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Noninvasive cardiac testing in the end-stage renal disease patient
R A Wilson1, D J Norman, J M Barry
1Division of Cardiology, Oregon Health Sciences University, Portland 97203.
Insights
Renal transplant candidates face high cardiac death risk. Clinical risk factors can screen about half of candidates, potentially avoiding costly invasive tests like coronary angiography.
Area of Science:
- Nephrology
- Cardiology
- Transplantation Medicine
Background:
- Renal transplant candidates have a 5-10% annual risk of cardiac death.
- Coronary angiography is a common but invasive and costly method for cardiac risk assessment.
- Angiography poses risks to renal function and cardiac health.
Purpose of the Study:
- To evaluate cost-effective screening strategies for cardiac risk in renal transplant candidates.
- To determine if clinical risk factors can reduce the need for invasive cardiac testing.
- To explore the role of noninvasive testing in high-risk patients.
Main Methods:
- Review of current cardiac risk assessment strategies for renal transplant candidates.
- Analysis of the utility of clinical risk factors for initial screening.
- Evaluation of noninvasive testing modalities like exercise or dipyridamole thallium-201 stress testing.
- Consideration of revascularization strategies for diabetic patients with coronary artery disease.
Main Results:
- Clinical risk factor screening may obviate further testing in approximately 50% of candidates.
- Noninvasive stress testing is a potentially more cost-effective option than coronary angiography for high-risk patients.
- Revascularization may modify cardiac risk in diabetic renal transplant candidates with significant coronary artery disease.
Conclusions:
- Clinical risk factor assessment is a crucial first step in managing cardiac risk in renal transplant candidates.
- Noninvasive testing offers a viable alternative to coronary angiography for selected high-risk individuals.
- Further research is needed on revascularization efficacy in non-diabetic renal transplant candidates.
Abstract:
Renal transplant candidates are at increased risk for future cardiac death--approximately 5-10% per year. Invasive testing by coronary angiography has been used to assess the cardiac risk. However this is expensive and carries its own risks to residual renal function as well as cardiac morbidity and mortality. Screening of patients by clinical risk factors may obviate the need for invasive or noninvasive testing in a significant number (approximately 50%) of the renal transplant candidates. Further noninvasive testing with exercise or dipyridamole thallium-201 stress testing in the high-risk patients may be a more cost-effective screening test than coronary angiography. Other noninvasive testing modalities may also prove useful in the future but have not yet been proven in this unique patient population. The characterization of a renal transplant candidate's cardiac risk may assist the clinicians in prioritizing the candidate for transplantation. Recent evidence also suggests that revascularization of the diabetic renal transplant candidate with significant coronary artery disease (which is approachable by angioplasty or bypass surgery) may modify their cardiac risk. Randomized studies of the efficacy of revascularization or medical therapy interventions in the nondiabetic renal transplant candidate with coronary artery disease have not been performed.