Should we screen for coronary artery disease in asymptomatic chronic dialysis patients?

The hemodialysis population is characterized by a high prevalence of ‘asymptomatic’ coronary artery disease (CAD), which should be interpreted differently from asymptomatic disease in the general population. A hemodynamically significant stenosis may not become clinically apparent owing to impaired...

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Bibliographic Details
Published in:Kidney international 2012-01, Vol.81 (2), p.143-151
Main Authors: De Vriese, An S., Vandecasteele, Stefaan J., Van den Bergh, Barbara, De Geeter, Frank W.
Format: Article
Language:English
Subjects:
Asymptomatic Diseases - epidemiology
Biological and medical sciences
Cardiology. Vascular system
chronic dialysis
coronary angiography
coronary artery disease
Coronary Artery Disease - diagnosis
Coronary Artery Disease - epidemiology
Coronary heart disease
dipyridamole
Heart
Humans
Mass Screening - methods
Medical sciences
myocardial perfusion scintigraphy
Nephrology. Urinary tract diseases
Prevalence
Renal Dialysis
screening
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Summary:The hemodialysis population is characterized by a high prevalence of ‘asymptomatic’ coronary artery disease (CAD), which should be interpreted differently from asymptomatic disease in the general population. A hemodynamically significant stenosis may not become clinically apparent owing to impaired exercise tolerance and autonomic neuropathy. The continuous presence of silent ischemia may cause heart failure, arrhythmias, and sudden death. Whether revascularization of an asymptomatic dialysis patient improves outcome remains a moot point, although several observational studies and one small RCT suggest a benefit. It can therefore be defended to screen asymptomatic dialysis patients for CAD. A number of noninvasive screening tests are available, but none has proved equally practical and reliable in the dialysis population as in the general population. Myocardial perfusion scintigraphy (MPS) before and after a pharmacological stress such as dipyridamole can reveal both ischemia and myocardial scarring. When compared with coronary angiography, low sensitivities were reported and attributed to impaired vasodilation to dipyridamole in dialysis patients. A more likely explanation is that not every anatomical stenosis will lead to impaired coronary blood flow on MPS. Numerous studies have shown an incremental prognostic value of dipyridamole-MPS over clinical data for prediction of adverse cardiac events, in some studies even over coronary angiography. Pending the availability of high-quality evidence, in our opinion asymptomatic dialysis patients could undergo dipyridamole-MPS, followed by coronary angiography in case of an abnormal scan. This combined physiological and anatomical evaluation of the coronary circulation allows us to determine which coronary stenosis is clinically relevant and therefore should be revascularized.
ISSN:0085-2538
1523-1755
DOI:10.1038/ki.2011.340