Urinary chlorine: a potential biomarker of diuretic resistant patients

Background

Natriuresis is gaining growing interest in identifying diuretic resistance (DR) patients. However, it has not been proved useful beyond the first day with intravenous (iv) furosemide. Moreover, data regarding urinary chlorine (uCl) or urinary potassium (uK) are scarce. We sought to assess the urine electrolyte pattern in acute heart failure (AHF) outpatients to identify those who will present DR.

Methods

Single-center prospective registry of outpatients with AHF who need iv furosemide. In visit 1 (V1), baseline spot urine sample was collected. Furosemide iv bolus plus intensification of oral diuretics were performed. In control visit (V2), baseline spot urine sample was collected and congestion data were evaluated. Urine electrolytes were assessed in relation to DR (defined as need of iv furosemide in V2 due to persistent congestion).

Results

From June to December 2019, 76 patients were included: median age of 75.5 years (68.2–82), glomerular filtration 40 ml/min/1.73m2 (29.2–59.2) and NT-proBNP 3340 ng/L (1296–7044).

In V1, DR patients showed higher levels of uK and lower uNa/uK than NDR (p=0.014 and p=0.007, respectively). In V2, after a median of 6 (6–15) days of intensified diuretic treatment, uNa and uCl dropped with adequate decongestion but not in DR patients (p=0.020 and p=0.001, respectively). Thus, DR patients showed in V2 higher uCl and similar uNa than NDR (table).

Conclusions

After several days of intensified diuretic treatment, uCl and uNa dropped during proper decongestion but not in DR patients, showing higher levels of uCl than NDR. Mantained levels of uCl could help to identify patients with persistent congestion.

Funding Acknowledgement

Type of funding source: None

P1174Impact of sex-differences in long-term outcomes with cardiac resynchronization therapy: are women different?

Introduction

Women are frequently underrepresented in clinical trials for heart failure. Differences on cardiovascular background may imply differences on indications, device election and outcomes in patients receiving cardiac devices (CRT and ICD). We sought to compare sex-related differences in a real-life cohort.

Methods

We analyzed all subjects who underwent a cardiac resynchronization therapy (CRT) implantation (with or without ICD) between 2016 and 2019 in a single center, all of them followed by remote monitoring. Baseline characteristics and outcomes were compared according to gender. Response to resynchronization was defined as clinical improvement in NYHA class or an increase of > =10% in LVEF.

Results

A total of 430 devices (ICD or CRT) were implanted. 149 (35%) of them were CRTs: 116 (88%) CRT-D and 33 (22%) CRT-P. Of the whole cohort, 43 (29%) were women and the mean age was similar in both sex (70+/-9 years). Women had more likely non-ischemic cardiomyopathy (86% vs 49%, p < 0.01), higher proportion of NYHA class III-IV (26% vs 40%, p 0.04) and worse renal function (mean glomerular filtration 61ml/min vs 75ml/min, p 0.04), but tend to be less affected by atrial fibrillation (21% vs 40%, p 0.05). Left ventricular ejection fraction was similar at the moment of implantation among both sex (30+/-7%, p > 0.05) and no difference on optimal medical treatment was observed. Women trend to receive more frequently CRT-P than men (33% vs 18%, p 0.054). After a mean follow-up of 3 years, a four-fold higher response to CRT was observed in women (OR 4.0, 95% CI 2.0-10.7, p 0.002), after adjustment by the etiology of the myocardiopathy. No differences on all-cause mortality (6% in men vs 1% in women, p 0.2) or ventricular arrhythmias (10% in men vs 2% in women, p 0.3) were observed. 

Conclusions

in a real-life cohort, CRT implantation showed a sex-disparity: the proportion of women receiving a CRT was lower than in men, but a CRT without defibrillation was more frequently implanted in women, reflecting a higher prevalence of ischemic cardiomyopathy in men. The underlying myocardial substrate in women and a lower prevalence of AF may explain a more favorable response to CRT, despite more pronounced symptoms of heart failure at the moment of implantation.

Role of Vascular Disease in the Evolution of Heart Transplant Patients

BACKGROUND

The clinical profile of heart transplantation (HT) recipients has changed in recent years. Nowadays, we have to deal with a higher number of co-morbidities, including peripheral vascular disease (PVD). Previous studies suggest an increase in post-HT morbidity and mortality associated with PVD, especially when it is symptomatic. Our study aims were to analyze the prognostic implications of the presence of PVD before transplantation and to determine the factors associated with its development after it.

