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Bautz J, Stypmann J, Reiermann S, Pavenstädt HJ, Suwelack B, Stegger L, Rahbar K, Reuter S, Schäfers M. Prognostic implication of myocardial perfusion and contractile reserve in end-stage renal disease: A direct comparison of myocardial perfusion scintigraphy and dobutamine stress echocardiography. J Nucl Cardiol 2022; 29:2988-2999. [PMID: 34750727 PMCID: PMC9834353 DOI: 10.1007/s12350-021-02844-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 08/25/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND We aimed to compare the prognostic value of myocardial perfusion scintigraphy (MPS) and dobutamine stress echocardiography (DSE) in patients with end-stage renal disease (ESRD) without known coronary artery disease. METHODS Two-hundred twenty-nine ESRD patients who applied for kidney transplantation at our centre were prospectively evaluated by MPS and DSE. The primary endpoint was a composite of myocardial infarction (MI) or all-cause mortality. The secondary endpoint included MI or coronary revascularization (CR) not triggered by MPS or DSE at baseline. RESULTS MPS detected reversible ischemia in 31 patients (13.5%) and fixed perfusion defects in 13 (5.7%) patients. DSE discovered stress-induced wall motion abnormalities (WMAs) in 28 (12.2%) and at rest in 18 (7.9%) patients. MPS and DSE results agreed in 85.6% regarding reversible defects (κ = 0.358; P < .001) and in 90.8% regarding fixed defects (κ = 0.275; P < .001). Coronary angiography detected relevant stenosis > 50% in only 15 of 38 patients (39.5%) with pathological findings in MPS and/or DSE. At a median follow-up of 8 years and 10 months, the primary endpoint occurred in 70 patients (30.6%) and the secondary endpoint in 24 patients (10.5%). The adjusted Cox hazard ratios (HRs) for the primary endpoint were 1.77 (95% CI 1.02-3.08; P = .043) for perfusion defects in MPS and 1.36 (95% CI 0.78-2.37; P = ns) for WMA in DSE. The secondary endpoint was significantly correlated with the findings of both modalities, MPS (HR 3.21; 95% CI 1.35-7.61; P = .008) and DSE (HR 2.67; 95% CI 1.15-6.20; P = .022). CONCLUSION Perfusion defects in MPS are a stronger determinant of all-cause mortality, MI and the need for future CR compared with WMAs in DSE. Given the complementary functional information provided by MPS vs DSE, results are sometimes contradictory, which may indicate differences in the underlying pathophysiology.
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Affiliation(s)
- Joachim Bautz
- Department of Nuclear Medicine, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany
- Department of Internal Medicine D, Nephrology, University Hospital Münster, Münster, Germany
| | - Jörg Stypmann
- Department of Cardiology, University Hospital Münster, Münster, Germany
| | - Stefanie Reiermann
- Department of Internal Medicine D, Nephrology, University Hospital Münster, Münster, Germany
| | | | - Barbara Suwelack
- Department of Internal Medicine D, Nephrology, University Hospital Münster, Münster, Germany
| | - Lars Stegger
- Department of Nuclear Medicine, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany
| | - Kambiz Rahbar
- Department of Nuclear Medicine, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany
| | - Stefan Reuter
- Department of Internal Medicine D, Nephrology, University Hospital Münster, Münster, Germany
| | - Michael Schäfers
- Department of Nuclear Medicine, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany.
- European Institute for Molecular Imaging, University of Münster, Münster, Germany.
- DFG EXC 1003 'Cells in Motion' Cluster of Excellence, University of Münster, Münster, Germany.
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Baman JR, Knapper J, Raval Z, Harinstein ME, Friedewald JJ, Maganti K, Cuttica MJ, Abecassis MI, Ali ZA, Gheorghiade M, Flaherty JD. Preoperative Noncoronary Cardiovascular Assessment and Management of Kidney Transplant Candidates. Clin J Am Soc Nephrol 2019; 14:1670-1676. [PMID: 31554619 PMCID: PMC6832054 DOI: 10.2215/cjn.03640319] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
The pretransplant risk assessment for patients with ESKD who are undergoing evaluation for kidney transplant is complex and multifaceted. When considering cardiovascular disease in particular, many factors should be considered. Given the increasing incidence of kidney transplantation and the growing body of evidence addressing ESKD-specific cardiovascular risk profiles, there is an important need for a consolidated, evidence-based model that considers the unique cardiovascular challenges that these patients face. Cardiovascular physiology is altered in these patients by abrupt shifts in volume status, altered calcium-phosphate metabolism, high-output states (in the setting of arteriovenous fistulization), and adverse geometric and electrical remodeling, to name a few. Here, we present a contemporary review by addressing cardiomyopathy/heart failure, pulmonary hypertension, valvular dysfunction, and arrhythmia/sudden cardiac death within the ESKD population.
