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Psychosocial Risk and Health Behaviors as Predictors of Clinical Events in Patients Wait-Listed for a New Heart: Results from 7 Years of Follow-Up. Life (Basel) 2021; 11:life11121438. [PMID: 34947969 PMCID: PMC8706706 DOI: 10.3390/life11121438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 12/09/2021] [Accepted: 12/10/2021] [Indexed: 11/16/2022] Open
Abstract
We examined the long-term relationship of psychosocial risk and health behaviors on clinical events in patients awaiting heart transplantation (HTx). Psychosocial characteristics (e.g., depression), health behaviors (e.g., dietary habits, smoking), medical factors (e.g., creatinine), and demographics (e.g., age, sex) were collected at the time of listing in 318 patients (82% male, mean age = 53 years) enrolled in the Waiting for a New Heart Study. Clinical events were death/delisting due to deterioration, high-urgency status transplantation (HU-HTx), elective transplantation, and delisting due to clinical improvement. Within 7 years of follow-up, 92 patients died or were delisted due to deterioration, 121 received HU-HTx, 43 received elective transplantation, and 39 were delisted due to improvement. Adjusting for demographic and medical characteristics, the results indicated that frequent consumption of healthy foods (i.e., foods high in unsaturated fats) and being physically active increased the likelihood of delisting due improvement, while smoking and depressive symptoms were related to death/delisting due to clinical deterioration while awaiting HTx. In conclusion, psychosocial and behavioral characteristics are clearly associated with clinical outcomes in this population. Interventions that target psychosocial risk, smoking, dietary habits, and physical activity may be beneficial for patients with advanced heart failure waiting for a cardiac transplant.
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Bhimani SA, Hsich E, Boyle G, Liu W, Worley S, Bostdorff H, Nasman C, Saarel E, Amdani S. Sex disparities in the current era of pediatric heart transplantation in the United States. J Heart Lung Transplant 2021; 41:391-399. [PMID: 34933797 DOI: 10.1016/j.healun.2021.10.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 10/21/2021] [Accepted: 10/31/2021] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND While sex-related differences in transplant outcomes have been well characterized amongst adults, there are no sex-specific pediatric heart transplant studies over the last decade and none evaluating waitlist outcomes. In a contemporary cohort of children undergoing heart transplantation in the United States, this analysis was performed to determine if there were sex disparities in waitlist and/or post-transplant outcomes. METHODS Retrospective review of Scientific Registry of Transplant Recipients database from December 16, 2011 to February 28, 2019 to compare male and female children after listing and after transplant. Demographic, clinical characteristics and outcomes were compared unadjusted and after 1:1 propensity matching for selected covariates. RESULTS Of 4089 patients, 2299 (56%) were males. At listing, males were more likely to be older, have congenital heart disease (58% vs 48%), renal dysfunction (49% vs 44%) and implantable cardioverter defibrillator (9% vs 7%). At transplant, males were more likely to have renal (42 % vs 35%) and liver dysfunction (13% vs 10%), PRA >10% (29% vs 22%) and ischemic time >3.5 hours (p < 0.05 for all). There were no significant sex differences found in unadjusted rates of transplant or mortality. After propensity matching, females had increased waitlist mortality (HR 1.3, 95%CI 1.04-1.5; p =0.019) compared to males. There were no significant differences in post-transplant morbidity or mortality (HR 1.2, 95% CI 0.93-1.5; p = 0.18) between groups. CONCLUSION In a contemporary pediatric cohort, females have inferior heart transplant waitlist survival compared to propensity-matched males despite lower acuity of illness at listing and similar rates of transplantation. There were no sex-disparities noted in post-transplant outcomes.
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Affiliation(s)
- Salima A Bhimani
- Department of Pediatric Cardiology, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Eileen Hsich
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Gerard Boyle
- Department of Pediatric Cardiology, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Wei Liu
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Sarah Worley
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Hannah Bostdorff
- Department of Pediatric Cardiology, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Colleen Nasman
- Department of Pediatric Cardiology, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | | | - Shahnawaz Amdani
- Department of Pediatric Cardiology, Cleveland Clinic Children's Hospital, Cleveland, Ohio.