METHODS

HT patients (n = 217) who survived the first year after surgery were included in the study. Mean follow-up was 9 ± 5 years.

RESULTS

There were no statistically significant differences in mortality rates between patients with PVD (before or after HT) and those without. One third of patients with PVD required surgery in the post-HT monitoring, either revascularization or amputation. Furthermore, the prevalence of PVD was doubled. Dyslipidemia before HT (odds ratio [OR]: 2.9, 95% confidence interval [CI]: 1.3-6.4; P < .01) and older recipient age (OR: 1.05, 95% CI: 1.01-1.09; P < .05) were independently associated with development of PVD by means of multivariate analysis.

CONCLUSIONS

The presence of PVD must be evaluated individually in candidates for heart transplantation despite being a relative contraindication to it at the present time.

Cost-Effectiveness of Highly Sensitive Cardiac Troponin T to Rule Out Acute Rejection After Heart Transplantation

BACKGROUND

Endomyocardial biopsy (EMB) remains the gold standard for detecting acute rejection (AR) after heart transplantation (HTx). Non-invasive detection of AR thus far remains a challenge. Several studies have demonstrated that highly sensitive cardiac troponin T (hs-cTnT) concentrations have a low positive predictive value for diagnosing AR. Nevertheless, hs-cTnT proved to be useful for ruling out AR after HTx. An hs-cTnT concentration <17 ng/L, a value close to that used for rule-in or rule-out myocardial infarction, was associated with a 100% negative predictive value of AR. However, the cost-effectiveness of a strategy with the use of hs-cTnT for ruling out AR in HTx patients remains to be proven.

METHODS

The cost-effectiveness of hs-cTnT determination for ruling out AR was assessed, comparing the costs of hs-cTnT measurements in 305 blood samples obtained at the time of EMB. Eighteen samples were excluded because the EMB was not assessable.

RESULTS

Hs-cTnT determination cost 16.00€ per sample, whereas EMB cost 1752.00€ per biopsy; cost estimations included direct and indirect (30%) charges. Thirty-nine (13.6%) of the 287 blood samples presented hs-cTnT concentrations <17 ng/L; in none of them was an AR >2R degree found in the EMB. The cost of the assessment in the 287 blood samples and biopsies was of 4592.00€ for hs-cTnT and 502,824.00€ for EMB. Hs-cTnT systematic measurement would have avoided 39 EMB, with a saving of 68,328.00€, which represents the 13.5% of the total budget expended in these cases.

CONCLUSIONS

The use of hs-cTnT values to rule out the need of EMB for AR diagnosis after HTx appears to be a cost-effective procedure.

Malignancy after heart transplantation: incidence, prognosis and risk factors

The Spanish Post-Heart-Transplant Tumour Registry comprises data on neoplasia following heart transplantation (HT) for all Spanish HT patients (1984-2003). This retrospective analysis of 3393 patients investigated the incidence and prognosis of neoplasia, and the influence of antiviral prophylaxis. About 50% of post-HT neoplasias were cutaneous, and 10% lymphomas. The cumulative incidence of skin cancers and other nonlymphoma cancers increased with age at HT and with time post-HT (from respectively 5.2 and 8.9 per 1000 person-years in the first year to 14.8 and 12.6 after 10 years), and was greater among men than women. None of these trends held for lymphomas. Induction therapy other than with IL2R-blockers generally increased the risk of neoplasia except when acyclovir was administered prophylactically during the first 3 months post-HT; prophylactic acyclovir halved the risk of lymphoma, regardless of other therapies. Institution of MMF during the first 3 months post-HT reduced the incidence of skin cancer independently of the effects of sex, age group, pre-HT smoking, use of tacrolimus in the first 3 months, induction treatment and antiviral treatment. Five-year survival rates after first tumor diagnosis were 74% for skin cancer, 20% for lymphoma and 32% for other tumors.

Burden of myocardial damage in cardiac allograft rejection: scintigraphic evidence of myocardial injury and histologic evidence of myocyte necrosis and apoptosis

BACKGROUND

Because myocardial damage determines morbidity and outcomes in heart transplant rejection, assessment of total burden of myocardial damage is highly desirable. In addition to myocyte necrosis, programmed cell death, or apoptosis, has recently been shown to contribute to cardiac allograft rejection. In the present study, we noninvasively determined myocardial damage by antimyosin scintigraphy and compared it with necrotic and apoptotic myocardial damage in endomyocardial biopsy (EMB) specimens.

