Cardiac Assessment for Renal Transplantation: Pre-Operative Clearance is Only the Tip of the Iceberg

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1 Cardiac Assessment for Renal Transplantation: Pre-Operative Clearance is Only the Tip of the Iceberg 2 nd Annual Duke Renal Transplant Symposium March 1, 2014 Durham, NC Joseph G. Rogers, M.D. Associate Professor of Medicine Senior Vice Chief for Clinical Affairs, Division of Cardiology Medical Director, Cardiac Transplant and Mechanical Circulatory Support Program Duke University

2 Disclosures None

3 Case A 53 y/o man presents from the nephrology clinic for cardiac evaluation prior to renal transplantation ESRD secondary to focal segmental glomerulosclerosis Past history of lymphoma treated with chemotherapy (unknown) Diabetes and hyperlipidemia PVD with a right BKA Metoprolol on non-dialysis days

4 Case He denies chest pain or dyspnea at rest Mild exertional dyspnea although mobility limited by amputation No palpitation or syncope Edema between dialysis days

5 Case 6, 102 kg P=84, BP=98/72 The lung fields were clear. Cardiac exam notable for a soft apical systolic murmur Abdomen obese Right leg surgically absent below the knee

6 Case

7 ARS Question #1 What do the guidelines suggest about appropriate cardiac testing to evaluate for ischemia A. No testing is required in this patient prior to renal transplantation B. The patient should have a symptom-limited exercise test with imaging to rule out myocardial ischemia C. The patient should have a cardiac CT to examine for coronary calcification D. The patient should undergo coronary angiography because of the poor sensitivity of stress testing in the ESRD population

8 ARS Question #2 Our patient undergoes coronary angiography and is found to have a 50% stenosis in OM1, and a 70% lesion in the mid right coronary artery with negative stress perfusion imaging. Should you insist that the RCA lesion is corrected prior to transplant? A. Yes B. No

9 ARS #3 The patient is listed for transplantation with a long anticipated wait time. Should he undergo annual evaluation of his CAD? A. Yes B. No

10 Assessing Cardiovascular Risk in Renal Transplantation Assess the patient s risk of cardiovascular disease Assess the likelihood that a patient will experience a peri-operative cardiovascular event (recognizing that the operation may not be in the near future) Provide an opinion regarding long-term outcomes related to cardiovascular disease Develop a plan to mitigate risk

11 Cardiac Conditions Relevant to Renal Transplantation Coronary artery disease LV dysfunction, heart failure Arrhythmias Valvular heart disease Pulmonary hypertension

12 The Burden of CV Risk in Patient with ESRD Registry Data from USRDS No with Characteristic (%) Predictor of Post-Transplant MI N=35,847 Age > (22.4) ESRD secondary to DM 8912 (24.9) Pre-transplant dialysis duration > 2 yrs 20,587 (57.4) Diabetes 16,038 (44.7) Pre-transplant MI 2887 (8.0) Angina, CAD without known MI 3254 (9.1) Arrhythmia 11,675 (32.6) PVD 7578 (21.1) Dyslipidemia 12,059 (33.6) HTN 6081 (17.0) Smoking history 2863 (8.3) J Am Soc Nephrol 2005;16:

13 Circulation 2012;126:617-63

14 Grading the Evidence Understanding ACC/AHA Recommendations Recommendation I X IIa IIb X X III X Intervention is useful and effective Evidence conflicts/opinions differ but leans towards efficacy Evidence conflicts/opinions differ but leans against efficacy Intervention is not useful/effective and may be harmful Level of Evidence A: Data derived from multiple randomized clinical trials or metaanalyses B: Data derived from a single randomized trial or non-randomized studies C: Only consensus opinion of experts, case studies, or standard-ofcare

15 AHA/ACC Recommendation Regarding Screening Circulation 2012;126:617-63

16 Guideline Recommended CAD Screening for Kidney Transplant Candidates: Source of Confusion Reference 2012 AHA Scientific Statement 2007 ACC/AHA Perioperative Guidelines for Noncardiac Surgery Recommendations Consider non-invasive testing in candidates with no active cardiac disease on the basis of risk factors ( 3) regardless of functional status Risk factors: DM, prior CV disease, dialysis > 1 year, LVH, age > 60, smoking, HTN dyslipidemia No testing if functional status 4 METS. Non-invasive testing if < METS or unknown based upon at least 1-2 risk factors: ischemic heart disease, heart failure, DM, renal insufficiency, cerebrovascular disease 2007 Lisbon Conference Non-invasive testing in high-risk patients: DM, known cardiovascular disease, multiple risk factors 2005 NKF/KDOQI Guidelines Annual non-invasive testing for DM known CAD, prior PCI, CABG. Non-invasive testing every 2 years in high-risk non-diabetics: 2 traditional risk factors, history of CAD, EF 40, PVD 2001 AST Guidelines Non-invasive testing for high-risk patients: DM, CAD or risk factors. Angiogram in those with positive stress test, revascularization for those with critical lesions 2000 European Best Practice Guidelines Thallium stress in prior MI or high risk, angiography in those with + stress test, revascularization for significant lesions Circulation 2012;126:617-63

