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Toff WD, Hildick-Smith D, Kovac J, Mullen MJ, Wendler O, Mansouri A, Rombach I, Abrams KR, Conroy SP, Flather MD, Gray AM, MacCarthy P, Monaghan MJ, Prendergast B, Ray S, Young CP, Crossman DC, Cleland JGF, de Belder MA, Ludman PF, Jones S, Densem CG, Tsui S, Kuduvalli M, Mills JD, Banning AP, Sayeed R, Hasan R, Fraser DGW, Trivedi U, Davies SW, Duncan A, Curzen N, Ohri SK, Malkin CJ, Kaul P, Muir DF, Owens WA, Uren NG, Pessotto R, Kennon S, Awad WI, Khogali SS, Matuszewski M, Edwards RJ, Ramesh BC, Dalby M, Raja SG, Mariscalco G, Lloyd C, Cox ID, Redwood SR, Gunning MG, Ridley PD. Effect of Transcatheter Aortic Valve Implantation vs Surgical Aortic Valve Replacement on All-Cause Mortality in Patients With Aortic Stenosis: A Randomized Clinical Trial. JAMA 2022; 327:1875-1887. [PMID: 35579641 PMCID: PMC9115619 DOI: 10.1001/jama.2022.5776] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
IMPORTANCE Transcatheter aortic valve implantation (TAVI) is a less invasive alternative to surgical aortic valve replacement and is the treatment of choice for patients at high operative risk. The role of TAVI in patients at lower risk is unclear. OBJECTIVE To determine whether TAVI is noninferior to surgery in patients at moderately increased operative risk. DESIGN, SETTING, AND PARTICIPANTS In this randomized clinical trial conducted at 34 UK centers, 913 patients aged 70 years or older with severe, symptomatic aortic stenosis and moderately increased operative risk due to age or comorbidity were enrolled between April 2014 and April 2018 and followed up through April 2019. INTERVENTIONS TAVI using any valve with a CE mark (indicating conformity of the valve with all legal and safety requirements for sale throughout the European Economic Area) and any access route (n = 458) or surgical aortic valve replacement (surgery; n = 455). MAIN OUTCOMES AND MEASURES The primary outcome was all-cause mortality at 1 year. The primary hypothesis was that TAVI was noninferior to surgery, with a noninferiority margin of 5% for the upper limit of the 1-sided 97.5% CI for the absolute between-group difference in mortality. There were 36 secondary outcomes (30 reported herein), including duration of hospital stay, major bleeding events, vascular complications, conduction disturbance requiring pacemaker implantation, and aortic regurgitation. RESULTS Among 913 patients randomized (median age, 81 years [IQR, 78 to 84 years]; 424 [46%] were female; median Society of Thoracic Surgeons mortality risk score, 2.6% [IQR, 2.0% to 3.4%]), 912 (99.9%) completed follow-up and were included in the noninferiority analysis. At 1 year, there were 21 deaths (4.6%) in the TAVI group and 30 deaths (6.6%) in the surgery group, with an adjusted absolute risk difference of -2.0% (1-sided 97.5% CI, -∞ to 1.2%; P < .001 for noninferiority). Of 30 prespecified secondary outcomes reported herein, 24 showed no significant difference at 1 year. TAVI was associated with significantly shorter postprocedural hospitalization (median of 3 days [IQR, 2 to 5 days] vs 8 days [IQR, 6 to 13 days] in the surgery group). At 1 year, there were significantly fewer major bleeding events after TAVI compared with surgery (7.2% vs 20.2%, respectively; adjusted hazard ratio [HR], 0.33 [95% CI, 0.24 to 0.45]) but significantly more vascular complications (10.3% vs 2.4%; adjusted HR, 4.42 [95% CI, 2.54 to 7.71]), conduction disturbances requiring pacemaker implantation (14.2% vs 7.3%; adjusted HR, 2.05 [95% CI, 1.43 to 2.94]), and mild (38.3% vs 11.7%) or moderate (2.3% vs 0.6%) aortic regurgitation (adjusted odds ratio for mild, moderate, or severe [no instance of severe reported] aortic regurgitation combined vs none, 4.89 [95% CI, 3.08 to 7.75]). CONCLUSIONS AND RELEVANCE Among patients aged 70 years or older with severe, symptomatic aortic stenosis and moderately increased operative risk, TAVI was noninferior to surgery with respect to all-cause mortality at 1 year. TRIAL REGISTRATION isrctn.com Identifier: ISRCTN57819173.
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Affiliation(s)
| | - William D Toff
- Department of Cardiovascular Sciences, University of Leicester, Leicester, England
- National Institute for Health Research Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, England
| | - David Hildick-Smith
- Sussex Cardiac Centre, Brighton and Sussex University Hospitals NHS Trust, Brighton, England
| | - Jan Kovac
- Department of Cardiovascular Sciences, University of Leicester, Leicester, England
- National Institute for Health Research Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, England
| | - Michael J Mullen
- Institute of Cardiovascular Science, University College London, London, England
| | - Olaf Wendler
- Department of Cardiothoracic Surgery, King's College Hospital NHS Foundation Trust, London, England
| | - Anita Mansouri
- Oxford Clinical Trials Research Unit, Nuffield Department of Orthopedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, England
| | - Ines Rombach
- Oxford Clinical Trials Research Unit, Nuffield Department of Orthopedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, England
| | - Keith R Abrams
- Centre for Health Economics, University of York, York, England
- Department of Statistics, University of Warwick, Coventry, England
- Department of Health Sciences, University of Leicester, Leicester, England
| | - Simon P Conroy
- Department of Health Sciences, University of Leicester, Leicester, England
| | - Marcus D Flather
- Norwich Medical School, University of East Anglia, Norwich, England
| | - Alastair M Gray
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, England
| | - Philip MacCarthy
- Department of Cardiology, King's College Hospital NHS Foundation Trust, London, England
| | - Mark J Monaghan
- Department of Cardiology, King's College Hospital NHS Foundation Trust, London, England
| | | | - Simon Ray
- Department of Cardiology, Manchester University NHS Foundation Trust, Manchester, England
| | | | | | - John G F Cleland
- Robertson Centre for Biostatistics and Glasgow Clinical Trials Unit, Institute of Health and Wellbeing, University of Glasgow, Glasgow, Scotland
| | - Mark A de Belder
- National Institute for Cardiovascular Outcomes Research, Barts Health NHS Trust, London, England
| | - Peter F Ludman
- Institute of Cardiovascular Sciences, Birmingham University, Birmingham, England
| | - Stephen Jones
- Surgical Intervention Trials Unit, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, England
| | - Cameron G Densem
- Department of Cardiology, Royal Papworth Hospital, Cambridge, England
| | - Steven Tsui
- Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, England
| | - Manoj Kuduvalli
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, England
| | - Joseph D Mills
- Department of Cardiology, Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, England
| | - Adrian P Banning
- Department of Cardiology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, England
| | - Rana Sayeed
- Department of Cardiothoracic Surgery, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, England
| | - Ragheb Hasan
- Department of Cardiothoracic Surgery, Manchester University NHS Foundation Trust, Manchester, England
| | - Douglas G W Fraser
- Department of Cardiovascular Medicine, University of Manchester, Manchester, England
| | - Uday Trivedi
- Sussex Cardiac Centre, Brighton and Sussex University Hospitals NHS Trust, Brighton, England
| | - Simon W Davies
- Cardiac Department, Royal Brompton Hospital, Royal Brompton and Harefield NHS Foundation Trust, London, England
| | - Alison Duncan
- Cardiac Department, Royal Brompton Hospital, Royal Brompton and Harefield NHS Foundation Trust, London, England
| | - Nick Curzen
- Wessex Cardiothoracic Centre, University Hospital Southampton, Southampton, England
| | - Sunil K Ohri
- Wessex Cardiothoracic Centre, University Hospital Southampton, Southampton, England
| | | | - Pankaj Kaul
- Department of Cardiac Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, England
| | - Douglas F Muir
- Department of Cardiology, James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, England
