Preoperative Cardiovascular Evaluation and Management

Abstract

Cardiovascular disease is a leading cause of morbidity and mortality among patients with end-stage renal disease (ESRD) including transplant candidates and recipients. Although transplantation improves cardiovascular risk in the long term compared with dialysis, cardiovascular diseases in aggregate comprise the most common cause of death in patients with functioning allografts at all times after kidney transplant. Achieving clinically and cost-effective management of cardiovascular disease in kidney transplant candidates is a challenging endeavor due to the large size of the target population, prevalent disease burden, and the often extended waiting periods between initial candidate evaluation and transplantation surgery. Further, there is a paucity of randomized clinical trials addressing the efficacy of cardiac screening, surveillance, coronary revascularization, and medical management among patients with ESRD, and extrapolation from trials performed in other populations or observational studies is often necessary to formulate practice recommendations. Recently, the American Heart Association and American College of Cardiology Foundation convened a working group including cardiologists, nephrologists, and intensivists to compose a Scientific Statement on “Cardiac Disease Evaluation and Management Among Kidney and Liver Transplantation Candidates.” The current chapter provides a practical summary of some of the key recommendations in this Scientific Statement relevant to kidney transplant candidates, focused as a practical guide for the clinician. Our synthesis includes a final algorithm emphasizing the importance of history and physical examination to assess for active cardiac conditions, use of resting echocardiography in dialysis patients to evaluate ventricular function and screen for valvular disease and pulmonary hypertension, and use of noninvasive stress testing in asymptomatic transplant candidates with three or more coronary disease risk factors to target screening on the subgroup with the highest pretest probability of prognostically significant coronary artery disease. Moving forward, we believe that pursuit of more evidence, ideally from randomized clinical trials, is an urgent priority to strengthen the evidence base for pretransplant cardiac evaluation and the management of cardiovascular disease before, during, and after transplant.