Long-term survival in lung transplant recipients after successful preoperative coronary revascularization

ObjectiveCoronary artery disease is considered a contraindication to lung transplantation. We studied effect of pre-lung transplantation nonobstructive coronary artery disease and revascularized coronary artery disease on long-term lung transplant survival.MethodsClinical courses of 172 lung transplant recipients from December 1990 to May 2003 were reviewed. Significant coronary artery disease, defined as left main stenosis of greater than 50% or other epicardial vessel stenosis of greater than 70%, was present in 7 patients; 6 received percutaneous coronary intervention and 1 received coronary artery bypass grafting before transplantation.ResultsGroups were similar with regard to sex, race, or length of intensive care days. The group with normal coronary arteries was significantly younger than the groups with coronary artery disease. The revascularized group had a significant increase in dysrhythmias (P < .003) and 1-, 3-, and 5-year survivals of 85%, 85%, and 69%, respectively. Those with insignificant coronary artery disease (14 patients) demonstrated a 1-, 3-, and 5-year survival of 64%, 40%, and 32%, respectively. The normal coronary group (151 patients) had a 1-, 3-, and 5-year survival of 75%, 58%, and 40%, respectively. The revascularized group had a significant survival advantage compared with that of the insignificant coronary artery disease group (P < .04, log-rank test).ConclusionLong-term survival of lung transplant recipients with revascularized coronary arteries is similar to that of subjects with normal coronary arteries, despite an increased incidence of dysrhythmias. Lung transplant recipients with insignificant coronary artery disease had a worse survival than the revascularized group. More studies are needed to ascertain the cause and determine the optimal management for lung transplant recipients with insignificant coronary artery disease

Epidemiology and survival of the five stages of chronic kidney disease in a systolic heart failure population

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/102653/1/ejhfhfq077.pd

Open access to an outpatient intravenous diuresis program in a systolic heart failure disease management program

In order to provide efficient utilization of resources in an outpatient setting for acute exacerbation of heart failure (HF), the authors piloted an open-access outpatient intravenous (IV) diuretic program (IVDP) to evaluate utilization in an HF disease management program (HFDMP), patient characteristics for users of the program, and safety. An outpatient HFDMP at Jackson Memorial Hospital in Miami, Florida, enrolling 577 patients 18 years and older with an ejection fraction ≤40% was implemented. For symptoms or weight gain ≥5 pounds, patients were eligible to use an open-access IVDP during clinic hours. A total of 130 HFDM patients (22.5%) used the IVDP. IVDP users were more likely to be diabetic, with lower body mass indices than non-IVDP users. New York Heart Association class IV patients and previously hospitalized patients were more likely to use the IVDP. There were no documented adverse reactions for patients receiving treatment and no difference in mortality between groups. This open-access outpatient IVDP model for patients with HF was readily utilized by the HFDMP participants and appears safe for use in this population. This unique model may provide alternative access for acute HF treatment. Congest Heart Fail

The impact of a standardized disease management program on race/ethnicity and gender disparities in care and mortality

Data on racial and gender differences in mortality in patients followed in a standardized heart failure disease management program (HFDMP) are scarce. Survival was calculated by race/ethnicity and gender for 837 patients enrolled in a HFDMP. (The patients studied were indigent African American and White outpatients [39% African American, 36% female] enrolled into at Leonard J. Chabert Medical Center in Houma, Louisiana.) The hazard ratio associated with demographic and clinical characteristic individually and as a whole, was estimated for the four groups. White males had the highest mortality (African American female: HR=0.64, African American male: HR=0.65, White female: HR=0.67, p<.05). Age (HR=1.04, p<.001), ejection fraction (HR=0.97, p<.001), New York Heart Association (NYHA) (HR=1.57, p<.001), systolic blood pressure (HR=0.99, p<.05), hematocrit (HR=0.96, p<.01), diabetes (HR=0.98, p<.05), and body mass index (HR=0.98, p<.05) were significant predictors of mortality in the univariate model. Age (HR=1.04, p<.001), NYHA (HR=1.40, p<.001), diabetes (HR=2.52, p<.001), and White female (HR=.44, p<.01) were significant predictors of mortality in the multivariate model. With the exception of White females, who demonstrated lower mortality, amongst African American males and females and White males who participated in a HFDMP no difference in survival was observed