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García-Cosío MD, González-Vilchez F, López-Vilella R, Barge-Caballero E, Gómez Bueno M, Martínez-Selles M, María Arizón J, Rangel Sousa D, González-Costello J, Mirabet S, Pérez-Villa F, Molina BD, Rábago G, Portolés Ocampo A, de la Fuente Galán L, Garrido I, Delgado JF. Influence of Gender in Advanced Heart Failure Therapies and Outcome Following Transplantation. Front Cardiovasc Med 2021; 8:630113. [PMID: 33718453 PMCID: PMC7946818 DOI: 10.3389/fcvm.2021.630113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 01/12/2021] [Indexed: 11/13/2022] Open
Abstract
Biological differences between males and females change the course of different diseases and affect therapeutic measures' responses. Heart failure is not an exception to these differences. Women account for a minority of patients on the waiting list for heart transplantation or other advanced heart failure therapies. The reason for this under-representation is unknown. Men have a worse cardiovascular risk profile and suffer more often from ischemic heart disease. Conversely, transplanted women are younger and more frequently have non-ischemic cardiac disorders. Women's poorer survival on the waiting list for heart transplantation has been previously described, but this trend has been corrected in recent years. The use of ventricular assist devices in women is progressively increasing, with comparable results than in men. The indication rate for a heart transplant in women (number of women on the waiting list for millions of habitants) has remained unchanged over the past 25 years. Long-term results of heart transplants are equal for both men and women. We have analyzed the data of a national registry of heart transplant patients to look for possible future directions for a more in-depth study of sex differences in this area. We have analyzed 1-year outcomes of heart transplant recipients. We found similar results in men and women and no sex-related interactions with any of the factors related to survival or differences in death causes between men and women. We should keep trying to approach sex differences in prospective studies to confirm if they deserve a different approach, which is not supported by current evidence.
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Affiliation(s)
- María Dolores García-Cosío
- Servicio de Cardiología, Hospital 12 de Octubre Madrid, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain
- Centro de Investigación Biomédica en Red Cardiovascular (CIBERCV), Madrid, Spain
| | | | - Raquel López-Vilella
- Servicio de Cardiología, Hospital Universitari i Politecnic La Fe, Valencia, Spain
| | - Eduardo Barge-Caballero
- Centro de Investigación Biomédica en Red Cardiovascular (CIBERCV), Madrid, Spain
- Servicio de Cardiología, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain
| | - Manuel Gómez Bueno
- Centro de Investigación Biomédica en Red Cardiovascular (CIBERCV), Madrid, Spain
- Servicio de Cardiología, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
| | - Manuel Martínez-Selles
- Centro de Investigación Biomédica en Red Cardiovascular (CIBERCV), Madrid, Spain
- Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Universidad Europea, Universidad Complutense, Madrid, Spain
| | - Jose María Arizón
- Servicio de Cardiología, Hospital Universitario Reina Sofía, Cordoba, Spain
| | - Diego Rangel Sousa
- Servicio de Cardiología, Hospital Universitario Virgen Del Rocío, Seville, Spain
| | - José González-Costello
- Servicio de Cardiología, Hospital Universitari De Bellvitge, Hospitalet de Llobregat, Spain
| | - Sonia Mirabet
- Servicio de Cardiología, Hospital Santa Creu i Sant Pau, Barcelona, Spain
| | - Félix Pérez-Villa
- Servicio de Cardiología, Hospital Clínic i Provincial, Barcelona, Spain
| | - Beatriz Díaz Molina
- Servicio de Cardiología, Hospital Universitario Central De Asturias, Oviedo, Spain
| | - Gregorio Rábago
- Servicio de Cirugía Cardiaca, Clínica Universidad De Navarra, Navarra, Spain
| | - Ana Portolés Ocampo
- Servicio de Cardiología, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | | | - Iris Garrido
- Servicio de Cardiología, Hospital Universitario Virgen De La Arrixaca, Murcia, Spain
| | - Juan F. Delgado
- Servicio de Cardiología, Hospital 12 de Octubre Madrid, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain
- Centro de Investigación Biomédica en Red Cardiovascular (CIBERCV), Madrid, Spain
- Departamento de Medicina, Universidad Complutense de Madrid, Madrid, Spain
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Hsich EM, Blackstone EH, Thuita LW, McNamara DM, Rogers JG, Yancy CW, Goldberg LR, Valapour M, Xu G, Ishwaran H. Heart Transplantation: An In-Depth Survival Analysis. JACC-HEART FAILURE 2020; 8:557-568. [PMID: 32535125 DOI: 10.1016/j.jchf.2020.03.014] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 03/23/2020] [Indexed: 01/20/2023]
Abstract
OBJECTIVES This study aims to understand the complex factors affecting heart transplant survival and to determine the importance of possible sex-specific risk factors. BACKGROUND Heart transplant allocation is primarily focused on preventing waitlist mortality. To prevent organ wastage, future allocation must balance risk of waitlist mortality with post-transplantation mortality. However, more information regarding risk factors after heart transplantation is needed. METHODS We included all adults (30,606) in the Scientific Registry of Transplant Recipients database who underwent isolated heart transplantation from January 1, 2004, to July 1, 2018. Mortality (8,278 deaths) was verified with the complete Social Security Death Index with a median follow-up of 3.9 years. Temporal decomposition was used to identify phases of survival and phase-specific risk factors. The random survival forests method was used to determine importance of mortality risk factors and their interactions. RESULTS We identified 3 phases of mortality risk: early post-transplantation, constant, and late. Sex was not a significant risk factor. There were several interactions predicting early mortality such as pretransplantation mechanical ventilation with presence of end-organ function (bilirubin, renal function) and interactions predicting later mortality such as diabetes and older age (donor and recipient). More complex interactions predicting early-, mid-, and late-mortality existed and were identified with machine learning (i.e., elevated bilirubin, mechanical ventilation, and dialysis). CONCLUSIONS Post-heart transplant mortality risk is complex and dynamic, changing with time and events. Sex is not an important mortality risk factor. To prevent organ wastage, end-organ dysfunction should be resolved before transplantation as much as possible.