| | - W Andrew Owens
- Department of Cardiothoracic Surgery, James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, England
| | - Neal G Uren
- Edinburgh Heart Centre, Royal Infirmary of Edinburgh, Edinburgh, Scotland
| | - Renzo Pessotto
- Edinburgh Heart Centre, Royal Infirmary of Edinburgh, Edinburgh, Scotland
| | - Simon Kennon
- Barts Heart Centre, Barts Health NHS Trust, London, England
| | - Wael I Awad
- Barts Heart Centre, Barts Health NHS Trust, London, England
| | - Saib S Khogali
- Heart and Lung Centre, New Cross Hospital, Wolverhampton, England
| | | | - Richard J Edwards
- Cardiothoracic Department, Newcastle upon Tyne Hospitals, Newcastle upon Tyne, England
| | | | - Miles Dalby
- Department of Cardiology, Harefield Hospital, Royal Brompton and Harefield NHS Foundation Trust, London, England
| | - Shahzad G Raja
- Department of Cardiac Surgery, Harefield Hospital, Royal Brompton and Harefield NHS Foundation Trust, London, England
| | - Giovanni Mariscalco
- Department of Cardiovascular Sciences, University of Leicester, Leicester, England
- National Institute for Health Research Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, England
| | - Clinton Lloyd
- Department of Cardiothoracic Surgery, Derriford Hospital, Plymouth, England
| | - Ian D Cox
- Department of Cardiology, Derriford Hospital, Plymouth, England
| | - Simon R Redwood
- Cardiovascular Division, King's College London, British Heart Foundation Centre of Research Excellence, Rayne Institute, St Thomas' Hospital, London, England
| | - Mark G Gunning
- Cardiology Department, Royal Stoke University Hospital, Stoke-on-Trent, England
| | - Paul D Ridley
- Department of Cardiothoracic Surgery, Royal Stoke University Hospital, Stoke-on-Trent, England
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Spence MS, Baan J, Iacovelli F, Martinelli GL, Muir DF, Saia F, Bortone AS, Densem CG, Owens CG, van der Kley F, Vis M, van Mourik MS, Costa G, Sykorova L, Lüske CM, Deutsch C, Kurucova J, Thoenes M, Bramlage P, Tamburino C, Barbanti M. Prespecified Risk Criteria Facilitate Adequate Discharge and Long-Term Outcomes After Transfemoral Transcatheter Aortic Valve Implantation. J Am Heart Assoc 2020; 9:e016990. [PMID: 32715844 PMCID: PMC7792272 DOI: 10.1161/jaha.120.016990] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Despite the availability of guidelines for the performance of transcatheter aortic valve implantation (TAVI), current treatment pathways vary between countries and institutions, which impact on the mean duration of postprocedure hospitalization. Methods and Results This was a prospective, multicenter registry of 502 patients to validate the appropriateness of discharge timing after transfemoral TAVI, using prespecified risk criteria from FAST‐TAVI (Feasibility and Safety of Early Discharge After Transfemoral [TF] Transcatheter Aortic Valve Implantation), based on hospital events within 1‐year after discharge. The end point—a composite of all‐cause mortality, vascular access–related complications, permanent pacemaker implantation, stroke, cardiac rehospitalization, kidney failure, and major bleeding—was reached in 27.0% of patients (95% CI, 23.3–31.2) within 1 year after intervention; 7.5% (95% CI, 5.5–10.2) had in‐hospital complications before discharge and 19.6% (95% CI, 16.3–23.4) within 1 year after discharge. Overall mortality within 1 year after discharge was 7.3% and rates of cardiac rehospitalization 13.5%, permanent pacemaker implantation 4.2%, any stroke 1.8%, vascular‐access–related complications 0.7%, life‐threatening bleeding 0.7%, and kidney failure 0.4%. Composite events within 1 year after discharge were observed in 18.8% and 24.3% of patients with low risk of complications/early (≤3 days) discharge and high risk and discharged late (>3 days) (concordant discharge), respectively. Event rate in patients with discordant discharge was 14.3% with low risk but discharged late and increased to 50.0% in patients with high risk but discharged in ≤3 days. Conclusions The FAST‐TAVI risk assessment provides a tool for appropriate, risk‐based discharge that was validated with the 1‐year event rate after transfemoral TAVI. Registration URL: https://www.ClinicalTrials.gov; Unique identifier: NCT02404467.
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Affiliation(s)
- Mark S. Spence
- Cardiology DepartmentRoyal Victoria HospitalBelfastUnited Kingdom
| | - Jan Baan
- Department of CardiologyAmsterdam UMCUniversity of AmsterdamThe Netherlands
| | - Fortunato Iacovelli
- Cardiology DepartmentDepartment of Advanced Biomedical SciencesUniversity of NaplesItaly
- Cardiac Surgery DepartmentClinica San GaudenzioNovaraItaly
| | | | - Douglas F. Muir
- Cardiothoracic DivisionThe James Cook University HospitalMiddlesbroughUnited Kingdom
| | - Francesco Saia
- Cardiovascular and Thoracic DepartmentS. Orsola‐Malpighi University HospitalBolognaItaly
| | | | | | - Colum G. Owens
- Cardiology DepartmentRoyal Victoria HospitalBelfastUnited Kingdom
| | - Frank van der Kley
- Cardiology DepartmentLeiden University Medical CenterLeidenThe Netherlands
| | - Marije Vis
- Department of CardiologyAmsterdam UMCUniversity of AmsterdamThe Netherlands
| | | | - Giuliano Costa
- Catania Division of CardiologyPoliclinico‐Vittorio Emanuele HospitalUniversity of CataniaItaly
| | | | - Claudia M. Lüske
- Institute for Pharmacology and Preventive MedicineCloppenburgGermany
| | - Cornelia Deutsch
- Institute for Pharmacology and Preventive MedicineCloppenburgGermany
| | | | | | - Peter Bramlage
- Institute for Pharmacology and Preventive MedicineCloppenburgGermany
| | - Corrado Tamburino
- Catania Division of CardiologyPoliclinico‐Vittorio Emanuele HospitalUniversity of CataniaItaly
| | - Marco Barbanti
- Catania Division of CardiologyPoliclinico‐Vittorio Emanuele HospitalUniversity of CataniaItaly
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Giblett JP, Clarke S, Zhao T, McCormick LM, Braganza DM, Densem CG, O'Sullivan M, Adlam D, Clarke SC, Steele J, Fielding S, West NE, Villar SS, Hoole SP. The role of Glucagon-Like Peptide 1 Loading on periprocedural myocardial infarction During elective PCI (GOLD-PCI study): A randomized, placebo-controlled trial. Am Heart J 2019; 215:41-51. [PMID: 31277053 DOI: 10.1016/j.ahj.2019.05.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 05/27/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND The incretin hormone glucagon-like peptide 1 (GLP-1) has been shown to protect against lethal ischemia-reperfusion injury in animal models and against nonlethal ischemia reperfusion injury in humans. Furthermore, GLP-1 receptor agonists have been shown to reduce major adverse cardiovascular and cerebrovascular events (MACCE) in large-scale studies. We sought to investigate whether GLP-1 reduced percutaneous coronary intervention (PCI)-associated myocardial infarction (PMI) during elective PCI. METHODS The study was a randomized, double-blind controlled trial in which patients undergoing elective PCI received an intravenous infusion of either GLP-1 at 1.2 pmol/kg/min or matched 0.9% saline placebo before and during the procedure. Randomization was performed in 1:1 fashion, with stratification for diabetes mellitus. Six-hour cardiac troponin I (cTnI) was measured with a primary end point of PMI defined as rise ≫×5 upper limit of normal (280 ng/L). Secondary end points included cTnI rise and MACCE at 12 months. RESULTS A total of 192 patients were randomized with 152 (79%) male and a mean age of 68.1 ± 8.9 years. No significant differences in patient demographics were noted between the groups. There was no difference in the rate of PMI between GLP-1 and placebo (9 [9.8%] vs 8 [8.3%], P = 1.0) or in the secondary end points of difference in median cTnI between groups (9.5 [0-88.5] vs 20 [0-58.5] ng/L, P = .25) and MACCE at 12 months (7 [7.3%] vs 9 [9.4%], P = .61). CONCLUSIONS In this randomized, placebo-controlled trial, GLP-1 did not reduce the low incidence of PMI or abrogate biomarker rise during elective PCI, nor did it influence the 12-month MACCE rate which also remained low. CLINICAL TRIAL REGISTRATION Clinicaltrials.gov Number: NCT02127996https://clinicaltrials.gov/ct2/show/NCT02127996.
