Screening for coronary artery disease

Screening for cardiovascular disease in patients with advanced chronic kidney disease

Cardiovascular disease remains the major cause of mortality and morbidity in patients with advanced chronic kidney disease (CKD) and after renal transplantation. The mechanisms for cardiotoxicity are multiple. Identifying high-risk patients remains a challenge. Given, the poor long-term outcome of dialysis patients who do not receive renal transplantation and the lower supply of donor kidneys relative to demand, optimal selection of renal transplantation candidates is crucial. This requires a clear understanding of the validity of cardiac tests in this patient group. This paper explores the strengths and weaknesses of currently available diagnostic tools in patients with advanced CKD. Echocardiography is very useful for the detection of cardiomyopathy and prognosis. Stress echocardiography, myocardial perfusion imaging and coronary angiography are the best tools for the assessment of coronary artery disease. All predict outcome. No single gold standard investigation exists. At present, there is not an optimal technique for predicting sudden cardiac death in this patient group. Ultimately, the choice of cardiac test will always be determined by patient preference, local expertise and availability.

Diagnosis and therapy of coronary artery disease in renal failure, end-stage renal disease, and renal transplant populations

Even though cardiovascular disease is the leading cause of death in patients with CRF and end-stage renal disease (ESRD), ill-conceived notions have led to therapeutic nihilism as the predominant strategy in the management of cardiovascular disease in these populations. The recent data clearly support the application of proven interventions in the general population, such as angiotensin-converting enzyme inhibitors and statins to patients with CRF and ESRD. The advances in coronary stents and intracoronary irradiation have decreased the restenosis rates in renal failure patients. Coronary artery bypass with internal mammary graft might be the procedure of choice for coronary revascularization in these patients. The role of screening for asymptomatic coronary disease is established as a pretransplant procedure, but it is unclear whether this will be applicable to all patients with ESRD. Future studies need to focus on unraveling the mechanisms by which uremia leads to increased cardiovascular events to design optimal therapies targeted toward these mechanisms and improve cardiovascular outcomes.

Aortic calcification on plain chest radiography increases risk for coronary artery disease

STUDY OBJECTIVES

To determine whether an association exists between aortic calcification viewed on plain chest radiography and coronary artery disease.

METHODS

Retrospective review of all chest radiographs obtained from consecutive patients undergoing coronary angiography at a primary cardiac center during 1999. Plain chest radiographs were reviewed by blinded radiologists, and interobserver consistency was measured. The presence or absence of aortic arch calcification was abstracted and compared with the results of coronary angiography.

RESULTS

Of 654 cases, 329 of 360 patients with aortic arch calcification vs. 241 of 294 patients without aortic arch calcification had coronary artery disease demonstrated on angiography. The 9% absolute difference in proportions was significant (p = 0.0003). The relative risk (measured by risk ratio) was 1.11 (95% confidence interval, 1.05 to 1.19).

CONCLUSION

Several objective signs (e.g., hypertension, hyperlipidemia, and ECG changes) have been associated previously with the presence of coronary artery disease. This study further suggests an association between coronary disease and aortic arch calcification on plain chest radiography. These results may assist primary-care providers performing routine health assessments as well as emergency practitioners evaluating patients with potential angina.

Coronary artery disease in uremia: Etiology, diagnosis, and therapy

Cardiovascular disease is a major challenge to nephrologists, whether we deal with patients with pre-end-stage renal failure, on dialysis or after successful renal transplantation. It is the most common cause for death in patients with a functional allograft, and prevents many dialysis patients from being engrafted. Coronary artery disease is a diagnostic and therapeutic challenge, as it differs in some respects from that seen in non-uremic cohorts, and lacks much of the evidence-base on which therapeutic intervention rests. This review examines the experimental and clinical literature on cardiovascular disease in uremia, focusing on coronary artery disease. We focus on the incidence, presenting syndromes, screening tools, and interventions in the context of acute and chronic coronary syndromes. Recent evidence comparing coronary angioplasty, coronary artery stenting, and bypass surgery in subjects with renal failure is also reviewed. Coronary artery disease is more prevalent in uremia, more difficult to diagnose and less rewarding to treat compared to non-uremic subjects. Many more randomized trials are needed. In the absence of information from such trials, we advocate aggressive control of conventional and novel cardiovascular risk factors, and early intervention for symptomatic coronary disease.