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Kessler Iglesias C, Bloom JE, Xiao X, Moskovitch J, Eckford H, Offen S, Kotlyar E, Keogh A, Jabbour A, Bergin P, Leet A, Hare JL, Taylor AJ, Hayward CS, Jansz P, Kaye DM, Macdonald PS, Muthiah K. Early Use of Aspirin for Coronary Allograft Prophylaxis in Heart Transplant Recipients. Transplantation 2024:00007890-990000000-00814. [PMID: 39020464 DOI: 10.1097/tp.0000000000005131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/19/2024]
Abstract
BACKGROUND Coronary allograft vasculopathy (CAV) remains a significant cause of morbidity and mortality after heart transplantation. The use of aspirin for CAV prophylaxis has recently garnered interest as a possible therapeutic adjunct in this setting. METHODS This 2-center retrospective cohort study included 372 patients who underwent heart transplantation between January 2009 and March 2018 and were stratified according to the commencement of aspirin during their index transplant admission. The primary outcome was the development of moderate or severe CAV (International Society for Heart and Lung Transplantation grade ≥2) at surveillance coronary angiography. Secondary endpoints included mortality at follow-up. RESULTS There were no differences in age, sex, and cause of heart failure. In the early aspirin group, the preponderant risk factors included use of ventricular assist devices, pretransplant smoking, and mild or moderate rejection. Multivariable analyses to assess for independent predictors of CAV development and mortality demonstrated that aspirin was associated with reduced mortality (adjusted hazard ratio = 0.19; 95% confidence interval, 0.08-0.47, P < 0.01) and a trend toward a protective effect against the development of moderate or severe CAV (adjusted hazard ratio = 0.24; 95% confidence interval, 0.54-1.19; P = 0.08). CONCLUSIONS In this retrospective risk-adjusted 2-center cohort study, early aspirin administration was associated with reduced risk of death and a trend toward a protective effect against CAV development. These findings warrant validation in prospective randomized trials.
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Affiliation(s)
- Cassia Kessler Iglesias
- Heart Failure and Transplant Unit, Department of Cardiology, St Vincent's Hospital, Sydney, NSW, Australia
- The Victor Chang Cardiac Research Institute, Sydney, NSW, Australia
| | - Jason E Bloom
- Department of Cardiology, Alfred Health, Melbourne, VIC, Australia
- Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
| | - Xiaoman Xiao
- Department of Cardiology, Alfred Health, Melbourne, VIC, Australia
| | | | - Hunter Eckford
- Heart Failure and Transplant Unit, Department of Cardiology, St Vincent's Hospital, Sydney, NSW, Australia
| | - Sophie Offen
- Heart Failure and Transplant Unit, Department of Cardiology, St Vincent's Hospital, Sydney, NSW, Australia
| | - Eugene Kotlyar
- Heart Failure and Transplant Unit, Department of Cardiology, St Vincent's Hospital, Sydney, NSW, Australia
| | - Anne Keogh
- Heart Failure and Transplant Unit, Department of Cardiology, St Vincent's Hospital, Sydney, NSW, Australia
| | - Andrew Jabbour
- Heart Failure and Transplant Unit, Department of Cardiology, St Vincent's Hospital, Sydney, NSW, Australia
- The Victor Chang Cardiac Research Institute, Sydney, NSW, Australia
| | - Peter Bergin
- Department of Cardiology, Alfred Health, Melbourne, VIC, Australia
| | - Angeline Leet
- Department of Cardiology, Alfred Health, Melbourne, VIC, Australia
| | - James L Hare
- Department of Cardiology, Alfred Health, Melbourne, VIC, Australia
| | - Andrew J Taylor
- Department of Cardiology, Alfred Health, Melbourne, VIC, Australia
| | - Christopher S Hayward
- Heart Failure and Transplant Unit, Department of Cardiology, St Vincent's Hospital, Sydney, NSW, Australia
- The Victor Chang Cardiac Research Institute, Sydney, NSW, Australia
| | - Paul Jansz
- Heart Failure and Transplant Unit, Department of Cardiology, St Vincent's Hospital, Sydney, NSW, Australia
| | - David M Kaye
- Department of Cardiology, Alfred Health, Melbourne, VIC, Australia
- Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
| | - Peter S Macdonald
- Heart Failure and Transplant Unit, Department of Cardiology, St Vincent's Hospital, Sydney, NSW, Australia
- The Victor Chang Cardiac Research Institute, Sydney, NSW, Australia
| | - Kavitha Muthiah
- Heart Failure and Transplant Unit, Department of Cardiology, St Vincent's Hospital, Sydney, NSW, Australia
- The Victor Chang Cardiac Research Institute, Sydney, NSW, Australia