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Barbanti M, van Mourik MS, Spence MS, Icovelli F, Martinelli GL, Muir DF, Saia F, Bortone AS, Densem CG, van der Kley F, Bramlage P, Vis M, Tamburino C. Optimising patient discharge management after transfemoral transcatheter aortic valve implantation: the multicentre European FAST-TAVI trial. EUROINTERVENTION 2019; 15:147-154. [DOI: 10.4244/eij-d-18-01197] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Axell RG, White PA, Giblett JP, Williams L, Rana BS, Klein A, O'Sullivan M, Davies WR, Densem CG, Hoole SP. Rapid Pacing-Induced Right Ventricular Dysfunction Is Evident After Balloon-Expandable Transfemoral Aortic Valve Replacement. J Am Coll Cardiol 2019; 69:903-904. [PMID: 28209229 DOI: 10.1016/j.jacc.2016.12.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Revised: 11/29/2016] [Accepted: 12/04/2016] [Indexed: 12/18/2022]
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6
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Barbanti M, Baan J, Spence MS, Iacovelli F, Martinelli GL, Saia F, Bortone AS, van der Kley F, Muir DF, Densem CG, Vis M, van Mourik MS, Seilerova L, Lüske CM, Bramlage P, Tamburino C. Feasibility and safety of early discharge after transfemoral transcatheter aortic valve implantation - rationale and design of the FAST-TAVI registry. BMC Cardiovasc Disord 2017; 17:259. [PMID: 29017461 PMCID: PMC5635502 DOI: 10.1186/s12872-017-0693-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 10/05/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is an increasing trend towards shorter hospital stays after transcatheter aortic valve implantation (TAVI), in particular for patients undergoing the procedure via transfemoral (TF) access. Preliminary data suggest that there exists a population of patients that can be discharged safely very early after TF-TAVI. However, current evidence is limited to few retrospective studies, encompassing relatively small sample sizes. METHODS The Feasibility And Safety of early discharge after Transfemoral TAVI (FAST-TAVI) registry is a prospective observational registry that will be conducted at 10 sites across Italy, the Netherlands and the UK. Patients will be included if they have been scheduled to undergo TF-TAVI with the balloon-expandable SAPIEN 3 transcatheter heart valve (THV; Edwards Lifesciences, Irvine, CA). The primary endpoint is a composite of all-cause mortality, vascular-access-related complications, permanent pacemaker implantation, stroke, re-hospitalisation due to cardiac reasons, kidney failure and major bleeding, occurring during the first 30 days after hospital discharge. Patients will be stratified according to whether they were high or low risk for early discharge (≤3 days) (following pre-specified criteria), and according to whether or not they were discharged early. Secondary endpoints will include time-to-event (Kaplan-Meier) analysis for the primary outcome and its individual components, analysis of the relative costs of early and late discharge, and changes in short- and long-term quality of life. Multivariate logistic regression will be used to identify factors that indicate that a patient may be suitable for early discharge. DISCUSSION The data gathered in the FAST-TAVI registry should help to clarify the safety of early discharge after TF-TAVI and to identify patient and procedural characteristics that make early discharge from hospital a safe and cost-effective strategy. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02404467 (registration first received March 23rd 2015).
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Affiliation(s)
- Marco Barbanti
- Catania Division of Cardiology, Ferrarotto Hospital, University of Catania, Via Salvatore Citelli 6, Catania, Italy.
| | - Jan Baan
- Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Mark S Spence
- Cardiology Department, Royal Victoria Hospital, Belfast, UK
| | - Fortunato Iacovelli
- Interventional Cardiology Service, "Montevergine" Clinic, Mercogliano, Italy.,Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples "Federico II", Naples, Italy
| | | | - Francesco Saia
- Cardiovascular and Thoracic Department, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | | | - Frank van der Kley
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Douglas F Muir
- Cardiothoracic Division, The James Cook University Hospital, Middlesbrough, UK
| | - Cameron G Densem
- Department of Interventional Cardiology, Papworth Hospital, Cambridge, UK
| | - Marije Vis
- Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands
| | | | | | - Claudia M Lüske
- Institute for Pharmacology and Preventive Medicine, Cloppenburg, Germany
| | - Peter Bramlage
- Institute for Pharmacology and Preventive Medicine, Cloppenburg, Germany
| | - Corrado Tamburino
- Catania Division of Cardiology, Ferrarotto Hospital, University of Catania, Via Salvatore Citelli 6, Catania, Italy
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7
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Steeds RP, Cowie MR, Rana BS, Chambers JB, Ray S, Srinivasan J, Schwarz K, Neil CJ, Scally C, Horowitz JD, Frenneaux MP, Pislaru C, Dawson DK, Rothwell OJ, George K, Somauroo JD, Lord R, Stembridge M, Shave R, Hoffman M, Ashley EA, Haddad F, Eijsvogels TMH, Oxborough D, Hampson R, Kinsey CD, Gurunathan S, Vamvakidou A, Karogiannis N, Senior R, Ahmadvazir S, Shah BN, Zacharias K, Bowen D, Robinson S, Ihekwaba U, Parker K, Boyd J, Densem CG, Atkinson C, Hinton J, Gaisie EB, Rakhit DJ, Yue AM, Roberts PR, Thomas D, Phen P, Sibley J, Fergey S, Russhard P. Report from the Annual Conference of the British Society of Echocardiography, November 2016, Queen Elizabeth II Conference Centre, London. Echo Res Pract 2017; 4:M1. [PMID: 30390608 PMCID: PMC8693153 DOI: 10.1530/erp-17-0046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 08/17/2017] [Indexed: 11/16/2022] Open
Affiliation(s)
- Richard P Steeds
- Queen Elizabeth Hospital, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Martin R Cowie
- Department of Cardiology, Imperial College London (Royal Brompton Hospital), London, UK
| | - Bushra S Rana
- Department of Cardiology, Papworth Hospital, Cambridge, UK
| | | | - Simon Ray
- University Hospital South Manchester, Manchester, UK
| | | | | | | | | | | | | | | | | | | | | | | | - Rachel Lord
- Cardiff Metropolitan University, Cardiff, UK
| | | | - Rob Shave
- Cardiff Metropolitan University, Cardiff, UK
| | - Martin Hoffman
- University of California Davis Medical Centre, Sacramento, California, USA
| | | | | | | | | | - Reinette Hampson
- Department of Cardiovascular Medicine, Northwick Park Hospital, Harrow, UK
| | - Chris D Kinsey
- Department of Cardiovascular Medicine, Northwick Park Hospital, Harrow, UK
| | - Sothinathan Gurunathan
- Department of Cardiology, Imperial College London (Royal Brompton Hospital), London, UK.,Department of Cardiovascular Medicine, Northwick Park Hospital, Harrow, UK
| | - Anastasia Vamvakidou
- Department of Cardiology, Imperial College London (Royal Brompton Hospital), London, UK.,Department of Cardiovascular Medicine, Northwick Park Hospital, Harrow, UK
| | | | - Roxy Senior
- Department of Cardiology, Imperial College London (Royal Brompton Hospital), London, UK.,Department of Cardiovascular Medicine, Northwick Park Hospital, Harrow, UK.,Institute for Medical Research, Northwick Park Hospital, Harrow, UK.,Cardiovascular Biomedical Research Unit, Imperial College London, London, UK.,Royal Brompton Hospital, London, UK
| | - Shahram Ahmadvazir
- Department of Cardiovascular Medicine, Northwick Park Hospital, Harrow, UK.,Institute for Medical Research, Northwick Park Hospital, Harrow, UK.,Cardiovascular Biomedical Research Unit, Imperial College London, London, UK.,Royal Brompton Hospital, London, UK
| | - Benoy N Shah
- Cardiovascular Biomedical Research Unit, Imperial College London, London, UK.,Royal Brompton Hospital, London, UK.,University Hospital of Southampton NHS Foundation Trust, Southampton, UK
| | - Konstantinos Zacharias
- Department of Cardiovascular Medicine, Northwick Park Hospital, Harrow, UK.,Institute for Medical Research, Northwick Park Hospital, Harrow, UK
| | - Dan Bowen
- Department of Cardiology, Papworth Hospital, Cambridge, UK
| | - Shaun Robinson
- Department of Cardiology, Papworth Hospital, Cambridge, UK
| | | | - Karen Parker
- Department of Cardiology, Papworth Hospital, Cambridge, UK