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Affiliation(s)
- Eileen M Hsich
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University School of Medicine, Cleveland, Ohio.
| | - Eugene H Blackstone
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University School of Medicine, Cleveland, Ohio; Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Lucy W Thuita
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | | | - Joseph G Rogers
- Division of Cardiology, Duke University, Durham, North Carolina
| | - Clyde W Yancy
- Division of Cardiology, Northwestern University Medical Center, Chicago, Illinois
| | - Lee R Goldberg
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Maryam Valapour
- Department of Pulmonary Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Gang Xu
- Division of Biostatistics, University of Miami, Miami, Florida
| | - Hemant Ishwaran
- Division of Biostatistics, University of Miami, Miami, Florida; Department of Public Health Sciences, University of Miami, Miami, Florida
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Hsich EM, Blackstone EH, Thuita L, McNamara DM, Rogers JG, Ishwaran H, Schold JD. Sex Differences in Mortality Based on United Network for Organ Sharing Status While Awaiting Heart Transplantation. Circ Heart Fail 2017; 10:CIRCHEARTFAILURE.116.003635. [PMID: 28611123 DOI: 10.1161/circheartfailure.116.003635] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Accepted: 05/15/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND There are sex differences in mortality while awaiting heart transplantation, and the reason remains unclear. METHODS AND RESULTS We included all adults in the Scientific Registry of Transplant Recipients placed on the heart transplant active waitlist from 2004 to 2015. The primary end point was all-cause mortality. Multivariable Cox proportional hazards models were performed to evaluate survival by United Network for Organ Sharing (UNOS) status at the time of listing. Random survival forest was used to identify sex interactions for the competing risk of death and transplantation. There were 33 069 patients (25% women) awaiting heart transplantation. This cohort included 7681 UNOS status 1A (26% women), 13 027 UNOS status 1B (25% women), and 12 361 UNOS status 2 (26% women). During a median follow-up of 4.3 months, 1351 women and 4052 men died. After adjusting for >20 risk factors, female sex was associated with a significant risk of death among UNOS status 1A (adjusted hazard ratio, 1.14; 95% confidence interval, 1.01-1.29) and UNOS status 1B (adjusted hazard ratio, 1.17; 95% confidence interval, 1.05-1.30). In contrast, female sex was significantly protective for time to death among UNOS status 2 (adjusted hazard ratio, 0.85; 95% confidence interval, 0.76-0.95). Sex differences in probability of transplantation were present for every UNOS status, and >20 sex interactions were identified for mortality and transplantation. CONCLUSIONS When stratified by initial UNOS status, women had a higher mortality than men as UNOS status 1 and a lower mortality as UNOS status 2. With >20 sex interactions for mortality and transplantation, further evaluation is warranted to form a more equitable allocation system.
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Affiliation(s)
- Eileen M Hsich
- From the Heart and Vascular Institute, Cleveland Clinic, OH (E.M.H., E.H.B.); Cleveland Clinic Lerner College of Medicine, Case Western Reserve University School of Medicine, OH (E.M.H., E.H.B.); Department of Quantitative Health Sciences, Cleveland Clinic, OH (E.H.B., L.T., J.D.S.); University of Pittsburgh Medical Center, PA (D.M.M.); Division of Cardiology, Duke University, Durham, NC (J.G.R.); and Division of Biostatistics, Department of Public Health Sciences, University of Miami, FL (H.I.).
| | - Eugene H Blackstone
- From the Heart and Vascular Institute, Cleveland Clinic, OH (E.M.H., E.H.B.); Cleveland Clinic Lerner College of Medicine, Case Western Reserve University School of Medicine, OH (E.M.H., E.H.B.); Department of Quantitative Health Sciences, Cleveland Clinic, OH (E.H.B., L.T., J.D.S.); University of Pittsburgh Medical Center, PA (D.M.M.); Division of Cardiology, Duke University, Durham, NC (J.G.R.); and Division of Biostatistics, Department of Public Health Sciences, University of Miami, FL (H.I.)
