Abstract 13935: Steroids Wean Failures After Heart Transplantation - Does It Lead to Mortality?

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Rafael Skorka ◽  
Keith Nishihara ◽  
Adriana Shen ◽  
Jignesh K Patel ◽  
David H Chang ◽  
...  
Keyword(s):  
Acute Cellular Rejection ◽  
Low Risk ◽  
Cardiac Events ◽  
Lower Survival Rate ◽  
Post Transplant ◽  
Antibody Mediated Rejection ◽  
Corticosteroid Withdrawal ◽  
Adverse Cardiac Events ◽  
Significant Difference ◽  
Cellular Rejection

Introduction: It is estimated that approximately 90% of heart transplant (HTx) patients who are low risk can be weaned off steroids after 6 months post-transplant. However, for those 10% who fail weaning subsequent outcome is not known. There is concern that failure to wean off steroids may lead to subsequent greater morbidity/mortality. Methods: Between 2010 and 2014, 178 HTx patients at low rejection risk were initiated to be weaned off steroids after 6 months post-transplant. Our protocol includes decreasing prednisone by 1mg per month from a baseline of 5mg daily. Monthly heart biopsy or use of Allomap are used to exclude rejection during weaning. 15 patients failed the corticosteroid wean due to either rejection (n=8), abnormal echocardiogram (n=2) or severe corticosteroid withdrawal symptoms (n=5). Study endpoints include subsequent 5-year survival, freedom from cardiac allograft vasculopathy (CAV) and non-fatal major adverse cardiac events (NF-MACE); and 1-year freedom from any treated rejection (ATR), antibody-mediated rejection (AMR), acute cellular rejection (ACR). Results: The failed wean group compared to the successful wean group had a trend for lower subsequent 5-year survival. There was no significant difference between the two groups in subsequent 5-year freedom from CAV or NF-MACE. Subsequent 1 Year freedom all rejection (ATR, ACR, AMR) were significantly lower in the failed steroid wean group compared to the successfully weaned group. Conclusions: HTx patients who are deemed low risk who failed corticosteroid weaning may be at risk to develop more rejection with compromised 5-year outcome, including a possible lower survival rate. It is unclear whether the act of corticosteroid weaning activated a deleterious response in these patients. Caution must be given to those patients who fail corticosteroid weaning.

Abstract 13046: Treatment of Highly Sensitized Patients Before Heart Transplant Associated With Long-term Post-transplant Benefit

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Timothy Ho ◽  
Jignesh K Patel ◽  
Keith Nishihara ◽  
Michelle M Kittleson ◽  
David H Chang ◽  
...  
Keyword(s):  
Acute Cellular Rejection ◽  
Cardiac Events ◽  
Donor Pool ◽  
Antibody Mediated Rejection ◽  
Adverse Cardiac Events ◽  
Significant Difference ◽  
Desensitization Therapy ◽  
Cellular Rejection ◽  
Reactive Antibody

Introduction: Highly sensitized patients awaiting heart transplantation (HTx) are disadvantaged by a narrow donor pool due to incompatible potential donors. Desensitization therapy has been demonstrated to be effective in lowering antibodies and thereby enlarging the donor pool. By desensitization, the calculated panel reactive antibody (cPRA) has been reported to decrease and result in a shorter waitlist time. It has not been established whether desensitization before transplant can have impact after HTx outcomes. Methods: Between 2010 and 2015, we assessed 34 patients awaiting HTx who had a PRA >50% and underwent desensitization therapy. Desensitization therapy included combinations of IVIG, rituximab, plasmapheresis, and bortezomib. These patients who underwent HTx were then assessed for outcomes, which included 5-year survival, freedom from cardiac allograft vasculopathy (CAV), freedom from non-fatal major adverse cardiac events (NF-MACE), and freedom from donor specific antibody (DSA) development and 1-year freedom from rejection (any treated rejection (ATR), acute cellular rejection (ACR), antibody mediated rejection (AMR)). Patients who underwent desensitization were compared to a similar group of patients with PRA >50% who did not undergo desensitization and underwent HTx. Results: Patients who underwent desensitization compared to those who did not had significantly greater freedom from 5-year development of CAV (94.1 vs 78.8%, p=0.039). There was no significant difference in 5-year survival, 5-year freedom from NF-MACE or DSA development, and 1-year freedom from ATR, ACR, AMR. Conclusions: Desensitization in highly sensitized patients awaiting HTx appears to have long ranging effects to modulate the immune system after HTx, resulting in less development of CAV. Further investigation should be pursued to understand the mechanism of this intervention.

scholarly journals Development of an ensemble machine learning prognostic model to predict 60-day risk of major adverse cardiac events in adults with chest pain

2021 ◽  
Author(s):  
Chris J. Kennedy ◽  
Dustin G. Mark ◽  
Jie Huang ◽  
Mark J. van der Laan ◽  
Alan E. Hubbard ◽  
...  
Keyword(s):  
Machine Learning ◽  
Logistic Regression ◽  
Chest Pain ◽  
Random Forest ◽  
Decision Trees ◽  
Low Risk ◽  
Major Adverse Cardiac Events ◽  
Risk Scores ◽  
Cardiac Events ◽  
Adverse Cardiac Events