| | - James Boyd
- Department of Cardiology, Papworth Hospital, Cambridge, UK
| | | | - Charlotte Atkinson
- University Hospital of Southampton NHS Foundation Trust, Southampton, UK
| | - Jonathan Hinton
- University Hospital of Southampton NHS Foundation Trust, Southampton, UK
| | - Edmund B Gaisie
- University Hospital of Southampton NHS Foundation Trust, Southampton, UK
| | - Dhrubo J Rakhit
- University Hospital of Southampton NHS Foundation Trust, Southampton, UK
| | - Arthur M Yue
- University Hospital of Southampton NHS Foundation Trust, Southampton, UK
| | - Paul R Roberts
- University Hospital of Southampton NHS Foundation Trust, Southampton, UK
| | - Dean Thomas
- The Essex Cardiothoracic Centre, Basildon and Thurrock University Hospital, Basildon, Essex, UK
| | - Pat Phen
- The Essex Cardiothoracic Centre, Basildon and Thurrock University Hospital, Basildon, Essex, UK
| | - Jonathan Sibley
- The Essex Cardiothoracic Centre, Basildon and Thurrock University Hospital, Basildon, Essex, UK
| | - Sarah Fergey
- The Essex Cardiothoracic Centre, Basildon and Thurrock University Hospital, Basildon, Essex, UK
| | - Paul Russhard
- The Essex Cardiothoracic Centre, Basildon and Thurrock University Hospital, Basildon, Essex, UK
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Axell RG, Giblett JP, White PA, Klein A, Hampton-Til J, O'Sullivan M, Braganza D, Davies WR, West NEJ, Densem CG, Hoole SP. Stunning and Right Ventricular Dysfunction Is Induced by Coronary Balloon Occlusion and Rapid Pacing in Humans: Insights From Right Ventricular Conductance Catheter Studies. J Am Heart Assoc 2017; 6:JAHA.117.005820. [PMID: 28588092 PMCID: PMC5669185 DOI: 10.1161/jaha.117.005820] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Background We sought to determine whether right ventricular stunning could be detected after supply (during coronary balloon occlusion [BO]) and supply/demand ischemia (induced by rapid pacing [RP] during transcatheter aortic valve replacement) in humans. Methods and Results Ten subjects with single‐vessel right coronary artery disease undergoing percutaneous coronary intervention with normal ventricular function were studied in the BO group. Ten subjects undergoing transfemoral transcatheter aortic valve replacement were studied in the RP group. In both, a conductance catheter was placed into the right ventricle, and pressure volume loops were recorded at baseline and for intervals over 15 minutes after a low‐pressure BO for 1 minute or a cumulative duration of RP for up to 1 minute. Ischemia‐induced diastolic dysfunction was seen 1 minute after RP (end‐diastolic pressure [mm Hg]: 8.1±4.2 versus 12.1±4.1, P<0.001) and BO (end‐diastolic pressure [mm Hg]: 8.1±4.0 versus 8.7±4.0, P=0.03). Impairment of systolic and diastolic function after BO remained at 15‐minutes recovery (ejection fraction [%]: 55.7±9.0 versus 47.8±6.3, P<0.01; end‐diastolic pressure [mm Hg]: 8.1±4.0 versus 9.2±3.9, P<0.01). Persistent diastolic dysfunction was also evident in the RP group at 15‐minutes recovery (end‐diastolic pressure [mm Hg]: 8.1±4.1 versus 9.9±4.4, P=0.03) and there was also sustained impairment of load‐independent indices of systolic function at 15 minutes after RP (end‐systolic elastance and ventriculo‐arterial coupling [mm Hg/mL]: 1.25±0.31 versus 0.85±0.43, P<0.01). Conclusions RP and right coronary artery balloon occlusion both cause ischemic right ventricular dysfunction with stunning observed later during the procedure. This may have intraoperative implications in patients without right ventricular functional reserve.
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Affiliation(s)
- Richard G Axell
- Medical Physics and Clinical Engineering, Cambridge University Hospital NHS Foundation Trust, Cambridge, United Kingdom.,Postgraduate Medical Institute, Anglia Ruskin University, Chelmsford, United Kingdom
| | - Joel P Giblett
- Department of Interventional Cardiology, Papworth Hospital, Cambridge, United Kingdom.,Division of Cardiovascular Medicine, University of Cambridge, United Kingdom
| | - Paul A White
- Medical Physics and Clinical Engineering, Cambridge University Hospital NHS Foundation Trust, Cambridge, United Kingdom.,Postgraduate Medical Institute, Anglia Ruskin University, Chelmsford, United Kingdom
| | - Andrew Klein
- Department of Interventional Cardiology, Papworth Hospital, Cambridge, United Kingdom
| | - James Hampton-Til
- Postgraduate Medical Institute, Anglia Ruskin University, Chelmsford, United Kingdom
| | - Michael O'Sullivan
- Department of Interventional Cardiology, Papworth Hospital, Cambridge, United Kingdom
| | - Denise Braganza
- Department of Interventional Cardiology, Papworth Hospital, Cambridge, United Kingdom
| | - William R Davies
- Department of Interventional Cardiology, Papworth Hospital, Cambridge, United Kingdom
| | - Nick E J West
- Department of Interventional Cardiology, Papworth Hospital, Cambridge, United Kingdom
| | - Cameron G Densem
- Department of Interventional Cardiology, Papworth Hospital, Cambridge, United Kingdom
| | - Stephen P Hoole
- Department of Interventional Cardiology, Papworth Hospital, Cambridge, United Kingdom
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Calvert PA, Obaid DR, O'Sullivan M, Shapiro LM, McNab DC, Densem CG, Hoole SP, Schofield PM, Braganza DM, Clarke SC, West NE, Bennett MR. 053 LONGTERM NATURAL HISTORY OF RADIOFREQUENCY INTRAVASCULAR ULTRASOUND IDENTIFIED CORONARY PLAQUES. Heart 2013. [DOI: 10.1136/heartjnl-2013-304019.53] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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10
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Calvert PA, Obaid DR, O'Sullivan M, Shapiro LM, McNab D, Densem CG, Schofield PM, Braganza D, Clarke SC, Ray KK, West NE, Bennett MR. Association Between IVUS Findings and Adverse Outcomes in Patients With Coronary Artery Disease. JACC Cardiovasc Imaging 2011; 4:894-901. [DOI: 10.1016/j.jcmg.2011.05.005] [Citation(s) in RCA: 385] [Impact Index Per Article: 29.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2011] [Revised: 04/15/2011] [Accepted: 05/05/2011] [Indexed: 01/28/2023]
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11
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Calvert PA, Liew TV, Gorenne I, Clarke M, Costopoulos C, Obaid DR, O'Sullivan M, Shapiro LM, McNab DC, Densem CG, Schofield PM, Braganza D, Clarke SC, Ray KK, West NEJ, Bennett MR. Leukocyte telomere length is associated with high-risk plaques on virtual histology intravascular ultrasound and increased proinflammatory activity. Arterioscler Thromb Vasc Biol 2011; 31:2157-64. [PMID: 21680897 DOI: 10.1161/atvbaha.111.229237] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Leukocyte telomere length (LTL), a marker of cellular senescence, is inversely associated with cardiovascular events. However, whether LTL reflects plaque extent or unstable plaques, and the mechanisms underlying any association are unknown. METHODS AND RESULTS One hundred seventy patients with stable angina or acute coronary syndrome referred for percutaneous coronary intervention underwent 3-vessel virtual histology intravascular ultrasound; 30 372 mm of intravascular ultrasound pullback and 1096 plaques were analyzed. LTL was not associated with plaque volume but was associated with calcified thin-capped fibroatheroma (OR, 1.24; CI, 1.01-1.53; P=0.039) and total fibroatheroma numbers (OR, 1.19; CI, 1.02-1.39; P=0.027). Monocytes from coronary artery disease patients showed increased secretion of proinflammatory cytokines. To mimic leukocyte senescence, we disrupted telomeres and binding and expression of the telomeric protein protection of telomeres protein-1, inducing DNA damage. Telomere disruption increased monocyte secretion of monocyte chemoattractant protein-1, IL-6, and IL-1β and oxidative burst, similar to that seen in coronary artery disease patients, and lymphocyte secretion of IL-2 and reduced lymphocyte IL-10. CONCLUSIONS Shorter LTL is associated with high-risk plaque morphology on virtual histology intravascular ultrasound but not total 3-vessel plaque burden. Monocytes with disrupted telomeres show increased proinflammatory activity, which is also seen in coronary artery disease patients, suggesting that telomere shortening promotes high-risk plaque subtypes by increasing proinflammatory activity.
