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Updated: May 29, 2026
Assessment of Vascular Function in Patients With Chronic Kidney Disease
Published on: June 16, 2014
Should we screen for coronary artery disease in asymptomatic chronic dialysis patients?
An S De Vriese1, Stefaan J Vandecasteele, Barbara Van den Bergh
1Renal Unit, Department of Internal Medicine, AZ Sint-Jan Brugge-Oostende AV, Brugge, Belgium. an.devriese@azsintjan.be
Insights
Asymptomatic coronary artery disease (CAD) in hemodialysis patients requires different interpretation. Dipyridamole myocardial perfusion scintigraphy (MPS) can help identify significant blockages, guiding revascularization decisions.
Area of Science:
- Cardiology
- Nephrology
- Nuclear Medicine
Background:
- The hemodialysis population exhibits a high prevalence of asymptomatic coronary artery disease (CAD), distinct from the general population due to factors like impaired exercise tolerance and autonomic neuropathy.
- Silent ischemia in these patients can lead to severe cardiac events, including heart failure, arrhythmias, and sudden death.
- The clinical significance of revascularization in asymptomatic dialysis patients remains debated, despite some evidence suggesting potential benefits.
Purpose of the Study:
- To evaluate the utility of noninvasive screening tests for CAD in asymptomatic hemodialysis patients.
- To assess the role of dipyridamole myocardial perfusion scintigraphy (MPS) in identifying hemodynamically significant coronary stenosis.
- To determine the optimal diagnostic pathway for guiding revascularization decisions in this high-risk population.
Main Methods:
- Review of available noninvasive screening tests for CAD in hemodialysis patients.
- Analysis of dipyridamole-MPS performance compared to coronary angiography, considering potential limitations in vasodilation.
- Evaluation of the prognostic value of dipyridamole-MPS in predicting adverse cardiac events.
Main Results:
- Noninvasive tests for CAD lack the established practicality and reliability in dialysis patients compared to the general population.
- Dipyridamole-MPS can detect both ischemia and myocardial scarring, with studies showing prognostic value over clinical data and even coronary angiography.
- Observed lower sensitivities of dipyridamole-MPS compared to coronary angiography may be due to factors beyond impaired vasodilation, such as anatomical stenosis not always causing flow impairment.
Conclusions:
- Asymptomatic dialysis patients may benefit from screening with dipyridamole-MPS.
- An abnormal dipyridamole-MPS result warrants further investigation with coronary angiography.
- A combined physiological (MPS) and anatomical (angiography) assessment is recommended to identify clinically relevant coronary stenoses for revascularization.
Abstract:
The hemodialysis population is characterized by a high prevalence of 'asymptomatic' coronary artery disease (CAD), which should be interpreted differently from asymptomatic disease in the general population. A hemodynamically significant stenosis may not become clinically apparent owing to impaired exercise tolerance and autonomic neuropathy. The continuous presence of silent ischemia may cause heart failure, arrhythmias, and sudden death. Whether revascularization of an asymptomatic dialysis patient improves outcome remains a moot point, although several observational studies and one small RCT suggest a benefit. It can therefore be defended to screen asymptomatic dialysis patients for CAD. A number of noninvasive screening tests are available, but none has proved equally practical and reliable in the dialysis population as in the general population. Myocardial perfusion scintigraphy (MPS) before and after a pharmacological stress such as dipyridamole can reveal both ischemia and myocardial scarring. When compared with coronary angiography, low sensitivities were reported and attributed to impaired vasodilation to dipyridamole in dialysis patients. A more likely explanation is that not every anatomical stenosis will lead to impaired coronary blood flow on MPS. Numerous studies have shown an incremental prognostic value of dipyridamole-MPS over clinical data for prediction of adverse cardiac events, in some studies even over coronary angiography. Pending the availability of high-quality evidence, in our opinion asymptomatic dialysis patients could undergo dipyridamole-MPS, followed by coronary angiography in case of an abnormal scan. This combined physiological and anatomical evaluation of the coronary circulation allows us to determine which coronary stenosis is clinically relevant and therefore should be revascularized.
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