Acute myocardial infarction in cardiac transplant recipients

doi:10.1016/0002-9149(89)90858-8

The American Journal of Cardiology

Volume 64, Issue 18, 15 November 1989, Pages 1093-1097

https://doi.org/10.1016/0002-9149(89)90858-8 Get rights and content

Abstract

To characterize the clinical and pathologic features of acute myocardial infarction (AMI) in cardiac transplant recipients, 22 Stanford patients who had 25 documented infarcts at a mean of 3.86 years after transplantation were reviewed. Symptoms included chest pain (2), arm pain (3), weakness (16), dyspnea (11) and palpitations (8). Three episodes were clinically silent, detected only as new etectrocardiographic changes during routine follow-up. Of 18 patients hospitalized with symptoms, only 7 had electrocardiographic changes of typical Q-wave AMI; 5 had nonspecific ST-segment changes and 2 had no documented changes. Two had old Q waves. Twelve of the 18 were misdiagnosed at admission as having infection or congestive heart failure. Serial creatine phosphokinase levels were obtained in 13 patients, and values were elevated in 8. Six of 25 AMI episodes were associated with development of congestive heart failure and 4 others led to development of cardiogenic shock. Seven patients died during the acute phase of infarction, 12 were retransplanted from 2 days to 6 months after infarct and 1 died suddenly after discharge. Two healed myocardial infarctions of unknown duration were found at autopsy or on explantation in patients not clinically suspected of having an AMI. All infarcts occurred in patients known to have angiographic evidence of transplant coronary artery disease, based on annual coronary arteriography. At autopsy or explantation all hearts were found to have characteristic diffuse concentric coronary artery narrowing, and 4 (18%) had an unusual pattern of multiple foci of nontransmural AMI. We conclude that AMIs in cardiac transplant recipients are characterized by lack of chest pain or typical etectrocardiographic changes, high mortality rate, diffuseness of coronary artery disease and high incidence of multiple foci of nontransmural infarction.

References (11)

SZ Gao et al.
Accelerated coronary vascular disease in the heart transplant patient: coronary arteriographic findings
JACC
(1988)
ME Billingham
Diseases of the transplanted heart
SZ Gao et al.
Clinical and laboratory correlates of accelerated coronary artery disease in cardiac transplant patients
Circulation
(1987)
SA Hunt
Complications of heart transplantation
Heart Transplant
(1981)
DKC Cooper et al.
Heart transplantation: the South African experience
Heart Transplant
(1982)

There are more references available in the full text version of this article.

Cited by (104)