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Affiliation(s)
| | | | - Zankhana Raval
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York Presbyterian Hospital, New York, New York; and
| | - Matthew E Harinstein
- Division of Cardiology, Cardiovascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - John J Friedewald
- Division of Nephrology, Department of Medicine.,Division of Transplantation, Department of Surgery, and
| | | | - Michael J Cuttica
- Division of Pulmonary and Critical Care, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Ziad A Ali
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York Presbyterian Hospital, New York, New York; and
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3
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Halawa A. Evaluation of the Cardiovascular Prior to Transplantation; An Endless Debate. ACTA ACUST UNITED AC 2017. [DOI: 10.15406/unoaj.2017.04.00126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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4
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Dundon BK, Pisaniello AD, Nelson AJ, Maia M, Teo KS, Worthley SG, Coates PT, Russ GR, Faull RJ, Bannister K, Worthley MI. Dobutamine Stress Cardiac MRI for Assessment of Coronary Artery Disease Prior to Kidney Transplantation. Am J Kidney Dis 2015; 65:808-9. [DOI: 10.1053/j.ajkd.2015.02.319] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2015] [Accepted: 02/10/2015] [Indexed: 11/11/2022]
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Baker S, Chambers C, McQuillan P, Janicki P, Kadry Z, Bowen D, Bezinover D. Myocardial perfusion imaging is an effective screening test for coronary artery disease in liver transplant candidates. Clin Transplant 2015; 29:319-26. [PMID: 25604507 DOI: 10.1111/ctr.12517] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2015] [Indexed: 12/15/2022]
Abstract
A reliable screening test for coronary artery disease (CAD) in liver transplant (LT) candidates with end-stage liver disease is essential because a high percentage of perioperative mortality and morbidity is CAD-related. In this study, the effectiveness of myocardial perfusion imaging (MPI) for identification of significant CAD in LT candidates was evaluated. Records of 244 patients meeting criteria for MPI were evaluated: 74 met inclusion criteria; 40 had a positive MPI and cardiology follow-up; 27 had a negative MPI and underwent LT; and seven had a negative MPI and then had coronary angiography or a significant cardiac event. A selective MPI interpretation strategy was established where MPI-positive patients were divided into high, intermediate, and low CAD risk groups. The overall incidence of CAD in this study population was 5.1% and our strategy resulted in PPV 20%, NPV 94%, sensitivity 80%, and specificity 50% for categorizing CAD risk. When applied only to the subset of patients categorized as high CAD risk, the strategy was more effective, with PPV 67%, NPV 97%, sensitivity 80%, and specificity 94%. We determined that renal dysfunction was an independent predictive factor for CAD (p < 0.0001, odds ratio = 8.1), and grades of coronary occlusion correlated significantly with chronic renal dysfunction (p = 0.0079).