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Mayerova L, Wohlfahrt P, Sonka M, Chen Z, Kautzner J, Melenovsky V, Karmazin V, Malek I, Bedanova H, Tomasek A, Ozabalova E, Krejci J, Kovarnik T, Pazdernik M. Acetylsalicylic acid use and development of cardiac allograft vasculopathy: A national prospective study using highly automated 3-D optical coherence tomography analysis. Clin Transplant 2024; 38:e15275. [PMID: 38477134 PMCID: PMC10939248 DOI: 10.1111/ctr.15275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 02/10/2024] [Accepted: 02/16/2024] [Indexed: 03/14/2024]
Abstract
BACKGROUND There is conflicting evidence on the role of acetylsalicylic acid (ASA) use in the development of cardiac allograft vasculopathy (CAV). METHODS A nationwide prospective two-center study investigated changes in the coronary artery vasculature by highly automated 3-D optical coherence tomography (OCT) analysis at 1 month and 12 months after heart transplant (HTx). The influence of ASA use on coronary artery microvascular changes was analyzed in the overall study cohort and after propensity score matching for selected clinical CAV risk factors. RESULTS In total, 175 patients (mean age 52 ± 12 years, 79% male) were recruited. During the 1-year follow-up, both intimal and media thickness progressed, with ASA having no effect on its progression. However, detailed OCT analysis revealed that ASA use was associated with a lower increase in lipid plaque (LP) burden (p = .013), while it did not affect the other observed pathologies. Propensity score matching of 120 patients (60 patient pairs) showed similar results, with ASA use associated with lower progression of LPs (p = .002), while having no impact on layered fibrotic plaque (p = .224), calcification (p = .231), macrophage infiltration (p = .197), or the absolute coronary artery risk score (p = .277). According to Kaplan-Meier analysis, ASA use was not associated with a significant difference in survival (p = .699) CONCLUSION: This study showed a benefit of early ASA use after HTx on LP progression. However, ASA use did not have any impact on the progression of other OCT-observed pathologies or long-term survival.
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Affiliation(s)
| | - Peter Wohlfahrt
- Department of Preventive Cardiology, IKEM, Prague, Czech Republic
| | - Milan Sonka
- Iowa Institute for Biomedical Imaging, The University of Iowa, Iowa City, IA, USA
| | - Zhi Chen
- Iowa Institute for Biomedical Imaging, The University of Iowa, Iowa City, IA, USA
| | | | | | | | - Ivan Malek
- Department of Cardiology, IKEM, Prague, Czech Republic
| | - Helena Bedanova
- Cardiovascular and Transplantation Surgery, Brno, Czech Republic
| | - Ales Tomasek
- Cardiovascular and Transplantation Surgery, Brno, Czech Republic
| | - Eva Ozabalova
- Department of Cardiovascular Diseases, St. Anne’s University Hospital and Masaryk University Brno, Czech Republic
| | - Jan Krejci
- Department of Cardiovascular Diseases, St. Anne’s University Hospital and Masaryk University Brno, Czech Republic
| | - Tomas Kovarnik
- 2nd Department of Internal Medicine, Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic
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Virani SS, Newby LK, Arnold SV, Bittner V, Brewer LC, Demeter SH, Dixon DL, Fearon WF, Hess B, Johnson HM, Kazi DS, Kolte D, Kumbhani DJ, LoFaso J, Mahtta D, Mark DB, Minissian M, Navar AM, Patel AR, Piano MR, Rodriguez F, Talbot AW, Taqueti VR, Thomas RJ, van Diepen S, Wiggins B, Williams MS. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2023; 82:833-955. [PMID: 37480922 DOI: 10.1016/j.jacc.2023.04.003] [Citation(s) in RCA: 67] [Impact Index Per Article: 67.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/24/2023]
Abstract
AIM The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease." METHODS A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. STRUCTURE This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.
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4
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Virani SS, Newby LK, Arnold SV, Bittner V, Brewer LC, Demeter SH, Dixon DL, Fearon WF, Hess B, Johnson HM, Kazi DS, Kolte D, Kumbhani DJ, LoFaso J, Mahtta D, Mark DB, Minissian M, Navar AM, Patel AR, Piano MR, Rodriguez F, Talbot AW, Taqueti VR, Thomas RJ, van Diepen S, Wiggins B, Williams MS. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation 2023; 148:e9-e119. [PMID: 37471501 DOI: 10.1161/cir.0000000000001168] [Citation(s) in RCA: 126] [Impact Index Per Article: 126.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Abstract
AIM The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease." METHODS A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. STRUCTURE This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.