Outcomes among heart transplant recipients following acute coronary syndrome: A nationwide population based study
2023, International Journal of Cardiology
Citation Excerpt :
Apart from shock, other presentations such as dyspnea, chest pressure or heart failure could not be accurately determined within the dataset. Transplant and non-transplant patients may have suffered previous myocardial infarctions including silent events which may have affected outcomes but could not be verified [22]. However, these limitations are counterbalanced by the considerable sample size, absence of selection bias and use of risk adjustment modeling followed by a robustness check with propensity matching.
For patients with refractory heart failure despite optimal medical therapy, orthotopic heart transplantation (OHT) remains the treatment of choice. Since transplanted hearts have variable cardiac denervation and acute coronary syndrome often presents as a silent myocardial infarction or with atypical symptoms, the true impact of ACS on outcomes within this population needs more study. The aim of this study is to evaluate in-hospital mortality in post-transplant patients with ACS.
Utilizing data from the 2002–15 Nationwide Inpatient Sample database, patients with a primary diagnosis of acute coronary syndrome among those with prior heart transplantation were included. A risk adjusted regression analysis was performed to assess if ACS post-OHT had an independent impact on the risk of in-hospital mortality. A 2:1 propensity matching was used to match ACS patients with and without OHT, respectively to assess differences in mortality.
A total of 3,224,073 patients with a primary diagnosis of acute coronary syndrome were included, of which 842 (0.03%) were heart-transplant recipients. The type of ACS: NSTEMI (76.0% vs 74.5%; p = 0.32) and STEMI (24.8% vs 26.7%; p = 0.21) between heart transplant and non-heart transplant patients was similar in both groups. Following ACS, patients with heart transplant were more likely to have accompanying shock of any etiology (15.6% vs 3.8%; p < 0.001) and cardiogenic shock (11.2% vs 2.6%; p < 0.001) compared to those with native hearts. OHT patients also had significantly higher in-hospital mortality (14.3% vs. 3.7%; p < 0.001) that remain significant following regression analysis (aOR 3.6, 95% CI 2.8–4.5; p < 0.001) irrespective of the presence of cardiogenic shock compared to native hearts. This relationship remained consistent following propensity matching where patients with OHT had significantly higher in-hospital mortality (13.5% vs. 7%; p < 0.001).
ACS following OHT was more likely to have accompanying cardiogenic shock. ACS in the setting of prior OHT remained a strong independent predictor of higher mortality as compared to native hearts.
Failing mitochondria and coronary allograft vasculopathy
2022, Journal of Heart and Lung Transplantation
Acute myocardial infarction in heart transplant recipients: An 18-year national study
2022, American Heart Journal Plus: Cardiology Research and Practice
Among 11,622,528 acute myocardial infarction (AMI) hospitalizations, 892 had a history of heart transplantation (HT). In comparison to AMI admissions without HT, those with prior HT were more frequently complicated with cardiac arrest (8.3 % vs 5.0 %, p < 0.001), acute non-cardiac organ failure (17.4 % vs 9.4 %) (p < 0.001), lower rates of coronary angiography (55.4 % vs 63.6 %, p < 0.001), comparable rates of percutaneous coronary intervention (38.8 % vs 41.5 %, p = 0.10), higher rates of pulmonary artery catheterization (2.7 % vs 1.1 %, p < 0.001), invasive mechanical ventilation and acute hemodialysis compared to AMI admissions without HT. Compared to AMI admissions without HT, prior HT recipients had higher in-hospital mortality (11.8 % vs 6.2 %, adjusted odds ratio 2.87 [95 % CI 2.23–3.70]; p < 0.001).
Symptomatic Presentation of Acute Myocardial Infarction in Heart Transplantation Patients
2021, JACC: Case Reports
Patients with acute myocardial infarction with a history of an orthotopic heart transplantation rarely present with classic anginal symptoms, secondary to cardiac denervation. We present 2 cases, the first of a patient with a ST-segment elevation myocardial infarction and the second who presented with a non-ST-segment elevation myocardial infarction. Both patients presented with typical symptoms and were treated with percutaneous coronary intervention. (Level of Difficulty: Intermediate.)
A primer for managing cardiac transplant patients in the emergency department setting
2021, American Journal of Emergency Medicine
Citation Excerpt :
While reinnervation can occur within 5 years, it is usually incomplete [10,13]. Dyspnea, diaphoresis, nausea, vomiting, and presyncope or syncope are also atypical in CAV but may occur [107,110]. One study of 22 cardiac transplant patients found weakness was most common symptom (16 patients), followed by dyspnea in 11 and palpitations in 8 [110].
Cardiac transplant is an effective long-term management option for several severe cardiac diseases. These cardiac transplant patients may present to the emergency department with a range of issues involving the cardiac transplantation, including complications due to their transplant as well as altered presentations of disease resulting from their transplant.
This narrative review provides a focused guide to the evaluation and management of patients with cardiac transplantation and its complications.
Cardiac transplant is an effective therapy for end-stage heart failure. A transplanted heart varies both anatomically and physiologically from a native heart. Several significant complications may occur. Graft failure, rejection, and infection are common causes of morbidity and mortality within the first year of transplant. As these patients are on significant immunosuppressive medication regimens, they are at risk of infection, but inadequate immunosuppression increases the risk of acute rejection. A variety of dysrhythmias such as atrial fibrillation and ventricular dysrhythmias may occur. These patients are also at risk of acute coronary syndrome, cardiac allograft vasculopathy, and medication adverse events. Importantly, patients with acute coronary syndrome can have an altered presentation with the so-called “painless” myocardial infarction. Consultation with the transplant physician is recommended, if available, for these patients to assist in evaluation and management.
An understanding of the presentations and various complications that may affect patients with cardiac transplant will assist emergency clinicians in the care of these patients.
Initial Intravascular Ultrasound Without a Routine Early Baseline Study in the Evaluation of Cardiac Transplant Vasculopathy has Prognostic Valve
2019, Cardiovascular Revascularization Medicine
Abnormal minimal intimal thickening (MIT) on intravascular ultrasound (IVUS) defined as difference of ≥0.5 mm between baseline and one-year post-transplantation has been shown to have prognostic value. The goal of this retrospective cohort study was to evaluate whether abnormal MIT found on routine IVUS studies in cardiac transplant patients after 6 months without an early baseline study (modified MIT or MMIT), has any prognostic value. Furthermore, we evaluated the prognostic effect of serial IVUS performed beyond one year.
A cohort of 149 cardiac transplant patients who underwent IVUS examination > 6 months post-transplant were evaluated retrospectively. Of these 149 patients, 109 patients underwent a subsequent IVUS study approximately 1 year following the initial study. MMIT values of ≥0.5 mm without an early baseline study were correlated with major adverse cardiac event (MACE).
The all-cause mortality was 4.7% (5/107) in patients with MMIT of <0.5 mm vs. 14.6% (6/41) in patients with MMIT of ≥0.5 mm [hazards ratio (HR): 3.2; 95% confidence interval (CI): 1.002–12.17; p = 0.039]. The overall MACE rate was 8.4% (9/107) in patients with MMIT of <0.5 mm vs. 24.4% (10/41) in patients with MMIT of ≥0.5 mm [HR: 6.7; 95% CI: 1.30–9.42; p = 0.009]. After adjusting for age, abnormal MMIT remained a significant independent predictor of MACE (HR: 3.93; CI 1.21–12.81; p = 0.023).
The presence of abnormal MMIT noted on IVUS performed after 6 months post-transplantation without a routine baseline IVUS carries important prognostic value.

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Acute myocardial infarction in cardiac transplant recipients

Abstract

JACC

Clinical and laboratory correlates of accelerated coronary artery disease in cardiac transplant patients

Circulation

Complications of heart transplantation

Heart Transplant

Heart transplantation: the South African experience

Heart Transplant