Coronary Angiography Is the Best Predictor of Events in Renal Transplant Candidates Compared With Noninvasive Testing

Abstract

Abstract-Guidelines for the detection of coronary artery disease (CAD) and assess of risk in renal transplant candidates are based on the results of noninvasive testing, according to data originated in the nonuremic population. We evaluated prospectively the accuracy of 2 noninvasive tests and risk stratification in detecting CAD (Ն70% obstruction) and assessing cardiac risk by using coronary angiography (CA). One hundred twenty-six renal transplant candidates who were classified as at moderate (Ն50 years) or high (diabetes, extracardiac atherosclerosis, or clinical coronary artery disease) coronary risk underwent myocardial scintigraphy (SPECT), dobutamine stress echocardiography, and CA and were followed for 6 to 48 months. The prevalence of CAD was 42%. The sensitivities and negative predictive values for the 2 noninvasive tests and risk stratification were Ͻ75%. After 6 to 48 months, there were 18 cardiac events, 9 fatal. Risk stratification (Pϭ0.007) and CA (Pϭ0.0002) predicted the crude probability of surviving free of cardiac events. The probability of event-free survival at 6, 12, 24, 36, and 48 months were 98%, 98%, 94%, 94%, and 94% in patients with Ͻ70% stenosis on CA and 97%, 87%, 61%, 56%, and 54% in patients with Ն70% stenosis. Multivariate analysis showed that the sole predictor of cardiac events was critical coronary lesions (Pϭ0.003). Coronary angiography may still be necessary for detecting CAD and determining cardiac risk in renal transplant candidates. The data suggest that current algorithms based on noninvasive testing in this population should be revised.

Avaliação cardiológica de pacientes portadores de doença renal crônica: quais as lições?

“…16 The high LVH rate we found confirmed the data reported by Kundhal et al, 18 who observed LVH in 74% of the dialysis population. There are several factors implicated in the development of LVH in the CKD population, such as arterial thickening (due to alterations of the calcium, phosphorus, PTH and vitamin D metabolism) and systolic hypertension (due to a chronic state of hypervolemia and anemia-related increased after-load).…”

“…These peculiarities, among others, make the cardiovascular assessment of CKD patients a particularly difficult task. In spite of the high rate of electrocardiographic abnormalities found, which is in agreement with the literature data, 16 there was no significant difference between Groups A and B. This decreases the importance of electrocardiography for the cardiac assessment of CKD patients.…”

Escore de cálcio coronariano prediz estenose e eventos na insuficiência renal crônica pré-transplante

“…Screening was done by the CRF specialized outpatient unit at the Hypertension Service, Heart Institute, University of São Paulo at São Paulo. In that service, the management of high risk patients or patients with suspicion of CAD includes ICA for its better prognostic performance 7 . Nonionic iodinated contrast was performed after the exclusion of contra-indication to the study and after the informed consent was signed.…”

“…Therefore, they must be submitted to invasive diagnostic procedure 6 . As for CAD evaluation strategies for those patients and their association to prognosis, De Lima et al 7 have published conclusive data showing that invasive coronary angiography (ICA) proved to be of higher prognostic value for CAD evaluation when compared to non-invasive tests (nuclear medicine and stress ECG) 7 . That paved the way for the investigation of new noninvasive diagnostic methods not yet under use for this group of CRF patients and which had been showing good performance in CAD patients in the general population.…”

“…While ICA has proven to be a very effective prognostic exam 7 , the new MDCT techniques have not been extensively tested in pretransplant CRF patients. Therefore, our assumption was that MDCT may be useful for the diagnosis of significant CAD as well as for prognostic estimate in CRF patients who are candidates for renal transplant.…”