1. Dr Cristina Constantin Consultant Cardiologist Princess of Wales Hospital

2.  Not written for end-stage organ failure pt  Kidney transplantation is considered intermediate-risk surgery  Traditional guidelines look at short term risk assessment

3.  Large size of target population  > 60% candidates are ≥ 50 years old  Time between evaluation and surgery  Cardiovascular disease is the most common cause of death after kidney transplant (30% of total mortality)

4.  Under-screening can result in increased mortality with a functioning graft  Over-screening can result in non listing, delaying transplant, increased cost, complications  Can we safely list patients after coronray revascularization?

5.  History and physical examination  Active cardiac condition?  ACS/severe angina/recent MI  Heart failure  Arrhythmia  Severe valvular disease  Asymptomatic patient?  Risk stratification

6.  MI related chest pain is less common in patients on dialysis (44% vs 68%)  Patients are more likely to report dyspnoea

7.  Diabetes  Prior cardiovascular disease  > 1 year on dialysis  LVH  Age > 60 years  Smoking  Hypertension  Dyslipidaemia 2007 Lisbon conference on the care of the kidney transplant recipient

8. RiskPost transplant events 5 year survival High31.3%82.8% Low 6.5%93.1%

9. 1 year2 years5 years Event rate0.5%3.5%5.8% Kasiske BL et al. Transplantation 2005;80:815-820 High NPV of basic history, clinical information, ECG and chest X ray in asymptomatic non-diabetic patients 43.6% of patients were deemed to be low risk and therefore were not screened

10.  Prevalence of ischaemic events at 5 years is 18.9%  41% of revascularized patients had post- transplant events Jeloka TK et al. Clin Transplant 2007; 21:609-614 Kasiske BL et al. Transplantation 2005;80:815-820

11. Event free survival from cardiovascular deathEvent free survival from all-cause death Yamada et al. Clin J Am Soc Nephrol 2010; 5:1793-8

12.  Increased incidence of aortic calcification  The rate of AS progression is twice the normal rate  Moderate AS should be monitored yearly

13.  Increased incidence of mitral valve calcification  Mitral regurgitation ◦ Severity varies with volume status and BP ◦ Patients need to be assessed at dry weight, with optimal HR and BP ◦ Severity may improve with transplantation

14.  PAP ≥ 50 mmHg is associated with increased risk of post-transplantation death  If PAP > 45 mmHg or RV pressure overload by echo, RH cath may be considered  If confirmed by RH cath - > referral to PAH specialist

15. Sharma R et al. Heart 2007; 93:464-469

16.  No testing recommended if functional status ≥ 4 METS  If functional status < 4 METS noninvasive testing in patients with ≥ 3 risk factors:  IHD  HF  DM  Renal insufficiency  Cerebrovascular disease 2007 ACC/AHA Perioperative Guidelines for Noncardiac Surgery

17.  Younger patients  80% of 204 consecutive transplant candidates had a functional capacity of ≥ 4 METS  Diabetes common  ACC/AHA designed for short term risk assessment

18. GroupRelative risk of MIRelative risk of CD All studies2.732.92 Diabetic patients3.952.68 Rabbat et al. J Am Soc Nephrol 2003; 14:431-9

19. Hakeem et al. Circulation 2008; 118: 2540-9

21. Bergeron S et al. Am Heart J 2007;153:385-91

22. TestSensitivitySpecificity Dobutamine stress echo0.800.89 Myocardial perfusion0.690.77

23.  Age  Diabetic nephropathy  Claudication  Prior cardiac events

24.  Framingham score has a modest ability to predict long term coronary events in kidney transplant patients  Tends to underestimate risk, especially in diabetic patients

25. Hachamovitch et al. JACC 2003; 41:1329-40

26. Rakhit et al. Heart 2006;92:1402-8

27. ◦ Cardiovascular events constant in the first 3 years  5.3-6.6 per 100 patient-years ◦ Dramatic increase in the peritransplantation period  39.6% per 100 patient years ◦ Fewer investigations in the clinical assessment group than periodic screening group ◦ Similar cardiovascular event rate Gill JS et al. J Am Soc Nephrol 2005; 16:808-16

28.  CAD in 42-90 % transplant candidates  Only for high risk patients with positive stress imaging tests  Perioperative evaluation mail fail to identify patients at risk of plaque rupture (vulnerable plaque)  Poor correlation with patient survival

29. GroupsCAD stenosis severityVascular events 1< 50%11% 250-74%30% 3≥ 75%55% Manske CL et al. Am J Kidney Dis 1997; 29:601-607

30. GroupEventsDeath Medical (13)104 CABG (13)20 Manske CL et al Lancet 1992; 340: 998-1002

31.  Age < 45  Non-smoking  No ST segment changes  < 25 year diabetic history Manske CL et al. Kidney Int 1993; 44: 617-21

32.  Noninvasive testing ◦ prognostic value for morbidity and mortality ◦ Imperfect sensitivity and specificity in detecting CAD  Angiography is poor at predicting subsequent survival ◦ plaque instability vs stenosis severity  For asymptomatic patients without end-stage organ failure, revascularization only benefits high risk coronary anatomy

33.  Noninvasive stress testing for patients with multiple risk factors irrespective of functional status (AHA 2012)  No testing if functional status ≥ 4 METS (ACC/AHA 2007)  Noninvasive and/or invasive testing for high risk patients (2007 Lisbon conference)

34.  The usefulness of periodical screening of asymptomatic patients on the W/L is uncertain (AHA 2012)  Serial non invasive testing for ◦ All patients with diabetes every 12 months ◦ Not revascularized CAD every 12 months ◦ Prior PCI every 12 months ◦ Prior CABG at 3 years and then every 12 months ◦ High risk non diabetic patients ever 24 months (NKF 2005)

35.  Basic clinical data  Physical examination  ECG  Chest X ray

36.  Echocardiography  Standard ETT ◦ If negative, no need for further tests ◦ If positive -> non-invasive stress imaging -> coronary angiography

37. Nephrol Dial Transplant 2013