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Affiliation(s)
- Patrick A Calvert
- Division of Cardiovascular Medicine, University of Cambridge, Cambridge, UK
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Calvert PA, Obaid DR, West NEJ, Shapiro LM, McNab DC, Densem CG, Schofield PM, Braganza D, Clarke SC, O'Sullivan M, Ray KK, Bennett MR. VIRTUAL HISTOLOGY INTRAVASCULAR ULTRASOUND FINDINGS PREDICT ADVERSE OUTCOME IN PATIENTS WITH CORONARY ARTERY DISEASE: THE VIVA (VH-IVUS IN VULNERABLE ATHEROSCLEROSIS) STUDY. J Am Coll Cardiol 2011. [DOI: 10.1016/s0735-1097(11)62055-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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13
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Calvert PA, Obaid DR, West NEJ, Shapiro LM, McNab D, Densem CG, Schofield PM, Braganza D, Clarke SC, O'Sullivan M, Ray KR, Bennett MR. 106 Which virtual histology intravascular ultrasound properties discriminate better between stable angina pectoris and troponin positive acute coronary syndrome: assessment of plaques or analysis of the whole coronary artery vasculature? Heart 2010. [DOI: 10.1136/hrt.2010.196089.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Calvert PA, Obaid DR, Malhotra A, West NEJ, Shapiro LM, McNab D, Densem CG, Schofield PM, Braganza D, Clarke SC, Ray KR, O'Sullivan M, Bennett MR. 107 Plaque composition and plaque volume in non-stented vessels determines serum biomarker levels after stenting in stable angina: a VH-IVUS study. Heart 2010. [DOI: 10.1136/hrt.2010.196089.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Calvert PA, Rafiq I, Ozdemir B, Watson W, Hansom S, McCormick L, Rana BS, Lee EM, Dunning J, Rusk RA, Webb ST, Klein AA, Sudarshan C, Tsui S, Shapiro LM, Densem CG. 091 Multi-disciplinary team assessment of high risk patients with severe aortic valve stenosis leads to better than predicted survival, earlier tracheal extubation and shorter intensive care stay. Heart 2010. [DOI: 10.1136/hrt.2010.196071.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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16
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Hoole SP, Khan SN, White PA, Heck PM, Kharbanda RK, Densem CG, Clarke SC, Shapiro LM, Schofield PM, O'Sullivan M, Dutka DP. Remote ischaemic pre-conditioning does not attenuate ischaemic left ventricular dysfunction in humans. Eur J Heart Fail 2009; 11:497-505. [DOI: 10.1093/eurjhf/hfp040] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Stephen P. Hoole
- Department of Cardiovascular Medicine; Addenbrooke's Hospital; ACCI, Level 6, Box 110, Hills Road Cambridge CB23 3RE UK
- Department of Cardiology; Papworth Hospital; Papworth Everard Cambridge CB3 8RE UK
| | - Sadia N. Khan
- Department of Cardiovascular Medicine; Addenbrooke's Hospital; ACCI, Level 6, Box 110, Hills Road Cambridge CB23 3RE UK
- Department of Cardiology; Papworth Hospital; Papworth Everard Cambridge CB3 8RE UK
| | - Paul A. White
- Department of Cardiology; Papworth Hospital; Papworth Everard Cambridge CB3 8RE UK
- Department of Medical Physics and Clinical Engineering; Addenbrooke's Hospital; Hills Road Cambridge CB2 0QQ UK
| | - Patrick M. Heck
- Department of Cardiovascular Medicine; Addenbrooke's Hospital; ACCI, Level 6, Box 110, Hills Road Cambridge CB23 3RE UK
- Department of Cardiology; Papworth Hospital; Papworth Everard Cambridge CB3 8RE UK
| | - Rajesh K. Kharbanda
- Department of Cardiovascular Medicine; Addenbrooke's Hospital; ACCI, Level 6, Box 110, Hills Road Cambridge CB23 3RE UK
| | - Cameron G. Densem
- Department of Cardiology; Papworth Hospital; Papworth Everard Cambridge CB3 8RE UK
| | - Sarah C. Clarke
- Department of Cardiology; Papworth Hospital; Papworth Everard Cambridge CB3 8RE UK
| | - Leonard M. Shapiro
- Department of Cardiology; Papworth Hospital; Papworth Everard Cambridge CB3 8RE UK
| | - Peter M. Schofield
- Department of Cardiology; Papworth Hospital; Papworth Everard Cambridge CB3 8RE UK
| | - Michael O'Sullivan
- Department of Cardiology; Papworth Hospital; Papworth Everard Cambridge CB3 8RE UK
| | - David P. Dutka
- Department of Cardiovascular Medicine; Addenbrooke's Hospital; ACCI, Level 6, Box 110, Hills Road Cambridge CB23 3RE UK
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Hoole SP, Heck PM, Sharples L, Khan SN, Duehmke R, Densem CG, Clarke SC, Shapiro LM, Schofield PM, O'Sullivan M, Dutka DP. Cardiac Remote Ischemic Preconditioning in Coronary Stenting (CRISP Stent) Study: a prospective, randomized control trial. Circulation 2009; 119:820-7. [PMID: 19188504 DOI: 10.1161/circulationaha.108.809723] [Citation(s) in RCA: 338] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Myocyte necrosis as a result of elective percutaneous coronary intervention (PCI) occurs in approximately one third of cases and is associated with subsequent cardiovascular events. This study assessed the ability of remote ischemic preconditioning (IPC) to attenuate cardiac troponin I (cTnI) release after elective PCI. METHODS AND RESULTS Two hundred forty-two consecutive patients undergoing elective PCI with undetectable preprocedural cTnI were recruited. Subjects were randomized to receive remote IPC (induced by three 5-minute inflations of a blood pressure cuff to 200 mm Hg around the upper arm, followed by 5-minute intervals of reperfusion) or control (an uninflated cuff around the arm) before arrival in the catheter laboratory. The primary outcome was cTnI at 24 hours after PCI. Secondary outcomes included renal dysfunction and major adverse cardiac and cerebral event rate at 6 months. The median cTnI at 24 hours after PCI was lower in the remote IPC compared with the control group (0.06 versus 0.16 ng/mL; P=0.040). After remote IPC, cTnI was <0.04 ng/mL in 44 patients (42%) compared with 24 in the control group (24%; P=0.01). Subjects who received remote IPC experienced less chest discomfort (P=0.0006) and ECG ST-segment deviation (P=0.005) than control subjects. At 6 months, the major adverse cardiac and cerebral event rate was lower in the remote IPC group (4 versus 13 events; P=0.018). CONCLUSIONS Remote IPC reduces ischemic chest discomfort during PCI, attenuates procedure-related cTnI release, and appears to reduce subsequent cardiovascular events.