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Affiliation(s)
| | | | | | | | | | | | - Dave L Dixon
- Former Joint Committee on Clinical Practice Guideline member; current member during the writing effort
| | - William F Fearon
- Society for Cardiovascular Angiography and Interventions representative
| | | | | | | | - Dhaval Kolte
- AHA/ACC Joint Committee on Clinical Data Standards
| | | | | | | | - Daniel B Mark
- Former Joint Committee on Clinical Practice Guideline member; current member during the writing effort
| | | | | | | | - Mariann R Piano
- Former Joint Committee on Clinical Practice Guideline member; current member during the writing effort
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5
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D'Addese L, Cantor RS, Koehl D, Reardon L, Ameduri R, Bock M, Morrison A, White S, Wisotzkey B, Kirklin JK, Godown J. Early aspirin use and the development of cardiac allograft vasculopathy in pediatric heart transplant recipients: A pediatric heart transplant society analysis. J Heart Lung Transplant 2023; 42:115-123. [PMID: 36328858 DOI: 10.1016/j.healun.2022.08.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 08/01/2022] [Accepted: 08/28/2022] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Cardiac allograft vasculopathy (CAV) remains a leading cause of graft loss in pediatric heart transplant (HTx) recipients. Adult literature suggests that aspirin (ASA) use in the early post-HTx period may reduce the risk of CAV. This study aimed to determine the impact of early ASA use on the development of CAV in pediatric HTx recipients. METHODS All subjects <17 years of age at time of primary HTx who survived ≥3 years without evidence of CAV were identified for inclusion from the Pediatric Heart Transplant Society database (1996-2019). Early ASA use was defined as ASA started within the first 3 years post-HTx and was classified as continuous or intermittent. Frequency of ASA use was described across centers. Kaplan-Meier method assessed freedom from CAV and overall graft survival. Multiphase parametric hazard analyses and propensity score matched analysis were used to identify independent risk factors. RESULTS 3,011 patients were included with 387 (13%) receiving continuous ASA, 676 (22%) receiving intermittent ASA, and 1,948 (65%) receiving no ASA. ASA use was highly variable across centers (0%-100%). At baseline patients receiving continuous ASA therapy demonstrated inferior graft survival (p < 0.001) and worse freedom from CAV (p = 0.002), but with lower CAV grades (p = 0.05). In multiphase parametric hazard modeling continuous ASA use was not independently associated with CAV, but remained associated with inferior graft survival. Propensity-matched sub-analysis between continuous and no ASA groups demonstrated no difference in freedom from CAV or overall graft loss. CONCLUSIONS ASA use varies widely across pediatric HTx centers. Early ASA use did not reduce the risk of CAV or graft loss in pediatric heart transplant recipients.
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Affiliation(s)
- Laura D'Addese
- Pediatric Cardiology, Joe DiMaggio Children's Hospital, Hollywood, Florida.
| | - Ryan S Cantor
- Surgery, Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama
| | - Devin Koehl
- Surgery, Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama
| | - Leigh Reardon
- Pediatric Cardiology, Mattel Children's Hospital, Los Angeles, California
| | - Rebecca Ameduri
- Pediatric Cardiology, University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota
| | - Matthew Bock
- Pediatric Cardiology, Loma Linda University Children's Hospital, Loma Linda, California
| | - Adam Morrison
- Pediatric Cardiology, Levine Children's Hospital-Atrium Health, Charlotte, North Carolina
| | - Shelby White
- Pediatric Cardiology, University of Virginia Medical Center, Charlottesville, Virginia
| | | | - James K Kirklin
- Surgery, Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama
| | - Justin Godown
- Pediatric Cardiology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
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Zhou L, Wolfson A, Vaidya AS. Noninvasive methods to reduce cardiac complications postheart transplant. Curr Opin Organ Transplant 2022; 27:45-51. [PMID: 34907978 DOI: 10.1097/mot.0000000000000953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Long-term success of heart transplantation is limited by allograft rejection and cardiac allograft vasculopathy (CAV). Classic management has relied on frequent invasive testing to screen for early features of rejection and CAV to allow for early treatment. In this review, we discuss new developments in the screening and prevention of allograft rejection and CAV. RECENT FINDINGS Newer noninvasive screening techniques show excellent sensitivity and specificity for the detection of clinically significant rejection. New biomarkers and treatment targets continue to be identified and await further studies regarding their utility in preventing allograft vasculopathy. SUMMARY Noninvasive imaging and biomarker testing continue to show promise as alternatives to invasive testing for allograft rejection. Continued validation of their effectiveness may lead to new surveillance protocols with reduced frequency of invasive testing. Furthermore, these noninvasive methods will allow for more personalized strategies to reduce the complications of long-term immunosuppression whereas continuing the decline in the overall rate of allograft rejection.
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Affiliation(s)
- Leon Zhou
- Department of Cardiology, Keck School of Medicine, Los Angeles, California, USA
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