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Affiliation(s)
- Sally Baker
- Department of Anesthesiology, Pennsylvania State University College of Medicine, Penn State Hershey Medical Center, Hershey, PA, USA
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6
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Abbott KC, Villines TC. Cardiac Stress Testing in Patients with End-Stage Renal Disease. Semin Dial 2014; 27:547-9. [DOI: 10.1111/sdi.12258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Kevin C. Abbott
- Nephrology Service; Walter Reed National Military Medical Center; Bethesda Maryland
| | - Todd C. Villines
- Cardiology Service; Walter Reed National Military Medical Center; Bethesda Maryland
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7
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Fellstrom B, Holdaas H, Jardine A. Functional cardiopulmonary exercise testing in potential renal transplant recipients. J Am Soc Nephrol 2013; 25:8-9. [PMID: 24231661 DOI: 10.1681/asn.2013090996] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- Bengt Fellstrom
- Division of Renal Medicine, Department of Medical Sciences, University of Uppsala, Uppsala, Sweden
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Chen MY, Bandettini WP, Shanbhag SM, Vasu S, Booker OJ, Leung SW, Wilson JR, Kellman P, Hsu LY, Lederman RJ, Arai AE. Concordance and diagnostic accuracy of vasodilator stress cardiac MRI and 320-detector row coronary CTA. Int J Cardiovasc Imaging 2013; 30:109-19. [PMID: 24122452 PMCID: PMC3905179 DOI: 10.1007/s10554-013-0300-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2013] [Accepted: 09/22/2013] [Indexed: 12/16/2022]
Abstract
Vasodilator stress cardiac magnetic resonance (CMR) detects ischemia whereas coronary CT angiography (CTA) detects atherosclerosis. The purpose of this study was to determine concordance and accuracy of vasodilator stress CMR and coronary CTA in the same subjects. We studied 151 consecutive subjects referred to detect or exclude suspected obstructive coronary artery disease (CAD) in patients without known disease or recurrent stenosis or ischemia in patients with previously treated CAD. Vasodilator stress CMR was performed on a 1.5 T scanner. CTA was performed on a 320-detector row system. Subjects were followed for cardiovascular events and downstream diagnostic testing. Subjects averaged 56 ± 12 years (60% male), and 62 % had intermediate pre-test probability for obstructive CAD. Follow-up averaged 450 ± 115 days and was 100% complete. CMR and CTA agreed in 92% of cases (κ 0.81, p < 0.001). The event-free survival was 97 % for non-ischemic and 39% for ischemic CMR (p < 0.0001). The event-free survival was 99% for non-obstructive and 36% for obstructive CTA (p < 0.0001). Using a reference standard including quantitative invasive angiography or major cardiovascular events, CMR and CTA had respective sensitivities of 93 and 98 %; specificities of 96 and 96%; positive predictive values of 91 and 91%; negative predictive values of 97 and 99%; and accuracies of 95 and 97%. Non-ischemic vasodilator stress CMR or non-obstructive coronary CTA were highly concordant and each confer an excellent prognosis. CMR and CTA are both accurate for assessment of obstructive CAD in a predominantly intermediate risk population.
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Affiliation(s)
- Marcus Y. Chen
- Advanced Cardiovascular Imaging Laboratory, Division of Intramural Research, Department of Health and Human Services, Cardiovascular and Pulmonary Branch, National Heart Lung and Blood Institute, National Institutes of Health, 10 Center Drive, Building 10, Room B1D416, Bethesda, MD 20892-1061 USA
| | - W. Patricia Bandettini
- Advanced Cardiovascular Imaging Laboratory, Division of Intramural Research, Department of Health and Human Services, Cardiovascular and Pulmonary Branch, National Heart Lung and Blood Institute, National Institutes of Health, 10 Center Drive, Building 10, Room B1D416, Bethesda, MD 20892-1061 USA
| | - Sujata M. Shanbhag
- Advanced Cardiovascular Imaging Laboratory, Division of Intramural Research, Department of Health and Human Services, Cardiovascular and Pulmonary Branch, National Heart Lung and Blood Institute, National Institutes of Health, 10 Center Drive, Building 10, Room B1D416, Bethesda, MD 20892-1061 USA
| | - Sujethra Vasu
