Emerging Evidence on Coronary Heart Disease Screening in Kidney and Liver Transplantation Candidates: A Scientific Statement From the American Heart Association: Endorsed by the American Society of Transplantation

Abstract

Coronary heart disease is an important source of mortality and morbidity among kidney transplantation and liver transplantation candidates and recipients and is driven by traditional and nontraditional risk factors related to end-stage organ disease. In this scientific statement, we review evidence from the past decade related to coronary heart disease screening and management for kidney and liver transplantation candidates. Coronary heart disease screening in asymptomatic kidney and liver transplantation candidates has not been demonstrated to improve outcomes but is common in practice. Risk stratification algorithms based on the presence or absence of clinical risk factors and physical performance have been proposed, but a high proportion of candidates still meet criteria for screening tests. We suggest new approaches to pretransplantation evaluation grounded on the presence or absence of known coronary heart disease and cardiac symptoms and emphasize multidisciplinary engagement, including involvement of a dedicated cardiologist. Noninvasive functional screening methods such as stress echocardiography and myocardial perfusion scintigraphy have limited accuracy, and newer noninvasive modalities, especially cardiac computed tomography-based tests, are promising alternatives. Emerging evidence such as results of the 2020 International Study of Comparative Health Effectiveness With Medical and Invasive Approaches-Chronic Kidney Disease trial emphasizes the vital importance of guideline-directed medical therapy in managing diagnosed coronary heart disease and further questions the value of revascularization among asymptomatic kidney transplantation candidates. Optimizing strategies to disseminate and implement best practices for medical management in the broader end-stage organ disease population should be prioritized to improve cardiovascular outcomes in these populations.

Keywords: AHA Scientific Statements; coronary angiography; coronary disease; exercise test; kidney transplantation; liver transplantation; mass screening; myocardial ischemia; risk evaluation and mitigation; risk factors.

Figure 1.

A reasonable approach to coronary heart disease (CHD) screening and risk stratification in kidney transplant (KTx) candidates without (1A) and with (1B) known CHD. * Symptomatic cardiac disease: Angina, angina-equivalent, or any possible symptoms referrable to known CHF, arrhythmias, or valvular disease. † Obtain resting TTE: Patients who are very low-risk for CHD and non-CHD conditions (age<40, no CKD-specific risk factor for CHD [see below], not on dialysis, and with no prior transplant) may not need to undergo this or any subsequent testing for cardiac assessment of KTx candidacy. ‡ Pulmonary hypertension: PASP>60mmHg or >45mmHg with abnormal right ventricle. § LVEF can be diminished for non-CHD reasons in ESKD. It is reasonable to reassess LVEF after 3 months of maximal dialytic and optimal medical therapy if no other high-risk features are present, and to proceed with CHD work-up if LVEF remains depressed. ‖ WMA (wall motion abnormality): New or unexpected regional left ventricular wall motion abnormalities. ¶ Non-CKD risk factor for CHD: diabetes mellitus, cerebrovascular disease, or peripheral artery disease. # Choice of modality depends on center expertise, local availability, and patient kidney reserve. Anatomic assessment may be CCTA or invasive coronary angiography. ** Normal or small: Consider diagnostic accuracy of the test modality and clinical context to guide further management. †† 1 year for patient with diabetes, 2 years for patients without diabetes. This is for initial evaluation and not necessarily for waitlist surveillance. ‡‡ Timing for KTx after revascularization needs to incorporate recovery from procedure and need for DAPT. Typically DAPT is continued for 1 year post PCI. Some KTx programs operate on DAPT. Some stents do not require 1 year of DAPT; discuss with the interventional cardiologist. Abbreviations: ACC/AHA, American College of Cardiology/American Heart Association; CABG, coronary artery bypass grafting; CCTA, coronary computed tomography angiography; CHD, coronary heart disease; CHF, congestive heart failure; DAPT, dual antiplatelet therapy; ECG, electrocardiogram; ESKD, end-stage kidney disease; GDMT, guideline-directed medical therapy; HTN, hypertension; KTx, kidney transplant; LVEF, left ventricular ejection fraction; MI, myocardial infarction; PASP, pulmonary artery systolic pressure; PCI: percutaneous intervention; TTE, transthoracic echocardiogram; WMA, wall motion abnormality.

Figure 2.

A reasonable approach to coronary heart disease screening (CHD) and risk stratification in liver transplant (LTx) candidates (including simultaneous liver-kidney transplant candidates). Known CHD is defined as a history of myocardial infarction (MI), revascularization (coronary artery bypass grafting [CABG] or percutaneous coronary intervention [PCI]), or known >50% stenosis in a major epicardial coronary artery. * Symptomatic cardiac disease: Angina, angina-equivalent, or any possible symptoms referrable to known CHF, arrhythmias, or valvular disease. † Pulmonary HTN: In the absence of significant volume overload, RVSP>45mmHg or RV dysfunction/hypertrophy or septal flattening or moderate tricuspid regurgitation. ‡ Highly suggestive of CHD: Silent MI on ECG or TTE with new or unexpected regional left ventricular WMA or new or unexpected left ventricular systolic (LVEF<50% or absolute global longitudinal strain<18%). § CHD risk factors: dyslipidemia, HTN history, chronic kidney disease, left ventricular hypertrophy, family history of premature CHD, active or past tobacco use, coronary artery calcification score >0. ‖ ≥4 METs: Patient can climb ≥1 flight of stairs without stopping or walk up hill for ≥1-2 blocks or scrub floors or move furniture or golf, dance, run or play tennis. ¶ Stress echocardiography (SE): Exercise SE preferred; dobutamine SE if patient cannot exercise; consider cardiac PET as an alternative if available. In patients whose critical illness precludes stress echocardiography, consider CCTA or coronary angiography (choice of modality depending on patient and center factors). # Coronary angiography: Should be performed as the last test prior to listing for LTx and requires multidisciplinary discussion of management plan if significant obstructive CAD is identified. Abbreviations: ACC/AHA, American College of Cardiology/American Heart Association; CCTA, coronary computed tomography angiography; CHD, coronary heart disease; CHF, congestive heart failure; ECG, electrocardiogram; HTN, hypertension; LTx, liver transplant; LVEF, left ventricular ejection fraction; MET, metabolic equivalent; MI, myocardial infarction; NASH, non-alcoholic steatohepatitis; PET, positron emissions tomography; RV, right ventricle; RVSP, right ventricular systolic pressure; SE, stress echocardiography; TTE, transthoracic echocardiogram; WMA, wall motion abnormality.

Figure 3.

A reasonable approach to management of coronary heart disease (CHD) in liver transplant (LTx) candidates. * RAAS blocker: RAAS blockers may be considered in patients with CHD and compensated Child Class A cirrhosis, but should be avoided in patients with more advanced or decompensated cirrhosis. † See references # ^& (Valgimigli M, Cao D, Makkar RR, et al. Design and rationale of the XIENCE short DAPT clinical program: An assessment of the safety of 3-month and 1-month DAPT in patients at high bleeding risk undergoing PCI with an everolimus-eluting stent. Am Heart J 2021;231:147-56. Varenne O, Cook S, Sideris G, et al. Drug-eluting stents in elderly patients with coronary artery disease (SENIOR): a 34andomized single-blind trial. Lancet 2018;391:41-50.) Abbreviations: CABG, coronary artery bypass grafting; CAD, coronary artery disease; DAPT, dual antiplatelet therapy; DES, drug-eluting stent; MELD, Model for End-stage Liver Disease; PCI, percutaneous coronary intervention; RAAS, renin-angiotensin-aldosterone system.