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Affiliation(s)
- Stephen P Hoole
- Department of Cardiology, Papworth Hospital, Papworth Everard, UK
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18
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Densem CG, Ray M, Hutchinson IV, Yonan N, Brooks NH. Interleukin-6 Polymorphism: A Genetic Risk Factor for Cardiac Transplant Related Coronary Vasculopathy? J Heart Lung Transplant 2005; 24:559-65. [PMID: 15896753 DOI: 10.1016/j.healun.2004.03.016] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
AIMS Interleukin- (IL-) 6 is a pleiotropic cytokine with effects on the acute phase response, inflammation, and vascular function. A G to C polymorphism has been described at position -174 in the promoter region of the IL-6 gene. We investigated the influence of this polymorphism on the development of cardiac transplant related coronary vasculopathy (CV). METHODS Sequence specific polymerase chain reaction identified the -174*G/C allele for 116 cardiac transplant recipients. Coronary disease was identified by routine surveillance post-transplant coronary angiography. RESULTS Prevalence of the -174*G/C polymorphism was different between the transplant and control cohorts; *CC 27.6%, *CG 45.7%, and *GG 26.7% vs. 13.2%, 44.1% and 42.7% respectively (p = 0.004). Median time to the first diagnosis of CV was different between the 3 alleles; *CC 2.8 years (2.0-4.0); *CG 3.9 years (2.1-4.5); *GG 5.3 years (3.2-6.1) (p = 0.05). By Kaplan-Meier survival analysis C homozygotes developed CV significantly earlier than the other cohorts (p = 0.035). At 5 years 100% of C homozygotes had evidence for CV. G homozygotes had a more gradual onset of CV with an approximate 60% prevalence at 5 years. *CC genotype was the most predictive risk factor for CV development (Hazard ratio 4.2 (95% CI 1.3-12.9); p = 0.014). Increasing donor age was also significant (Hazard ratio 1.04 (95% CI, 1.0-1.08); p = 0.023). CONCLUSIONS Polymorphism at position -174 within the promoter region of the IL-6 gene may be an important risk factor for cardiac transplant related coronary vasculopathy. This may improve patient selection and allow tailored immunosuppressive treatment.
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Affiliation(s)
- Cameron G Densem
- Cardiothoracic Transplant Unit, Wythenshawe Hospital, Manchester, United Kingdom.
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Fildes JE, Walker AH, Densem CG, Deiraniya AK, Hutchinson IV, Leonard CT, Yonan N. Angiotensin converting enzyme insertion/deletion polymorphism does not influence postcardiac transplantation hypertension onset or progression. J Heart Lung Transplant 2005; 24:406-10. [PMID: 15797740 DOI: 10.1016/j.healun.2003.11.407] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2003] [Revised: 11/06/2003] [Accepted: 11/10/2003] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The angiotensin converting enzyme insertion deletion polymorphism (ACE I/D) has been associated with much cardiovascular pathology, including posttransplantation hypertension. Hypertension is a significant cause of morbidity and mortality after cardiac transplantation. We investigated the influence of the ACE I/D polymorphism on posttransplantation hypertension. METHODS A total of 211 heart transplant recipients and 154 corresponding donors were genotyped for the ACE I/D polymorphism by polymerase chain reaction. ACE enzymatic activity was measured by spectrophotometric kinetic analysis. Sitting systolic and diastolic blood pressures were recorded at 3 consecutive visits, and the mean was calculated. Clinical data, including demographics and medication, were collected for all recipients. Results were analyzed by the chi-square test and analysis of variance, taking a p value of <0.05 to be significant. RESULTS A total of 41.7% of the subjects were hypertensive (diastolic blood pressure >90 mm Hg) at the time of the study, with 79.6% taking at least one antihypertensive agent. We found no difference between the number of antihypertensive agents, cyclosporin dose and level, renal function, or systolic blood pressure for the different recipient or donor genotypes. We also found no significant correlation between ACE enzymatic activity and systolic or diastolic blood pressure. CONCLUSIONS Our study of 211 recipients and 154 corresponding donors is the largest investigation of this polymorphism in a cardiac transplantation population. We found no apparent relationship between the ACE genotype (of either donor or recipient) and systemic hypertension (absolute measurements and the number or dose of antihypertensive agents used).
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Affiliation(s)
- J E Fildes
- Transplant Centre, South Manchester University Hospitals NHS Trust, Wythenshawe Hospital, Manchester, United Kingdom
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20
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Densem CG, Mutlak ASM, Pravica V, Brooks NH, Yonan N, Hutchinson IV. A novel polymorphism of the gene encoding furin, a TGF-β1 activator, and the influence on cardiac allograft vasculopathy formation. Transpl Immunol 2004; 13:185-90. [PMID: 15381201 DOI: 10.1016/j.trim.2004.04.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2003] [Revised: 04/07/2004] [Accepted: 04/16/2004] [Indexed: 11/28/2022]
Abstract
BACKGROUND Coronary vasculopathy (CV) is an important determinant of survival following cardiac transplantation. We have previously shown that G915C polymorphism of the Transforming Growth Factor-beta1 (TGF-beta1) gene strongly influences CV development. Furin is a proprotein convertase enzyme important in TGF-beta1 activation. We investigated for polymorphism within the promoter region of the gene for furin (fur). Allelic variation of the fur gene, in conjunction with TGF-beta1 polymorphism, was subsequently related to the development of CV. METHODS AND RESULTS The fur gene promoter region (position -1199 to +39) was analysed by SSCP and sequencing. A C/T single nucleotide substitution polymorphism at position -231* was identified. Using PCR the fur and TGFB1 genotypes were identified in 115 cardiac transplant recipients. CV was diagnosed at routine surveillance post-transplant coronary angiography. Fur polymorphism had no influence on vasculopathy development; median time to diagnosis, *C/C homozygotes, 2.27 years (2.10-4.32), *C/T heterozygotes 2.97 years (2.09-4.24), *T/T homozygotes 2.65 years (2.33-4.08), (P=0.95). Allelic variation did not influence Kaplan Meier actuarial analysis of disease onset (P=0.54). Ninety-three percent of recipients were high TGF-beta1 producers. We used fur polymorphism to substratify patients with the +915*G/G TGFB1 (high producing) allele. Fur polymorphism did not influence CV development within this TGF-beta1 high producer cohort, when analysed by time to first diagnosis and Kaplan Meier testing. CONCLUSIONS We have described a novel polymorphism at position -231* in the gene encoding furin. The fur -231* single nucleotide polymorphism in isolation, or in conjunction with TGFB1 polymorphism, is not useful as a genetic risk marker for cardiac transplant associated coronary vasculopathy.
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Affiliation(s)
- C G Densem
- Cardiothoracic Transplant Unit, Wythenshawe Hospital, Manchester, UK.
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Densem CG, Hutchinson IV, Yonan N, Brooks NH. Donor and recipient-transforming growth factor-beta 1 polymorphism and cardiac transplant-related coronary artery disease. Transpl Immunol 2004; 13:211-7. [PMID: 15381204 DOI: 10.1016/j.trim.2004.06.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2004] [Revised: 06/27/2004] [Accepted: 06/28/2004] [Indexed: 10/26/2022]
Abstract
BACKGROUND Transforming growth factor-beta1 (TGF-beta1) has been implicated in the pathogenesis of coronary vasculopathy following cardiac transplantation. The TGFB1 gene contains polymorphisms at positions +915* (Arg25Pro) and +869* (Leu10Pro) which may influence TGF-beta1 expression. We investigated the relationship between the development of coronary vasculopathy and the prevalence of these alleles in a cardiac transplant population. METHODS Vasculopathy was diagnosed at routine surveillance post-transplant coronary angiography. Using sequence-specific polymerase chain reaction we identified the TGFB1 +915* and +869* genotypes in 147 cardiac transplant recipients and 134 cardiac donors. RESULTS TGFB1 +915*C allele carriers (low producers) made up 10.5% of the recipient population but were significantly less likely to develop coronary vasculopathy (P=0.03). Median time to diagnosis was 6.0 years (3.9-8.72) in +915*C allele carriers compared to 2.75 years (2.10-4.22) in *G/G homozygotes (p=0.002). Pre- and 1 year post-transplant clinical variables were equivalent between the two groups. Multivariate analysis identified the recipient +915*G/G genotype (hazard ratio 2.96 (95% CI, 1.09-9.98); p=0.039), donor age (hazard ratio 1.05 (95% CI, 1.02-1.09); p=0.008) and number of acute rejection episodes of ISHLT grade 3 or greater in the first year (hazard ratio 1.12 (95% CI, 1.01-1.23); p=0.03) as significant predictors of vasculopathy. The recipient TGFB1 +869*, and both alleles in the donor, had no influence on vasculopathy development. CONCLUSIONS Recipient TGFB1 +915* genotype influences the development of cardiac transplant-related coronary vasculopathy. This gives an important insight to the pathophysiology of the disease. On the contrary, donor TGFB1 +915* and TGFB1 +869* polymorphisms do not appear to be important and cannot be used as genetic risk factors.