17 Goals of Stress Testing Transplant Candidates 1. Reduce cardiovascular morbidity and mortality Screening should provide more benefit than harm Should be an actionable outcome of + test All Cause Death or MI P=0.48 N Engl J Med 2004;351: J Am Coll Cardiol 2007;49:1763-9

18 Goals of Stress Testing Transplant Candidates 2. Exclude patients at exceptionally high risk Outcomes of High Risk Patients with Renal Transplantation Low Risk High Risk 71 patients had angiogram 43 patients had + angiogram 28 patients were revascularized Post-transplant event rates: 41% CAD with intervention 28% CAD without intervention 6.5% without known CAD JAMA 1993;270: Clin Transplant 2007;21:609-14

19 AHA/ACC Recommendations Regarding Stress Testing in Asymptomatic Patients* Patient Cohort Unstable angina Decompensated HF Significant arrhythmia Severe valvular disease Circulation 2012;126: Exercise < 4 METS ± Risk Factors DM CV disease 1 yr dialysis LVH Age > 60 yrs Tobacco HTN Dyslipidemia Stress Exercise 4 METS (climbing stairs) No further testing *No definitive evidence for or against screening asymptomatic renal transplant candidates

20 Accuracy of Non-Invasive Testing for Detection of CAD in ESRD Patients Circulation 2012;126:617-63

21 Impact of Renal Function on Cardiac Death Circulation 2008;118:2540-9

22 Periodic CAD Screening While Listed: SPECT 7376 patients with normal SPECT perfusion scans Mean follow-up: 665 ±200 days Events: Death and non-fatal MI Only 10 % diabetics J Am Coll Cardiol 2003:41:

23 The Role of Echo Imaging Resting Echo Stress Echo Clin J Am Soc Nephrol 2010;5: Am Heart J 2007;153:385-9

24 Role for CT Calcium Scoring ESRD patients have more medial calcification Am J Kidney Dis 2004;43:313-19

25 AHA/ACC Recommendations for Revascularization Prior to Renal Transplant Dual antiplatelet therapy: BMS= 1 month DES 6 months NSTEMI= 12 months Transplant surgery within 3 months of BMS and 12 months is not recommended, particularly if dual APT will be shortened. Class III, LOE=B

26 Valvular Heart Disease Rate of aortic stenosis progression: Non-dialysis: cm 2 /yr Dialysis: 0.23 cm 2 /yr Am J Kidney Dis 2005; 45 (Suppl 3):S1-153

27 Pulmonary Hypertension Nephrol Dial Transplant 2010; Transplantation 2008;86:

28 Risk Factor Management in Renal Transplant Candidates Hypertension Lancet 2009;373:

29 Managing Lipids Prior to Transplant Reductions in cardiovascular mortality Reduction in cardiovascular events Safe * Excluded AURORA and SHARP trial data BMJ 2008;336:645-51

30 Peri- and Post-operative Medical Management Agent Recommendation Evidence Beta Blocker Continuation Initiate for CV disease or ischemia Initiate the AM of surgery I IIa-b III Aspirin for CAD secondary prevention IIa B Statin Continue peri- and post-operatively Atherosclerosis: low-mod dose statin LDL target < 100 mg/dl in recipients Hypoglycemics for strict glucose control IIb B I IIa IIa A C C B B B Circulation 2012;126:617-63

31 AHA/ACC Recommendations for Cardiology Referral

32 Summary and Conclusions ESRD patients have significant CV co-morbidities and a high prevalence of cardiac disease It is reasonable to try to partner with a small number of cardiovascular providers to perform the initial CV evaluation and ongoing follow-up The general evaluation and management of cardiovascular disease is largely guideline driven. However, these should be tailored to specific characteristics of the individual patient The high prevalence of CV disease (particularly atherosclerotic) will require aggressive and lifelong secondary prevention strategies

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