Background: Chest pain is the second leading reason for emergency department (ED) visits and is commonly identified as a leading driver of low-value health care. Accurate identification of patients at low risk of major adverse cardiac events (MACE) is important to improve resource allocation and reduce over-treatment. Objectives: We sought to assess machine learning (ML) methods and electronic health record (EHR) covariate collection for MACE prediction. We aimed to maximize the pool of low-risk patients that are accurately predicted to have less than 0.5% MACE risk and may be eligible for reduced testing. Population Studied: 116,764 adult patients presenting with chest pain in the ED and evaluated for potential acute coronary syndrome (ACS). 60-day MACE rate was 1.9%. Methods: We evaluated ML algorithms (lasso, splines, random forest, extreme gradient boosting, Bayesian additive regression trees) and SuperLearner stacked ensembling. We tuned ML hyperparameters through nested ensembling, and imputed missing values with generalized low-rank models (GLRM). We benchmarked performance to key biomarkers, validated clinical risk scores, decision trees, and logistic regression. We explained the models through variable importance ranking and accumulated local effect visualization. Results: The best discrimination (area under the precision-recall [PR-AUC] and receiver operating characteristic [ROC-AUC] curves) was provided by SuperLearner ensembling (0.148, 0.867), followed by random forest (0.146, 0.862). Logistic regression (0.120, 0.842) and decision trees (0.094, 0.805) exhibited worse discrimination, as did risk scores [HEART (0.064, 0.765), EDACS (0.046, 0.733)] and biomarkers [serum troponin level (0.064, 0.708), electrocardiography (0.047, 0.686)]. The ensemble's risk estimates were miscalibrated by 0.2 percentage points. The ensemble accurately identified 50% of patients to be below a 0.5% 60-day MACE risk threshold. The most important predictors were age, peak troponin, HEART score, EDACS score, and electrocardiogram. GLRM imputation achieved 90% reduction in root mean-squared error compared to median-mode imputation. Conclusion: Use of ML algorithms, combined with broad predictor sets, improved MACE risk prediction compared to simpler alternatives, while providing calibrated predictions and interpretability. Standard risk scores may neglect important health information available in other characteristics and combined in nuanced ways via ML.

scholarly journals Prehospital Modified HEART Score Predictive of 30-Day Adverse Cardiac Events

2018 ◽  
Vol 33 (1) ◽  
pp. 58-62 ◽  
Author(s):  
Jason P. Stopyra ◽  
William S. Harper ◽  
Tyson J. Higgins ◽  
Julia V. Prokesova ◽  
James E. Winslow ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Chest Pain ◽  
Decision Aid ◽  
Care Center ◽  
Tertiary Care ◽  
Low Risk ◽  
Cardiac Events ◽  
Predictive Values ◽  
Heart Score ◽  
Adverse Cardiac Events

AbstractIntroductionThe History, Electrocardiogram (ECG), Age, Risk Factors, and Troponin (HEART) score is a decision aid designed to risk stratify emergency department (ED) patients with acute chest pain. It has been validated for ED use, but it has yet to be evaluated in a prehospital setting.HypothesisA prehospital modified HEART score can predict major adverse cardiac events (MACE) among undifferentiated chest pain patients transported to the ED.MethodsA retrospective cohort study of patients with chest pain transported by two county-based Emergency Medical Service (EMS) agencies to a tertiary care center was conducted. Adults without ST-elevation myocardial infarction (STEMI) were included. Inter-facility transfers and those without a prehospital 12-lead ECG or an ED troponin measurement were excluded. Modified HEART scores were calculated by study investigators using a standardized data collection tool for each patient. All MACE (death, myocardial infarction [MI], or coronary revascularization) were determined by record review at 30 days. The sensitivity and negative predictive values (NPVs) for MACE at 30 days were calculated.ResultsOver the study period, 794 patients met inclusion criteria. A MACE at 30 days was present in 10.7% (85/794) of patients with 12 deaths (1.5%), 66 MIs (8.3%), and 12 coronary revascularizations without MI (1.5%). The modified HEART score identified 33.2% (264/794) of patients as low risk. Among low-risk patients, 1.9% (5/264) had MACE (two MIs and three revascularizations without MI). The sensitivity and NPV for 30-day MACE was 94.1% (95% CI, 86.8-98.1) and 98.1% (95% CI, 95.6-99.4), respectively.ConclusionsPrehospital modified HEART scores have a high NPV for MACE at 30 days. A study in which prehospital providers prospectively apply this decision aid is warranted.StopyraJP, HarperWS, HigginsTJ, ProkesovaJV, WinslowJE, NelsonRD, AlsonRL, DavisCA, RussellGB, MillerCD, MahlerSA. Prehospital modified HEART score predictive of 30-day adverse cardiac events. Prehosp Disaster Med. 2018;33(1):58–62.

scholarly journals The Natural History of Inflammatory Bowel Disease and Primary Sclerosing Cholangitis after Liver Transplantation – a Single-Centre Experience