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Affiliation(s)
- C G Densem
- Cardiothoracic Transplant Unit, Wythenshawe Hospital, Manchester, UK.
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Densem CG, Wassel J, Cooper A, Yonan N, Brooks NH, Keevil B. Haptoglobin phenotype correlates with development of cardiac transplant vasculopathy. J Heart Lung Transplant 2004; 23:43-9. [PMID: 14734126 DOI: 10.1016/s1053-2498(03)00061-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
OBJECTIVES The purpose of this study was to investigate the association between haptoglobin phenotypic variation and development of cardiac transplant vasculopathy. BACKGROUND The development of coronary vasculopathy determines long-term survival after cardiac transplantation. Serum haptoglobin levels are associated with non-transplant atherosclerosis. In addition to free hemoglobin binding, haptoglobin influences free radical formation, prostaglandin synthesis and angiogenesis. Three phenotypes of haptoglobin exist in humans, which have both quantitative and qualitative differences. METHODS Coronary disease was diagnosed at post-transplant routine surveillance angiography. Hemoglobin (10%) was added to recipient plasma to form a haptoglobin-hemoglobin complex. Sample aliquots were applied to acid hemoglobin plates and electrophoretically separated. Phenotypes were recognized by comparing the electrophoretic pattern with that of established standards. Haptoglobin concentrations were measured using an immunoturbidimetric technique with polyethylene glycol (PEG)-enhanced precipitation. RESULTS Ninety-three patients were independently studied. Phenotype 1-1 was found in 20.4%, 2-1 in 41.9% and 2-2 in 37.6%. Haptoglobin levels were highest in 1-1 recipients (2.1 +/- 0.58 g/liter) compared with 1.78 +/- 0.88 g/liter and 1.3 +/- 0.81 g/liter in 2-1 and 2-2 individuals, respectively (p = 0.001). Haptoglobin phenotype was significantly related to the development of vasculopathy; recipients with a 2-1 phenotype were more likely to develop angiographic disease (p = 0.0084). No differences were found among the 3 groups according to univariate analysis. Multivariate analysis identified 3 risk factors for vasculopathy development: age of donor (hazard ratio 1.056 [95% confidence interval 1.02 to 1.094], p = 0.0023); pre-transplant recipient body mass index (hazard ratio 1.116 [95% confidence interval 1.015 to 1.23], p = 0.024), and haptoglobin phenotype (hazard ratio 2.725 [95% confidence interval 1.031 to 7.19], p = 0.012). CONCLUSIONS Haptoglobin, through phenotype-dependent mechanisms, correlates with the development of coronary vasculopathy. This finding furthers our understanding of the disease, opens up new areas of research, and may lead to novel therapies.
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Affiliation(s)
- Cameron G Densem
- Cardiothoracic Transplant Unit, Wythenshawe Hospital, Manchester, UK
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Densem CG, Hutchinson IV, Yonan N, Brooks NH. Influence of IFN-γ polymorphism on the development of coronary vasculopathy after cardiac transplantation. Ann Thorac Surg 2004; 77:875-80. [PMID: 14992891 DOI: 10.1016/j.athoracsur.2003.07.031] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/30/2003] [Indexed: 11/20/2022]
Abstract
BACKGROUND The development of coronary vasculopathy (CV) limits survival after cardiac transplantation. Interferon (IFN)-gamma is an important immunomodulator affecting the growth and function of T cells and macrophages, free radical formation, adhesion molecule, and MHC class I and II expression, which are important processes for CV formation. IFN-gamma is expressed early after transplantation and neutralization or genetic absence of the cytokine can abrogate CV development. The expression of IFN-gamma is influenced by a dinucleotide repeat in the first intron of the IFN-gamma gene. We investigated the effect of this polymorphism on the development of CV. METHODS Using sequence specific primers to the IFN-gamma polymorphic region, polymerase chain reaction (PCR) and gel electrophoresis identified the genotype in 144 cardiac transplant recipients and 134 donors. An association was sought between the presence of a high, intermediate or low IFN-gamma producing genotype and the development of CV diagnosed by routine surveillance posttransplant angiography. RESULTS High, intermediate, and low IFN-gamma producers made up 29.2%, 44.4%, 26.4% and 24.6%, 40.3%, 35.1% of recipients and donors respectively (p = NS). IFN-gamma polymorphism in cardiac graft recipients had no impact on the time to first diagnosis of CV; high producers 4.03 years (+/- 129.9 days), intermediate producers 3.40 years (+/- 79.7 days), low producers 4.01 years (+/- 102.9 days); p = 0.16. Similar results were found on investigating donor polymorphism; high producers (3.68 years +/- 120.1 days), intermediate producers (3.83 years +/- 105.9 days), low producers (3.3 years +/- 77.7 days); p = 0.35. Multivariate analysis identified the number of rejection episodes of ISHLT grade 3 or greater and increasing donor age to be independent risk factors for CV development. CONCLUSIONS Dinucleotide repeat polymorphism in the first intron of the human IFN-gamma gene does not influence CV development and cannot be used as a genetic risk marker.
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Affiliation(s)
- Cameron G Densem
- Cardiothoracic Transplant Unit, Wythenshawe Hospital, United Kingdom.
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Densem CG, Bennett DH, Davidson NC. Fusion of permanent pacing leads. Europace 2004; 6:77-8. [PMID: 14697730 DOI: 10.1016/j.eupc.2003.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- C G Densem
- Department of Cardiology, Wythenshawe Hospital, Manchester, UK.
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Densem CG, Hutchinson IV, Yonan N, Brooks NH. Influence of interleukin-10 polymorphism on the development of coronary vasculopathy following cardiac transplantation. Transpl Immunol 2003; 11:223-8. [PMID: 12799207 DOI: 10.1016/s0966-3274(03)00015-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Interleukin-10 (IL-10), an important anti-inflammatory cytokine has been implicated in the pathogenesis of acute rejection and long term graft tolerance. Polymorphism in the IL-10 promoter at positions -1082, -819 and -592, correlates with IL-10 production. Haplotype inheritance of these alleles determines whether individuals are high, intermediate, or low producers of IL-10. We investigated the effect of this polymorphism on the development of cardiac transplant vasculopathy (CV). METHODS CV was defined at routine surveillance coronary angiography as any abnormality in 1 or more epicardial vessels. Recipient and donor DNA was amplified by PCR using primers to the 3 allele sites. After identifying the phenotype by electrophoresis, freedom from CV was analysed by Kaplan-Meier and the log rank test. RESULTS One hundred and forty eight recipients and 135 donors were studied. High, intermediate and low producers made up 26.4, 47.3 and 26.3% of recipients and 35.6, 48.2 and 16.2% of donors (P=0.42). No significant differences were noted between the phenotype groups. The recipient and donor genotypes, when considered in isolation, had no effect on the freedom from CV; recipients: P=0.85; donors: P=0.52. When the recipient and donor genotypes were combined for an individual patient the freedom from CV was again unaffected; high producing IL-10 allele in donor or recipient: P=0.76, low producing IL-10 allele in donor or recipient: P=0.51. Increasing donor age and acute rejection episodes and the presence of a high producing TGF-beta1 phenotype were independent risk factors for CV. CONCLUSIONS Polymorphism of the IL-10 promoter region fails to predict the development of CV and cannot be used as a genetic risk marker. This may be due to the effects of immunosuppressive treatment.
