DIAGNOSIS AND MANAGEMENT OF CORONARY-ARTERY DISEASE IN PATIENTS WITH END-STAGE RENAL-DISEASE ON HEMODIALYSIS

Cardiovascular disease accounts for almost half of the total mortality in patients with ESRD. Ischemic heart disease is responsible for many cardiovascular deaths, with myocardial infarction accounting for appr oximately 15% and sudden cardiac death or severe left ventricular dysf unction accounting for much of the remainder, The markedly increased p revalence of atherosclerotic cardiovascular disease in patients with E SRD is influenced, at least in part, by numerous risk factors for athe rosclerosis, with hypertension, diabetes mellitus, and hypercholestero lemia being particularly important, Because atherosclerotic coronary a rtery disease (CAD), whether symptomatic or asymptomatic, is associate d with an increased incidence of allograft failure and mortality, the results of this study suggest the need for careful evaluation for the presence of CAD in those persons who are under consideration for renal transplantation. Candidates with angina pectoris, previous myocardial infarction, or congestive heart failure are at particularly high risk of a cardiac event, and, therefore, should routinely undergo pretrans plant coronary angiography and subsequent surgical revascularization i f angina is refractory to medical therapy or CAD is extensive. In cont rast, although young, nondiabetic transplant candidates without sympto ms or electrocardiographic evidence of CAD have an increased relative risk of cardiac death when compared with age-matched control subjects, their absolute risk of such an event is very low. As a result, they d o not require a cardiac evaluation before transplantation. For the rem aining transplant candidates at neither low nor high risk of a fatal o r nonfatal cardiac event (i.e., those at intermediate risk), the autho rs of this study routinely perform (1) thallium imaging with dipyridam ole or (2) two-dimensional echocardiography with intravenous dobutamin e. If the result of these investigations are normal, transplantation p roceeds; if abnormal, coronary angiography is performed, followed by s urgical revascularization if CAD is extensive. Percutaneous translumin al coronary angioplasty is not recommended in patients with ESRD becau se it appears to be accompanied by a high likelihood of acute and chro nic complications. Although it is hoped that surgical revascularizatio n before renal transplantation improves allograft and patient survival , prospectively obtained data proving that this, in fact, is true do n ot exist.