- Advanced Cardiovascular Imaging Laboratory, Division of Intramural Research, Department of Health and Human Services, Cardiovascular and Pulmonary Branch, National Heart Lung and Blood Institute, National Institutes of Health, 10 Center Drive, Building 10, Room B1D416, Bethesda, MD 20892-1061 USA
| | - Oscar J. Booker
- Advanced Cardiovascular Imaging Laboratory, Division of Intramural Research, Department of Health and Human Services, Cardiovascular and Pulmonary Branch, National Heart Lung and Blood Institute, National Institutes of Health, 10 Center Drive, Building 10, Room B1D416, Bethesda, MD 20892-1061 USA
| | - Steve W. Leung
- Advanced Cardiovascular Imaging Laboratory, Division of Intramural Research, Department of Health and Human Services, Cardiovascular and Pulmonary Branch, National Heart Lung and Blood Institute, National Institutes of Health, 10 Center Drive, Building 10, Room B1D416, Bethesda, MD 20892-1061 USA
| | - Joel R. Wilson
- Advanced Cardiovascular Imaging Laboratory, Division of Intramural Research, Department of Health and Human Services, Cardiovascular and Pulmonary Branch, National Heart Lung and Blood Institute, National Institutes of Health, 10 Center Drive, Building 10, Room B1D416, Bethesda, MD 20892-1061 USA
| | - Peter Kellman
- Advanced Cardiovascular Imaging Laboratory, Division of Intramural Research, Department of Health and Human Services, Cardiovascular and Pulmonary Branch, National Heart Lung and Blood Institute, National Institutes of Health, 10 Center Drive, Building 10, Room B1D416, Bethesda, MD 20892-1061 USA
| | - Li-Yueh Hsu
- Advanced Cardiovascular Imaging Laboratory, Division of Intramural Research, Department of Health and Human Services, Cardiovascular and Pulmonary Branch, National Heart Lung and Blood Institute, National Institutes of Health, 10 Center Drive, Building 10, Room B1D416, Bethesda, MD 20892-1061 USA
| | - Robert J. Lederman
- Advanced Cardiovascular Imaging Laboratory, Division of Intramural Research, Department of Health and Human Services, Cardiovascular and Pulmonary Branch, National Heart Lung and Blood Institute, National Institutes of Health, 10 Center Drive, Building 10, Room B1D416, Bethesda, MD 20892-1061 USA
| | - Andrew E. Arai
- Advanced Cardiovascular Imaging Laboratory, Division of Intramural Research, Department of Health and Human Services, Cardiovascular and Pulmonary Branch, National Heart Lung and Blood Institute, National Institutes of Health, 10 Center Drive, Building 10, Room B1D416, Bethesda, MD 20892-1061 USA
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Malhotra S, Sharma R, Kliner DE, Follansbee WP, Soman P. Relationship between silent myocardial ischemia and coronary artery disease risk factors. J Nucl Cardiol 2013; 20:731-8. [PMID: 23719838 DOI: 10.1007/s12350-013-9708-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2012] [Accepted: 03/18/2013] [Indexed: 12/16/2022]
Abstract
BACKGROUND The association between silent myocardial ischemia (SMI) and coronary artery disease (CAD) risk factors in asymptomatic patients with no prior history of CAD referred for stress myocardial perfusion imaging (MPI) is unknown. METHODS We retrospectively evaluated patients who underwent MPI over a 3.4-year period to identify those who did not have chest pain, dyspnea, or known CAD. The presence of risk factors was categorized as none, 1-2, 3-4, and ≥5. MPI was performed using a rest thallium-201/stress Tc-99m sestamibi protocol, and read using a standard five-point perfusion score (0 = normal to 4 = absent) and a 17-segment left ventricular model. Summed stress score and summed rest score were derived as the sum of individual segmental scores at stress and rest, respectively. SMI was diagnosed if the summed differences score (SDS) was ≥2. Prognostically significant ischemia was defined by a SDS ≥ 8. RESULTS Among 1,354 asymptomatic patients, SMI was present in 97 (7.2%) and prognostically significant in 60 (4.4%). The prevalence, but not severity, of SMI increased with increasing CAD risk factors--0 for none, 4.1% for 1-2, 8.8% for 3-4, and 12% for those with ≥5 CAD risk factors (P value for trend = .001), in patients <74 years of age. Of the 59 (4.4%) patients who underwent coronary angiography, only 31 (2%) had significant anatomical CAD. CONCLUSIONS The prevalence of SMI and prognostically significant ischemia is low in asymptomatic patients without known CAD, and is related to the number of CAD risk factors in patients younger than 74 years of age.
