Journal of Nuclear Cardiology | Official Journal of the American Society of Nuclear Cardiology Validation of a Clinical Pathway to Assess Asymptomatic Renal Transplant Candidates Using Myocardial Perfusion Imaging Rami Doukky, MD, MSc, FASNC Ibtihaj Fughhi, MD, MSc Tania Campagnoli, MD, MSc Marwan Wassouf, MD Michael Kharouta, BS, MS Aviral Vij, MD Chiedozie Anokwute, MD Andrew Appis, MD Amjad Ali, MD Copyright American Society of Nuclear Cardiology

Journal of Nuclear Cardiology | Official Journal of the American Society of Nuclear Cardiology BACKGROUND AHA/ACCF statement proposed 8 risk factors to assess the need for noninvasive CAD surveillance in asymptomatic patients undergoing kidney transplant evaluation: These risk factors have not been clinically validated The role of MPI in this context has not been defined Age >60 y DM Dyslipidemia Dialysis >1 y HTN History of CVD Smoking LVH Copyright American Society of Nuclear Cardiology

METHODS Study type: Retrospective cohort study Journal of Nuclear Cardiology | Official Journal of the American Society of Nuclear Cardiology METHODS Study type: Retrospective cohort study Population: Consecutive 581 kidney transplant recipients 401 had pre-transplant SPECT-MPI 90 had pre-transplant coronary angiography The sum of AHA/ACCF risk factors was calculated Study endpoints: Primary end point: obstructive CAD (≥ 70% or left main ≥ 50%) Secondary end points: 1) 30-day post-operative MACE (cardiac death or MI); 2) long-term MACE Copyright American Society of Nuclear Cardiology

Journal of Nuclear Cardiology | Official Journal of the American Society of Nuclear Cardiology RESULTS Discriminatory Capacity of the Sum of AHA/ACCF Risk Factors in Kidney Transplant Recipients ≥ 3 AHA/ACCF risk factors was an optimal threshold to predict study end points Copyright American Society of Nuclear Cardiology

Journal of Nuclear Cardiology | Official Journal of the American Society of Nuclear Cardiology RESULTS Long-Term MACE Rates after Kidney Transplant Based on Clinical Risk and MPI Findings MPI is most predictive of MACE in patients with 3 or 4 AHA/ACCF risk factors, following a Bayesian Model. Copyright American Society of Nuclear Cardiology

Journal of Nuclear Cardiology | Official Journal of the American Society of Nuclear Cardiology RESULTS Impact of MPI Finding on Long-Term MACE-Free Survival after Kidney Transplant Based on Pre-Transplant AHA/ACCF Risk Factors Abnormal MPI Ischemia Copyright American Society of Nuclear Cardiology

Journal of Nuclear Cardiology | Official Journal of the American Society of Nuclear Cardiology CONCLUSIONS In asymptomatic kidney transplant candidates, the sum of the AHA/ACCF risk factors provides diagnostic and prognostic value Having ≥3 risk factors defines patient with higher likelihood of obstructive CAD and at increased post-operative and long-term MACE risk SPECT-MPI provides significant incremental diagnostic and long-term prognostic value to AHA/ACCF risk factors. Patients with 3-4 AHA/ACCF risk factors (intermediate risk), receive the greatest long-term prognostic value from MPI Copyright American Society of Nuclear Cardiology