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Cholesterol-lowering intervention and coronary artery disease after cardiac transplantation
M Carrier1, G B Pelletier, J Genest
1Department of Surgery, Montreal Heart Institute, Quebec, Canada.
Insights
Lipid-lowering therapy after cardiac transplantation did not reduce allograft coronary artery disease. Lowering low-density lipoprotein (LDL) cholesterol to below 3 mmol/L may improve event-free survival, suggesting more aggressive LDL reduction is needed.
Area of Science:
- Cardiology
- Transplantation Medicine
- Lipid Metabolism
Background:
- Allograft coronary artery disease (ACAD) significantly impacts long-term survival post-cardiac transplant.
- Hyperlipidemia is a suspected major contributor to the development of ACAD.
Purpose of the Study:
- To assess the efficacy of a lipid-lowering intervention (diet and HMG-CoA reductase inhibitors) in preventing ACAD after cardiac transplantation.
- To compare outcomes in treated patients versus historical untreated controls.
Main Methods:
- A cohort of 46 cardiac transplant recipients (1988-1991) received American Heart Association phase 1 diet and statin therapy if LDL cholesterol > 3.4 mmol/L.
- Compared with 35 untreated patients (1983-1988).
- Annual coronary angiograms and lipid profiles were analyzed.
Main Results:
- The treated group exhibited significantly lower cholesterol, triglyceride, and LDL levels.
- Actuarial survival and event-free survival (EFS) rates were comparable between groups.
- Achieving LDL levels < 3 mmol/L was associated with improved EFS.
Conclusions:
- Current lipid-lowering interventions were insufficient to decrease ACAD prevalence.
- More aggressive strategies to reduce LDL cholesterol are likely required to impact ACAD.
- Further clinical trials are warranted to investigate intensified lipid-lowering protocols.
Abstract:
Allograft coronary artery disease is a major threat to long-term survival after cardiac transplantation. It has been suggested that hyperlipidemia plays a major role in allograft coronary disease. The objective of the present study was to evaluate the effect of a lipid-lowering intervention with diet and drug therapy after cardiac transplantation. Forty-six patients who underwent transplantation between 1988 and 1991 and who were treated with the American Heart Association phase 1 diet and an HMG coenzyme A reductase inhibitor (lovastatin or simvastatin) when low-density lipoprotein cholesterol levels were higher than 3.4 mmol/L were compared with 35 untreated patients having transplantation between 1983 and 1988. Annual coronary angiograms were obtained in both groups. Cholesterol, triglyceride, and low-density lipoprotein levels were significantly lower in the treated group. Actuarial survival and event-free survival (survival free from allograft coronary artery disease) were similar in both groups. Low-density lipoprotein levels lower than 3 mmol/L at the last follow-up had a positive effect on event-free survival. The cholesterol-lowering intervention was not effective in decreasing the prevalence of allograft coronary artery disease. This study suggests that more aggressive measures to lower low-density lipoprotein levels may be necessary to significantly affect allograft disease. Clinical trials should be developed to address this hypothesis.