May experience spontaneous remission.

CAD IN CARDIAC TRANSPLANT RECIPIENTS

Orthotopic transplanted hearts develop an accelerated form

of coronary vasculopathy, usually detected by serial coronary

angiography or intravascular ultrasound studies, that is a

leading cause of death after the first post-transplant year

(25,26). The coronary disease is different from that seen in

non-transplanted hearts with coronary atherosclerosis; the

disease is diffuse and characterized by pronounced intimal

thickening and involvement of the entire coronary tree.

Discrete stenoses of epicardial arteries can coexist in some

instances. Cardiac allografts are denervated, and although

some recipients may develop a degree of sympathetic reinnervation,

acute coronary syndromes may present with

atypical symptoms as opposed to angina (27). Noninvasive

testing for CAD is less sensitive in the transplant recipient;

many patients do not achieve VO2max, and cardiac denervation

can limit peak heart rate response and symptoms.

Provocative myocardial perfusion imaging can fail to detect

ischemia (25,27) although dobutamine echocardiography

has been shown to predict subsequent ischemic cardiac

events (26,28–31) after the first three to five years posttransplant.

In many cardiac transplant centers, a normal

stress echocardiogram justifies postponement of annual

coronary angiography (26,28–31). Coronary angiography

can also underestimate disease severity because of the diffuse

nature of the CAD process; intravascular ultrasound studies

increase the sensitivity (26).

Evaluation.

1. Cardiac transplant recipients participating in competitive

athletics should undergo yearly maximal exercise

testing with echocardiography using a protocol designed

to simulate the cardiac and metabolic demands of the

competitive event and its training.

2. Additional evaluation, including such procedures as

coronary angiography and intravascular ultrasonography

(IVUS) should be performed as directed by the transplant

center and the transplant cardiologist. Coronary

angiography/IVUS should also be performed if the

annual exercise test is abnormal and to evaluate unexplained

symptoms such as dyspnea or exertional fatigue

as these may be the only symptoms of progressive

vascular disease.

1351 JACC Vol. 45, No. 8, 2005 Thompson et al.

April 19, 2005:1348–53 Task Force 6: Coronary Artery Disease

Recommendations:

Because of the special issues involved with transplant

Patient management, decisions as to the feasibility of

Athletic competition for cardiac transplant recipients

should be made in conjunction with the patient’s

Transplant cardiologist.

Athletes with no coronary luminal narrowing, no

Exercise-induced ischemia, and with normal exercise

Tolerance for age (as previously defined ) can generally

Participate in all competitive sports as appropriate

For their exercise capacity.

Athletes with coronary luminal narrowing should be

Risk stratified as outlined in the section entitled

Date: 2016-03-03; view: 813