METHODS AND RESULTS

Forty scintigraphic and histologic studies were simultaneously performed. Of these, 19 patients had no EMB evidence of allograft rejection (group I, International Society of Heart and Lung Transplantation [ISHLT] grade 0/4), 12 had mild rejection (group II, ISHLT grades 1A and 1B), and 9 had evidence of moderate allograft rejection (group III, ISHLT grades 2, 3A, and 3B). None of the biopsies demonstrated severe allograft rejection (ISHLT grade 4/4). The severity of global myocyte damage in 40 patients was assessed by antimyosin scintigraphy. Endomyocardial biopsies were performed in these patients within 48 hours of imaging study; biopsy specimens were characterized for presence of myocyte necrosis and apoptosis. Evidence of myocyte necrosis was observed in 9 (23%) of 40 EMB specimens. Nineteen EMB specimens of group I had no inflammation and no myocyte necrosis, 12 of group II specimens showed interstitial mononuclear cell infiltration (only) but no myocyte necrosis, and all 9 of group III specimens had evidence of cellular infiltration and myocyte damage. Myocyte necrosis was assessed by hematoxylin-eosin and trichrome staining of EMB specimens. On the other hand, apoptosis of myocytes, as assessed by TUNEL staining of DNA fragments, was seen in 22 (55%) of the 40 biopsy specimens: 47%, 58%, and 67% in groups I, II and III, respectively. Abnormal antimyosin scan findings, indicating presence of myocardial damage, were observed in 9 of the 19 patients in group I and in all patients in groups II and III. Although positive antimyosin scan results in group III patients are concordant with the presence of histologic myocardial necrosis, myocardial uptake of antimyosin antibodies in groups I and II (no apparent myocyte damage at light microscopic examination) could reflect either sampling error of the biopsy or ongoing apoptotic myocyte damage.

CONCLUSIONS

Apoptosis of myocytes is frequently observed during cardiac allograft rejection. The presence of apoptotic myocytes in the absence of histologic rejection activity in patients with antimyosin uptake suggests that apoptosis could be an additional mechanism of transplant-associated myocardial damage.

Efficacy of augmented immunosuppressive therapy for early vasculopathy in heart transplantation

OBJECTIVES

The present study was undertaken to prospectively and comparatively evaluate the role of serial myocardial perfusion imaging and coronary angiography for the detection of early vasculopathy in a large patient population and also to determine the short- and long-term efficacy of augmented immunosuppressive therapy in the potential reversal of the early vasculopathy.

BACKGROUND

Allograft vasculopathy is the commonest cause of death after the first year of heart transplantation. Anecdotal studies have reported the efficacy of augmented immunosuppressive therapy after early detection of vascular involvement. However, no prospective study has evaluated the feasibility of early detection and treatment of allograft vasculopathy.

METHODS

In 76 cardiac allograft recipients, 230 coronary angiographic and 376 scintigraphic studies were performed in a follow-up period of 8 years. Angiography was performed at 1 month and every year after transplantation, and thallium-201 scintigraphy at 1, 3, 6 and 12 months after transplantation and twice a year thereafter. Prospective follow-up of 76 patients showed that 18 developed either angiographic or scintigraphic evidence of coronary vasculopathy. All episodes were treated with 3-day methylprednisolone pulse and antithymocyte globulin.

RESULTS

Twenty-two episodes of vasculopathy were diagnosed and treated in these 18 patients. Of these 22 episodes, two were detected only by angiography, seven by both angiography and scintigraphy, four by scintigraphy and histologic evidence of vasculitis and nine episodes only by thallium-201 scintigraphy studies. Angiographic and/or scintigraphic resolution was observed in 15 of the 22 episodes (68%) with augmented immunosuppression. The likelihood of regression was higher when treatment was instituted within the first year of transplantation (92%) than after the first year (40%) (p = 0.033). Eighty percent of patients who responded to follow-up.

CONCLUSIONS

The present study suggests that early detection of allograft coronary vasculopathy is feasible with surveillance myocardial perfusion or coronary angiographic studies. When identified early after transplantation, immunosuppressive treatment may result in regression of coronary disease.