DOBUTAMINE STRESS-INDUCED ANGINA IN PATIENTS WITH DENERVATED CARDIAC TRANSPLANTS - CLINICAL AND ANGIOGRAPHIC CORRELATES

Background: The clinical consequences of cardiac denervation include t he inability of the heart transplant recipient to sense cardiac pain, This is due mainly to interruption of ventricular sympathetic afferent s normally responsible for transmission of cardiac pain. Although angi na has been reported in transplant recipients, to our knowledge, its t emporal relationship to myocardial ischemia has not been previously de monstrated. Objective and methods: Eighty-two patients with heart tran splants were serially evaluated by dobutamine stress echocardiography (DSE), In patients who developed angina during DSE, we sought to deter mine if the onset of angina was related to myocardial ischemia as demo nstrated by stress-induced wall motion abnormalities, Coronary angiogr aphy was performed within 48 h of DSE in 45 of 82 patients. Results: M ean patient age and time since transplant were 53.1+/-1.1 years and 57 .7+/-30.4 months, respectively(mean SEM), Eleven patients developed ty pical angina during DSE, Three of the 11 (27%) had diagnostic ECG chan ges, All 11 had stress-induced regional wall motion abnormalities (WMA ), Nine of the 11 patients (82%) had coronary angiographic data availa ble that demonstrated significant coronary artery disease (CAD) in 8 ( 89%), All coronary lesions matched the observed segmental WMA. There w as no difference between the angina (n=11) and no angina (n=71) groups with respect to peak heart rate (HR) (141+/-7 vs 145+/-3 beats/min; p =NS), peak systolic blood pressure (SBP) (155+/-8 vs 149+/-3 mm Hg; p= NS), of rate pressure product (21,699+/-1,490 vs 21,646+/-621 mm Hgxbe ats/min; p=NS), However, the mean time since transplant was significan tly higher in patients with DSE-induced angina (80.3+/-6.2 vs 57.3+/-3 .5 months; p<0.05). Conclusions: These data suggest that (1) the occur rence of angina in long-term transplant recipients with CAD is directl y related to myocardial ischemia despite anatomic ventricular denervat ion, and (2) sympathetic reinnervation in the long-term may account fo r the occurrence of angina in cardiac transplant recipients.