF ablation utilizing HPSD ablation reduced procedure times with similar sinus rhythm maintenance compared to SPSD and TCNC ablation. This supports the movement to replace SPSD and TCNC with the novel HPSD approach. Further research is warranted with larger populations and longer follow-up

An insight into the impact of vitamin D on cardiovascular outcomes in CKD

Patients with chronic kidney disease (CKD) experience excess cardiovascular morbidity and mortality that is unexplained by traditional cardiovascular risk factors. Vitamin D deficiency is highly prevalent in CKD and is associated with increased cardiovascular mortality in both the general population and in CKD patients. Vitamin D supplementation is a reasonably safe and simple intervention and meta‐analyses of observational studies have suggested that vitamin D supplementation in CKD improves cardiovascular mortality. However, randomised controlled trials (RCTs) examining the impact of vitamin D supplementation in improving surrogate markers of cardiovascular structure and function remain inconclusive. This review investigates the impact of vitamin D supplementation on surrogate end‐points and cardiovascular events from trials in CKD; and discusses why results have been heterogenous, particularly critiquing the effect of different dosing regimens and the failure to take into account the implications of vitamin D supplementation in study participants with differing vitamin D binding protein genotypes

Insight into the impact of vitamin D on cardiovascular outcomes in chronic kidney disease

Patients with chronic kidney disease (CKD) experience excess cardiovascular morbidity and mortality that is unexplained by traditional cardiovascular risk factors. Vitamin D deficiency is highly prevalent in CKD and is associated with increased cardiovascular mortality in both the general population and in CKD patients. Vitamin D supplementation is a reasonably safe and simple intervention and meta‐analyses of observational studies have suggested that vitamin D supplementation in CKD improves cardiovascular mortality. However, randomized controlled trials examining the impact of vitamin D supplementation in improving surrogate markers of cardiovascular structure and function remain inconclusive. This review investigates the impact of vitamin D supplementation on surrogate end‐points and cardiovascular events from trials in CKD; and discusses why results have been heterogenous, particularly critiquing the effect of different dosing regimens and the failure to take into account the implications of vitamin D supplementation in study participants with differing vitamin D binding protein genotypes

Management of Acute Admissions of Heart Failure Patients with Kidney Disease.

Acute heart failure (HF) admissions are common. They are often associated with prolonged hospitalisations and poor outcomes. One-third of chronic HF patients also suffer from chronic kidney disease (CKD). Hence, acute admissions of HF with CKD are common and are associated with longer length of stay and increased mortality. Hyperkalaemia and acute on chronic renal impairment are important challenges in the management of these cases. Cautious introduction of high-dose diuretic therapy, followed by the re-commencement of renin-angiotensin-aldosterone (RAAS) inhibitors, improves length of stay, quality of life, and prognosis. During an admission on to the medical assessment unit careful monitoring and management of the patient's clinical condition and biochemistry is essential

Catheter ablation in patients with atrial fibrillation and heart failure with preserved ejection fraction: A systematic review and meta‐analysis

Abstract Background Catheter ablation for atrial fibrillation (AF) is a proven alternative to pharmacologic rhythm control in patients with heart failure with reduced ejection fraction (HFrEF). Whether outcomes differ in patients with heart failure with preserved ejection fraction (HFpEF) is of interest. Methods Medline, Scopus, and Cochrane Central Register of Controlled Trials were systematically searched to identify relevant studies. Primary efficacy outcomes of interest include atrial arrythmia recurrence and repeat ablation. Harm outcomes of interest include all‐cause mortality, all‐cause hospitalizations, cardiovascular hospitalizations, stroke/transient ischemic attack, and cardiac tamponade. Results We included 7 observational studies comprising 2554 patients with HFpEF who underwent catheter ablation for AF. When comparing patients with HFpEF versus without HF, there was no significant difference in atrial arrhythmia recurrence (risk ratio [RR] 1.39; 95% confidence interval [CI] 0.91–2.13), stroke or transient ischemic attack (TIA) (RR 0.47; 95% CI 0.03–6.54), or cardiac tamponade (RR 1.20; 95% CI 0.12–12.20). When comparing patients with HFpEF versus HFrEF, there was no significant difference in atrial arrhythmia recurrence (RR 1.12; 95% CI 0.92–1.37), repeat ablation (RR 1.19; 95% CI 0.74–1.93), all‐cause mortality (RR 0.87; 95% CI 0.67–1.13), all‐cause hospitalizations (RR 1.10; 95% CI 0.94–1.30), cardiovascular hospitalizations (RR 0.83; 95% CI 0.69–1.01), stroke or TIA (RR 0.81; 95% CI 0.29–2.25), or cardiac tamponade (RR 0.98; 95% CI 0.19–5.16). Conclusions Non‐randomized studies suggest that catheter ablation for AF in patients with HFpEF is associated with similar arrythmia‐free survival and safety profile when compared to patients with HFrEF or without heart failure