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Predictive Tools for the Presence of Significant Coronary Artery Disease Requiring Intervention in Chronic
Thana Thongsricome1,2, Sarawut Siwamogsatham3, Weerapat Kositanurit1
1Department of Physiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
Insights
Chest pain outside of hemodialysis (HD) sessions and regional wall motion abnormalities (RWMA) on echocardiograms can help identify coronary artery disease (CAD) in HD patients. These findings aid in prioritizing at-risk individuals for specialist evaluation.
Area of Science:
- Nephrology
- Cardiology
- Diagnostic Medicine
Background:
- Hemodialysis (HD) patients exhibit elevated cardiovascular risk.
- Coronary artery disease (CAD) presentation can be atypical in HD patients due to fluid and electrolyte fluctuations.
- Accurate CAD identification in HD patients is challenging but crucial.
Purpose of the Study:
- To evaluate the accuracy of diagnostic findings in identifying significant coronary artery disease (CAD) in hemodialysis (HD) patients.
- To identify specific clinical and echocardiographic factors that discriminate between HD patients with and without significant CAD.
Main Methods:
- Retrospective review of medical records for HD patients undergoing coronary angiography (CAG).
- A discovery cohort (n=108) was used to identify predictive factors for CAD.
- A validation cohort (n=41) was used to confirm the findings.
Main Results:
- Chest pain occurring outside of dialysis sessions was associated with significant CAD (OR 3.281).
- Regional wall motion abnormality (RWMA) on echocardiogram significantly predicted CAD (OR 2.579).
- Specific troponin T levels and percent change showed moderate predictive value, with combined predictors achieving 100% specificity but low sensitivity in validation.
Conclusions:
- Intradialytic symptoms are often non-cardiac; however, chest pain outside dialysis warrants cardiac investigation.
- RWMA and specific cardiac enzyme thresholds can help stratify HD patients for CAD risk.
- These findings can guide timely cardiologist referrals for at-risk HD patients.
Purpose:
Hemodialysis (HD) patients have increased cardiovascular risk. Coronary artery disease (CAD) may not typically manifest in these patients, and the investigational results can be confounded by the fluctuation of body fluid and electrolytes. This study explored the accuracy of these findings in identifying CAD in HD patients.
Methods:
Medical record data of all HD patients undergoing coronary angiography (CAG) at a tertiary hospital between January 2017 and March 2021 were retrospectively reviewed as a discovery cohort to identify factors discriminating patients with and without significant CAG-established CAD. HD patients receiving CAG between April 2021 and March 2023 were assigned as a validation cohort.
Results:
The discovery and validation cohorts included 108 and 41 patients, respectively. Chest pain out of the dialysis session, but not pulmonary congestion/edema nor other intradialytic events, was associated with significant CAD (odds ratio 3.281, 95% CI 1.313-8.200). The presence of regional wall motion abnormality (RWMA) from echocardiogram, but not other echocardiographic and electrocardiographic findings, significantly predicted significant CAD (odds ratio 2.579, 95% CI 1.052-6.324). Initial high-sensitivity troponin T > 111 ng/L and percent of troponin change > 22% had area under the ROC curve of 0.71 (95% CI 0.52-0.89) and 0.67 (95% CI 0.50-0.85), respectively, for predicting CAD. Applying a combination of these predictors resulted in a specificity of 100%, but low sensitivity for CAD in the validation cohort.
Conclusion:
Most intradialytic symptoms possibly result from noncardiac etiologies, while chest pain out of the HD session should alarm the physicians for further management. Applying the suggested cardiac enzyme cut points or the presence of RWMA could prioritize at-risk patients for timed cardiologist referral.
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