Prevalence of Stroke in Systolic Heart Failure

Heart disease is a major independent risk factor for stroke, ranking third after age and hypertension. Heart failure (HF) patient constitutes an important subgroup of patients with stroke, because of their poor outcome and high rates of mortality and stroke recurrence. We examined the prevalence of stroke in patients with heart failure from 3 different geographic regions. We compared the prevalence of self-reported history of stroke in participants with systolic HF from 3 different geographic regions (Houma, LA; Miami, FL; and Tbilisi, Georgia, Eastern Europe). We examined the prevalence of stroke/adjusting for patient demographic and health characteristics. Stroke prevalence was reported by 79 (7.8%) of 1017 participants from Louisiana, 51 (9.2%) of 556 participants from Florida, and 5 (1.3%) of 383 participants from Georgia. After multivariable adjustment, the prevalence of stroke was significantly lower in Georgia compared to Florida and Louisiana sites. Patients on β-blocker medication were 3.58 times (95% CI 1.96-6.55) more likely to report stroke compared to those without β-blockers (×2 = 19.5, P ≤ .0001). There were significantly fewer participants on β-blockers from Georgia (7%) compared to participants from Florida (87%) and Louisiana (94%; (×2 = 24.3, P<.001). Self-reported stroke prevalence in participants with HF was not consistent among the 3 sites. These differences in prevalence may in part be explained by the lower reported use of β-blockers in the Georgia site. Longitudinal studies are needed to determine whether β-blockers increase the risk of stroke in HF population

Utility of the 6-Minute Walk Test Following Lung Transplantation

Background: The 6-minute walk test (6-MWT) has replaced standard cardiopulmonary exercises for the evaluation of lung disease. However, data on the utility and characteristics of the 6-MWT following lung transplant are lacking. This study aimed to determine if 6-MWT distance has a normal distribution at 6 months post-transplant and if lower 6-MWT distance was predictive of all-cause mortality

Routine serial echocardiography in systolic heart failure: is it time for the heart failure guidelines to change?

The authors sought to obtain objective evidence for impacting the American College of Cardiology Heart Failure Guidelines for the routine use of serial echocardiography by assessing the reliability of the use of clinician-assessed patient symptoms and New York Heart Association (NYHA) functional classification compared with ejection fraction (EF) measured by echocardiography. A prospective study in 256 patients with systolic heart failure (HF) enrolled into an HF disease management program with EF ≤40% and at least 2 annual echocardiograms were included. Only 86 of 256 (33.5%) patients were correctly classified by NYHA class as showing improvement, no change, or deterioration as compared with echocardiographic assessments. Patients whose NYHA class showed no change between echocardiograms had the lowest survival rate. Quantification in patient's status with NYHA classification is not always a reliable assessment to evaluate prognosis and guide medical therapy for patients with systolic HF

Prevalence of conduction abnormalities in a systolic heart failure population by race, ethnicity, and gender

There is paucity of data regarding conduction abnormalities in the Hispanic population with systolic heart failure (HF). We aimed to evaluate the prevalence of electrocardiogram (ECG) abnormalities in a systolic HF population, with attention to the Hispanic population. A cross sectional study of 926 patients enrolled in a systolic HF disease management program. ECGS were obtained in patients with an ejection fraction (EF) ≤ 40% by echocardiography at enrollment. Univariate and multivariate analysis adjusted by ethnicities was performed. White patients exhibited higher prevalence of atrial fibrillation (14.7%) than black patients (8.0%, P = 0.01) whereas Hispanics presented higher prevalence of paced rhythm (14.3% in Hispanics vs. 6.5% in whites and 5.2% in blacks, P<0.01 for both comparisons), higher prevalence of left bundle branch block (LBBB, 14.5% in Hispanics vs. 8.8% in whites and 5.8% in blacks, P = 0.002) and increased frequency of abnormal QT intervals (76.7% in Hispanics) than whites (59.6%) and blacks (69%) patients (P< 0.01 for both comparisons). A QRS interval greater than 120 ms was less prevalent among blacks (15.8% vs. 26.0% in whites and 25.3% in Hispanics, P = 0.01 for both comparisons). Univariate and multivariate analysis disclosed no influence of other characteristics (age, sex, coronary artery disease, hypertension, ejection fraction, medications) in the ECG findings. Hispanics with Systolic HF presented with increased prevalence of paced rhythm, LBBB, and abnormal QT intervals. Attention should be addressed to these ECG variations to recommend additional guidance for therapeutic interventions and provide important prognostic information