| | - Lucy Thuita
- From the Heart and Vascular Institute, Cleveland Clinic, OH (E.M.H., E.H.B.); Cleveland Clinic Lerner College of Medicine, Case Western Reserve University School of Medicine, OH (E.M.H., E.H.B.); Department of Quantitative Health Sciences, Cleveland Clinic, OH (E.H.B., L.T., J.D.S.); University of Pittsburgh Medical Center, PA (D.M.M.); Division of Cardiology, Duke University, Durham, NC (J.G.R.); and Division of Biostatistics, Department of Public Health Sciences, University of Miami, FL (H.I.)
| | - Dennis M McNamara
- From the Heart and Vascular Institute, Cleveland Clinic, OH (E.M.H., E.H.B.); Cleveland Clinic Lerner College of Medicine, Case Western Reserve University School of Medicine, OH (E.M.H., E.H.B.); Department of Quantitative Health Sciences, Cleveland Clinic, OH (E.H.B., L.T., J.D.S.); University of Pittsburgh Medical Center, PA (D.M.M.); Division of Cardiology, Duke University, Durham, NC (J.G.R.); and Division of Biostatistics, Department of Public Health Sciences, University of Miami, FL (H.I.)
| | - Joseph G Rogers
- From the Heart and Vascular Institute, Cleveland Clinic, OH (E.M.H., E.H.B.); Cleveland Clinic Lerner College of Medicine, Case Western Reserve University School of Medicine, OH (E.M.H., E.H.B.); Department of Quantitative Health Sciences, Cleveland Clinic, OH (E.H.B., L.T., J.D.S.); University of Pittsburgh Medical Center, PA (D.M.M.); Division of Cardiology, Duke University, Durham, NC (J.G.R.); and Division of Biostatistics, Department of Public Health Sciences, University of Miami, FL (H.I.)
| | - Hemant Ishwaran
- From the Heart and Vascular Institute, Cleveland Clinic, OH (E.M.H., E.H.B.); Cleveland Clinic Lerner College of Medicine, Case Western Reserve University School of Medicine, OH (E.M.H., E.H.B.); Department of Quantitative Health Sciences, Cleveland Clinic, OH (E.H.B., L.T., J.D.S.); University of Pittsburgh Medical Center, PA (D.M.M.); Division of Cardiology, Duke University, Durham, NC (J.G.R.); and Division of Biostatistics, Department of Public Health Sciences, University of Miami, FL (H.I.)
| | - Jesse D Schold
- From the Heart and Vascular Institute, Cleveland Clinic, OH (E.M.H., E.H.B.); Cleveland Clinic Lerner College of Medicine, Case Western Reserve University School of Medicine, OH (E.M.H., E.H.B.); Department of Quantitative Health Sciences, Cleveland Clinic, OH (E.H.B., L.T., J.D.S.); University of Pittsburgh Medical Center, PA (D.M.M.); Division of Cardiology, Duke University, Durham, NC (J.G.R.); and Division of Biostatistics, Department of Public Health Sciences, University of Miami, FL (H.I.)
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Abstract
Heart transplantation is the most effective therapy for patients with Stage D heart failure with a median life expectancy of ≈10 to 15 years. Unfortunately, many patients die on the waiting list hoping for a chance of survival. The life boat cannot rescue everyone. Over a decade, the donor pool has remained relatively stable, whereas the number of heart transplant candidates has risen. Potential recipients often have many comorbidities and are older because the criteria for heart transplantation has few absolute contraindications. Women, Hispanics, and patients with restrictive heart disease and congenital heart disease are more likely to die while awaiting heart transplantation than men, white patients, and those with either ischemic or dilated cardiomyopathy. To better match the market, we need to (1) increase the donor pool, (2) reduce the waitlist, and (3) improve the allocation system. This review article addresses all 3 options and compares strategies in the United States to those in other countries.
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Affiliation(s)
- Eileen M Hsich
- From the Heart and Vascular Institute at the Cleveland Clinic, OH; and Case Western Reserve University School of Medicine, Cleveland, OH.
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Morris AA, Cole RT, Laskar SR, Kalogeropoulos A, Vega JD, Smith A, Butler J. Improved Outcomes for Women on the Heart Transplant Wait List in the Modern Era. J Card Fail 2015; 21:555-60. [DOI: 10.1016/j.cardfail.2015.03.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Revised: 01/20/2015] [Accepted: 03/09/2015] [Indexed: 10/23/2022]
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Spaderna H, Weidner G, Koch KC, Kaczmarek I, Wagner FM, Smits JM. Medical and psychosocial predictors of mechanical circulatory support device implantation and competing outcomes in the Waiting for a New Heart Study. J Heart Lung Transplant 2012; 31:16-26. [DOI: 10.1016/j.healun.2011.07.018] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2011] [Revised: 06/16/2011] [Accepted: 07/28/2011] [Indexed: 11/28/2022] Open
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