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Affiliation(s)
- Saurabh Malhotra
- Division of Cardiology, Heart and Vascular Institute, University of Pittsburgh Medical Center, A-429 Scaife Hall, 200 Lothrop Street, Pittsburgh, PA, 15213, USA,
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Patients with end-stage renal disease: optimal diagnostic and prognostic performance of myocardial gated-SPECT, initial results. Nucl Med Commun 2013; 34:314-21. [PMID: 23407369 DOI: 10.1097/mnm.0b013e32835ec88a] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE We investigated the role of Tc-99m sestamibi myocardial perfusion gated single photon emission computed tomography (GSPECT) in identifying those patients with end-stage renal disease (ESRD) in whom optimal diagnosis of coronary artery disease and prediction of cardiac events (CEs) could be achieved. METHODS This was a prospective study that included 41 asymptomatic ESRD patients who had been undergoing hemodialysis for 12 months or less (22 men and 19 women) with restricted selection criteria (asymptomatic traditional risk). Tc-99m sestamibi GSPECT was carried out for all patients, whereas coronary angiography (Cath) was carried out only for abnormal GSPECT patients, with a 2-year follow-up for CEs. Twenty individuals matched for age, sex, and BMI formed the control group. RESULTS Of the 41 ESRD patients, 13 showed abnormal GSPECT [11/13 with myocardial perfusion defects and left ventricular dysfunction in concordance with Cath and 2/13 with only left ventricular dysfunction (i.e. stunning)] compared with 1/20 in the control group. None of the patients with negative results experienced CEs (negative predictive value 100%); these patients had a 2-year CE-free survival rate of 100% compared with 46% for patients with positive results on GSPECT (P<0.0001; seven GSPECT-positive patients developed CEs during their follow-up). Patients with positive results were more frequently male (P<0.001), were significantly older (P=0.01), and had highly sensitive C-reactive protein levels (P=0.002). Abnormal GSPECT was the only independent predictor of CEs (95% confidence interval, 7.1-46.7; hazard ratio, 46.1; P<0.001). CONCLUSION GSPECT exhibited optimum performance for coronary artery disease detection and risk stratification in asymptomatic ESRD patients during their first year of regular hemodialysis who were selected according to our modification of the traditional risk category. This may help in selecting suitable candidates for Cath, revascularization, and future renal transplantation.
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De Vriese AS, Vandecasteele SJ, Van den Bergh B, De Geeter FW. Should we screen for coronary artery disease in asymptomatic chronic dialysis patients? Kidney Int 2011; 81:143-51. [PMID: 21956188 DOI: 10.1038/ki.2011.340] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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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Affiliation(s)
- An S De Vriese
- Renal Unit, Department of Internal Medicine, AZ Sint-Jan Brugge-Oostende AV, Brugge, Belgium.
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Hakeem A, Bhatti S, Trevino AR, Samad Z, Chang SM. Non-invasive risk assessment in patients with chronic kidney disease. J Nucl Cardiol 2011; 18:472-85. [PMID: 21394553 DOI: 10.1007/s12350-011-9359-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Abdul Hakeem
- Division of Cardiovascular Diseases, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Cai Q, Serrano R, Kalyanasundaram A, Shirani J. A preoperative echocardiographic predictive model for assessment of cardiovascular outcome after renal transplantation. J Am Soc Echocardiogr 2010; 23:560-6. [PMID: 20381999 DOI: 10.1016/j.echo.2010.03.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2009] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Major adverse cardiac events (MACE) frequently determine the outcome of renal transplantation (RT). Stress testing is advocated for preoperative risk assessment, but limited information is available on the prognostic value of these tests. We aimed to retrospectively assess the value of preoperative dobutamine stress echocardiography (DSE) in predicting MACE in patients undergoing RT. METHODS A total of 185 patients (age 56 +/- 11 years, 64% were men, creatinine level of 7.3 +/- 2.9 mg/d, 27% were smokers, 86% had hypertension, 54% had diabetes, 57% were dyslipidemic) with end-stage renal disease (ESRD) underwent DSE before RT. A standard DSE protocol was used with the administration of 5-50 mug/kg/min incremental doses in 3-minute intervals and up to 1 mg of atropine if needed to reach prespecified end points. RESULTS Regional left ventricular wall motion abnormality (WMA) at rest (fixed), with stress (inducible), or both were present in 54, 35, and 18 patients, respectively. In 38 patients who underwent coronary angiography, the sensitivity, specificity, and positive and negative predictive values of inducible WMA for predicting angiographic coronary artery disease (> or = 70% luminal diameter reduction) were 88%, 62%, 65%, and 87%, respectively. Cox regression analysis identified the presence of combined fixed and inducible WMA (ie, resting WMA that did not change during DSE, accompanied by new WMA evident during DSE; hazard ratio [HR] 5.6, P = .012), left atrial enlargement (HR 4.2, P = .002), and aortic valve sclerosis (HR 3.9, P = .013) as independent predictors of 48-month MACE (cardiac death, nonfatal acute myocardial infarction, and coronary revascularization after RT). Patients with all 3 predictors had a 48-month MACE of 60% compared with 5% in those with none (P = .007). Compared with those without WMA, patients with both fixed and inducible WMA had a higher rate of MACE at 48 months (7% vs 33%, P = .004). CONCLUSION In RT candidates, DSE can effectively identify those at low and high risk of MACE.
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Affiliation(s)
- Qiangjun Cai
- Department of Internal Medicine, Geisinger Medical Center, Danville, Pennsylvania 17822, USA
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