2010 ◽  
Vol 24 (1) ◽  
pp. 40-46 ◽  
Author(s):  
Karli J Moncrief ◽  
Anamaria Savu ◽  
Mang M Ma ◽  
Vince G Bain ◽  
Winnie W Wong ◽  
...  
Keyword(s):  
Inflammatory Bowel Disease ◽  
Natural History ◽  
Bowel Disease ◽  
Sclerosing Cholangitis ◽  
Patient Survival ◽  
Acute Cellular Rejection ◽  
Post Transplant ◽  
History Of ◽  
Inflammatory Bowel ◽  
Cellular Rejection

OBJECTIVE: To describe the natural history of primary sclerosing cholangitis (PSC) and inflammatory bowel disease (IBD) after liver transplant, the predictors of PSC and IBD recurrence, and the interaction of these disease processes.METHODS: Data regarding patients who received liver transplants for PSC at the University of Alberta Hospital (Edmonton, Alberta) from 1989 to 2006 were retrospectively reviewed. Recurrent PSC (rPSC) was defined by the Mayo Clinic criteria. Cox proportional hazards modelling and Kaplan-Meier statistics were used.RESULTS: Fifty-nine patients were studied, with a median follow-up of 68 months. A total of 71.2% of patients were diagnosed with IBD pre-transplant. Clinical IBD severity post-transplant compared with severity pretransplant was unchanged in 67%, worse in 26.5% and improved in 6.1% of patients. Twenty-five per cent of patients developed rPSC post-transplant. The occurrence of at least one episode of acute cellular rejection (hazard ratio 5.7; 95% CI 1.3 to 25.8) and cytomegalovirus mismatch (hazard ratio 4.2; 95% CI 1.1 to 15.4) were found to be significant predictors of rPSC. Although not statistically significant, there was no rPSC in patients without pre- or post-transplant IBD, and in only one patient with a colectomy. Actuarial patient survival rates at one, five and 10 years post-transplant were 97%, 86% and 79%, respectively. Although a significant proportion of patients experienced worsening IBD post-transplantation, the presence or severity of IBD did not influence rPSC or patient survival.CONCLUSION: Acute cellular rejection and cytomegalovirus mismatch were both identified as independent predictors of rPSC. The impact of steroids and the ideal immunosuppressive regimen for the control of both IBD and PSC post-transplant requires further examination in prospective studies.

scholarly journals The HEART score for early rule out of acute coronary syndromes in the emergency department: a systematic review and meta-analysis

2017 ◽  
Vol 7 (2) ◽  
pp. 111-119 ◽  
Author(s):  
Patricia Van Den Berg ◽  
Richard Body
Keyword(s):  
Systematic Review ◽  
Emergency Department ◽  
Diagnostic Accuracy ◽  
Meta Analysis ◽  
Low Risk ◽  
Major Adverse Cardiac Events ◽  
Current Evidence ◽  
Cardiac Events ◽  
Heart Score ◽  
Adverse Cardiac Events

Aims: The objective of this systematic review was to summarise the current evidence on the diagnostic accuracy of the HEART score for predicting major adverse cardiac events in patients presenting with undifferentiated chest pain to the emergency department. Methods and results: Two investigators independently searched Medline, Embase and Cochrane databases between 2008 and May 2016 identifying eligible studies providing diagnostic accuracy data on the HEART score for predicting major adverse cardiac events as the primary outcome. For the 12 studies meeting inclusion criteria, study characteristics and diagnostic accuracy measures were systematically extracted and study quality assessed using the QUADAS-2 tool. After quality assessment, nine studies including data from 11,217 patients were combined in the meta-analysis applying a generalised linear mixed model approach with random effects assumption (Stata 13.1). In total, 15.4% of patients (range 7.3–29.1%) developed major adverse cardiac events after a mean of 6 weeks’ follow-up. Among patients categorised as ‘low risk’ and suitable for early discharge (HEART score 0–3), the pooled incidence of ‘missed’ major adverse cardiac events was 1.6%. The pooled sensitivity and specificity of the HEART score for predicting major adverse cardiac events were 96.7% (95% confidence interval (CI) 94.0–98.2%) and 47.0% (95% CI 41.0–53.5%), respectively. Conclusions: Patients with a HEART score of 0–3 are at low risk of incident major adverse cardiac events. As 3.3% of patients with major adverse cardiac events are ‘missed’ by the HEART score, clinicians must ask whether this risk is acceptably low for clinical implementation.

scholarly journals Can the HEART Score Safely Reduce Stress Testing and Cardiac Imaging in Patients at Low Risk for Major Adverse Cardiac Events?

2011 ◽  
Vol 10 (3) ◽  
pp. 128-133 ◽  
Author(s):  
Simon A. Mahler ◽  
Brian C. Hiestand ◽  
David C. Goff ◽  
James W. Hoekstra ◽  
Chadwick D. Miller
Keyword(s):  
Cardiac Imaging ◽  
Stress Testing ◽  
Low Risk ◽  
Major Adverse Cardiac Events ◽  
Cardiac Events ◽  
Heart Score ◽  
Adverse Cardiac Events
Sign in / Sign up

Export Citation Format

Share Document