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Affiliation(s)
- C G Densem
- Cardiothoracic Transplant Unit, Wythenshawe Hospital, Manchester, UK
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Abstract
BACKGROUND Tumour necrosis factor alpha (TNF alpha) is implicated in the pathophysiology of heart failure. Plasma TNF alpha is raised in patients with myocardial dysfunction in proportion to the symptoms. OBJECTIVE To determine whether this genetic variant is over represented in heart transplant recipients. PATIENTS 175 heart transplant recipients and a control group of 212 healthy volunteers were studied. The reason for transplantation was severe symptomatic myocardial dysfunction in all cases. METHODS The TNF alpha genotype was determined by polymerase chain reaction and gel electrophoresis. The populations were compared for their fit to Hardy-Weinberg equilibrium by calculating the expected frequencies of each genotype and comparing them to the observed values. A chi(2) test was used to determine the significance of the difference between the observed and expected values. RESULTS No differences were found in the frequency of the TNF2 allele between all heart transplant recipients taken together (54/175, 31%) and healthy volunteers (58/212, 27%). A higher proportion of TNF2 allele carriers was present in cardiac recipients with a pretransplant diagnosis of viral mediated or idiopathic heart failure than in those with ischaemic myocardial dysfunction (26/69 (37.7%) v 28/106 (26.4%), p = 0.03). PATIENTS with a non-ischaemic aetiology had a higher prevalence of TNF2 than healthy volunteers (26/69 (37.7%) v 58/212 (27%), p = 0.05). CONCLUSIONS The TNF2 allele is overrepresented in patients with end stage non-ischaemic myocardial dysfunction. This may represent a genetic predisposition in a small subset of patients who could respond favourably to anti-TNF alpha treatment.
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Affiliation(s)
- C G Densem
- Cardiothoracic Transplant Unit, Wythenshawe Hospital, Manchester, UK School of Biological Sciences, Manchester University, UK
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Densem CG, Hutchinson IV, Yonan N, Brooks NH. Influence of tumor necrosis factor-alpha gene-308 polymorphism on the development of coronary vasculopathy after cardiac transplantation. J Heart Lung Transplant 2001; 20:1265-73. [PMID: 11744409 DOI: 10.1016/s1053-2498(01)00358-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Tumor necrosis factor-alpha (TNF-alpha) has been implicated in cardiovascular disease. Polymorphism of the TNF-alpha gene promoter region (position -308) influences an individual's production of TNF-alpha. This affects susceptibility to acute rejection after cardiac transplantation. Because the highest serum levels of TNF-alpha have been found in recipients with cardiac transplant vasculopathy and because TNF-alpha blockade can prevent the disease in rabbits, we investigated the effect of TNF-alpha promoter polymorphism on the development of vasculopathy in human cardiac allograft recipients. METHODS Using sequence-specific primers to the TNF-alpha gene and polymerase chain reaction, the genotypes of 147 cardiac transplant recipients and 134 heart donors were identified. An association was sought between the presence of high-producing (A homozygotes, GA heterozygotes) or low-producing (G homozygotes) TNF-alpha genotype and the development of coronary vasculopathy, diagnosed by routine surveillance coronary angiography. RESULTS We found that 31.9% of recipients and 27.0% of donors were high TNF-alpha producers. The presence of the high-producing TNF-alpha allele led to an earlier diagnosis of vasculopathy; 3.42 years (+/- 91.3 days) vs 3.84 years (+/- 76.3 days) for high- and low-producing cardiac graft recipients, respectively; 3.52 years (+/- 87.3 days) vs 3.78 years (+/- 77.4 days) for high- and low-producing donor grafts, respectively. However, neither of these differences were significant. By Kaplan Meier actuarial analysis and log-rank test, TNF-alpha polymorphism had no effect on the freedom from vasculopathy when considering either recipient (p = 0.99) or donor (p = 0.86) TNF-alpha genotype. Multivariate analysis identified increasing donor age and the number of acute rejection episodes of International Society for Heart and Lung Transplantation grade 3 or greater as independent risk factors for vasculopathy in both the recipient and donor cohorts. CONCLUSIONS Polymorphism at position -308 in the promoter region of the TNF-alpha gene fails to predict the development of cardiac transplant-related vasculopathy and cannot be used as a genetic risk marker. This may be because of the effects of immunosuppressive treatment.
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Affiliation(s)
- C G Densem
- Cardiothoracic Transplant Unit, Wythenshawe Hospital, United Kingdom, Manchester, UK
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Abstract
Aspirin is a widely used drug and perceived by most physicians to be inexpensive. High rates of concurrent gastroprotective agents are reported from a study of cardiology outpatients. Aspirin takers are more likely to also be taking a proton pump inhibitor, H(2) antagonist, or antacid than non-aspirin takers. They are more than 10 times as likely to be experiencing upper gastrointestinal symptoms. Although aspirin is inexpensive, it is emphasised that the overall cost implications for therapy can be significant and it is suggested that it may be more appropriate to consider the use of alternative antiplatelet agents in patients who tolerate aspirin poorly.
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Affiliation(s)
- M I Burgess
- Department of Cardiology, Wythenshawe Hospital, Southmoor Road, Manchester M23 9LT, UK.
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Densem CG, Hutchinson IV, Cooper A, Yonan N, Brooks NH. Polymorphism of the transforming growth factor-beta 1 gene correlates with the development of coronary vasculopathy following cardiac transplantation. J Heart Lung Transplant 2000; 19:551-6. [PMID: 10867335 DOI: 10.1016/s1053-2498(00)00114-5] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Expression of transforming growth factor-beta1 (TGF-beta1) is central to vascular repair due to its effects on smooth muscle cell, monocyte/macrophage, leucocyte, and extracellular matrix accumulation and proliferation. Genetic polymorphism at position +915 of the TGF-beta1 gene determines the degree of cytokine production in response to injury. We investigated this allelic variation on the development of cardiac transplant-related coronary vasculopathy (CV). METHODS Using sequence-specific primers to the TGF-beta1 gene region of interest, a polymerase chain reaction (PCR) and gel electrophoresis identified the genotype in 129 cardiac transplant recipients. An association was sought between the presence of a high- (GG) or low/intermediate-producing (CC/GC) genotype and the development of coronary vasculopathy diagnosed by coronary angiography. RESULTS C allele carriers made up 10.9% of the recipient population but were significantly less likely to develop coronary vasculopathy (p = 0. 0361). Mean time to diagnosis was 1240.5 days in G homozygotes relative to 2266.5 days in C allele carriers (p = 0.002). Pre- and 1-year posttransplant clinical variables were equivalent between the 2 groups. Multivariate analysis identified the GG genotype (p = 0. 042, hazard ratio 3.01, [95% CI, 1.056-10.99]), donor age (p = 0.002, hazard ratio 1.063, [95% CI, 1.029-1.097]), and number of acute-rejection episodes of grade 3 or greater in the first year (p = 0.029, hazard ratio 1.11, [95% CI, 1.05-1.26]) as significant predictors of vasculopathy. CONCLUSION This study demonstrates a correlation between a high-producing TGF-beta1 genotype and an earlier onset of cardiac-transplant coronary vasculopathy. This gives an important insight into the pathophysiology of cardiac transplant vasculopathy and suggests new treatment options.
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Affiliation(s)
- C G Densem
- Cardiothoracic Transplant Unit, Wythenshawe Hospital, Manchester, UK
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Densem CG, Hutchinson IV, Yonan N, Brooks NH. TGF-beta gene polymorphism does not influence the rise in creatinine following cardiac transplantation. Transpl Immunol 1999; 7:247-9. [PMID: 10638838 DOI: 10.1016/s0966-3274(99)80009-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- C G Densem
- Department of Cardiology, Wythenshawe University Hospital, Manchester, UK
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Densem CG. Prophylactic anticoagulation in chronic atrial flutter. Eur Heart J 1999; 20:317. [PMID: 10099928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/11/2023] Open
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Densem CG, Burgess MI. Development of echocardiography. Hosp Med 1999; 60:71. [PMID: 10197110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
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Densem CG, Lee HS. Risk stratification of patients post-myocardial infarction. Br J Hosp Med (Lond) 1997; 58:32-5. [PMID: 9337917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- C G Densem
- Department of Cardiology, Wythenshawe Hospital, Manchester
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Densem CG. Prognostic implications of elevated creatine kinase after coronary angioplasty. JAMA 1997; 277:1593. [PMID: 9168283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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