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[Hypertension after heart transplantation]
1I. interní-kardioangiologická klinika FN U sv. Anny, Brno.
Insights
Hypertension is a common complication after heart transplants, affecting 70-90% of patients on cyclosporine and prednisone. Management involves minimizing immunosuppressants and using calcium antagonists, ACE inhibitors, and diuretics.
Area of Science:
- Cardiology
- Immunology
- Nephrology
Context:
- Heart transplantation is a critical treatment for end-stage heart failure.
- Hypertension is a frequent long-term complication in heart transplant recipients.
- The incidence of hypertension ranges from 70-90% in patients treated with cyclosporine and prednisone.
Purpose:
- To explore the mechanisms of hypertension following heart transplantation.
- To identify contributing factors beyond classical pathways.
- To outline treatment strategies for managing post-transplant hypertension.
Summary:
- Hypertension development involves classical mechanisms (renin-angiotensin system, fluid volume, peripheral resistance) and non-classical factors like cardiac denervation, immunosuppression (cyclosporine, corticoids), and nephropathy.
- Cyclosporine-induced hypertension mechanisms include enhanced endothelin-1 effects, reduced nitric oxide (NO) production, increased calcium levels, and sympathicus activation.
- Absence of nocturnal blood pressure and pulse rate drop is noted.
Impact:
- Highlights the multifactorial etiology of hypertension post-heart transplant.
- Emphasizes the need for careful immunosuppression management, aiming for minimal effective cyclosporine levels and steroid discontinuation.
- Recommends calcium antagonists as first-line treatment due to their graft vasculopathy preventive effects, alongside ACE inhibitors and diuretics.
Abstract:
Transplantations of the heart are in recent years the therapeutic method in severe cardiac failure. One of the complications in the long-term follow-up of patients is the development of hypertension. The incidence of hypertension in patients treated with cyclosporin and prednisone is 70-90%. In the development of hypertension participates in addition to classical mechanisms (renin angiotensin system, fluid volume and peripheral resistance) also the negative effect of cardiac denervation, cyclosporin immunosuppression, corticoids and nephropathy. The nocturnal drop of pressure and pulse rate is lacking. Mechanisms of cyclosporin induced hypertension:enhancement of the vasoconstricting effect of endothelin 1, reduced NO production, activation of neurohumoral vasoconstrictors, increased calcium level in cytosols, increased thromboxane A production, reduced production of vasodilatating prostaglandins and activation of the sympathicus. The prerequisite of treatment are efforts to maintain the lowest possible effective cyclosporin level and if possible discontinue corticoids during the first year. The drug of first choice are calcium antagonists among others for their preventive effect on the vasculopathy of the graft. Other recommended groups of drugs are ACE inhibitors and diuretics.