Cardiac Disease Evaluation and Management Among Kidney and Liver Transplantation Candidates: A Scientific Statement From the American Heart Association and the American College of Cardiology Foundation

Perspective:

Challenges inherent to conducting accurate, clinically effective, and cost-effective cardiac evaluations among transplantation candidates relate to the large size of the target population, the prevalence of disease, the limited number of donated organs, and the often extended waiting periods between initial evaluation and transplantation surgery. This report evaluates the state of evidence regarding cardiac risk evaluation and management in patients undergoing evaluation for kidney or liver transplantation, considering data specific to these populations and the appropriateness of extrapolation when data from these populations are lacking.

The following are 10 points to remember from this Scientific Statement:

1. Preoperative 12-lead electrocardiogram (ECG). A preoperative resting 12-lead ECG is recommended for potential kidney transplantation candidates with known coronary heart disease, known peripheral arterial disease, or any cardiovascular symptoms (Class I, Level of Evidence C), and is reasonable in potential kidney transplantation candidates without known cardiovascular disease (Class IIa, Level of Evidence C).

2. Preoperative functional testing. Noninvasive stress testing may be considered in patients with no active cardiac conditions undergoing evaluation for kidney transplantation or for liver transplantation based on the presence of multiple coronary artery disease (CAD) risk factors regardless of functional status. Relevant risk factors among transplantation candidates include diabetes mellitus, prior cardiovascular disease, more than 1 year on dialysis, left ventricular (LV) hypertrophy, age >60 years, smoking, hypertension, and dyslipidemia. The specific number of risk factors that should be used to prompt testing remains to be determined, but the committee considers three or more as reasonable (Class IIb, Level of Evidence C). The usefulness of periodically screening asymptomatic kidney transplantation candidates for myocardial ischemia while on the transplant waiting list is uncertain (Class IIb, Level of Evidence C).

3. Computed tomography (CT) calcium scoring, CT angiography. The usefulness of noncontrast CT calcium scoring and cardiac CT angiography is uncertain for the assessment of pretransplantation cardiovascular risk (Class IIb, Level of Evidence B).

4. Preoperative echocardiography. It is reasonable to perform preoperative assessment of LV function by echocardiography in potential kidney transplantation candidates (Class IIa, Level of Evidence B). It is reasonable to perform resting echocardiography in patients who are potential liver transplant recipients for the purpose of identifying pulmonary hypertension and/or intrapulmonary arteriovenous shunt (Class IIa, Level of Evidence B).

5. Aortic stenosis. It may be reasonable to consider patients with end-stage renal disease and moderate aortic stenosis to be ‘rapid progressors’ who warrant a yearly echocardiogram and monitoring for early symptoms (Class IIb, Level of Evidence C).

6. Pulmonary artery hypertension. It may be reasonable to confirm echocardiographic evidence of elevated pulmonary arterial pressures in kidney transplantation candidates by right heart catheterization (Class IIb, Level of Evidence C). Echocardiographic evidence of significant pulmonary hypertension in this population is defined by right ventricular systolic pressure more than 45 mm Hg or ancillary evidence of right ventricular pressure overload. For either kidney or liver transplant candidates, if right heart catheterization confirms the presence of significant pulmonary arterial hypertension (defined by mean pulmonary artery pressure ≥25 mm Hg, pulmonary capillary wedge ≤15 mm Hg, and pulmonary vascular resistance of >3 Wood units) in the absence of an identified secondary cause (e.g., obstructive sleep apnea, left heart disease), referral to a consultant with expertise in pulmonary arterial hypertension management and advanced vasodilator therapies is reasonable (Class IIa, Level of Evidence C [kidney transplant]; Class IIb, Level of Evidence C [liver transplant]).

7. Referral to cardiovascular medicine. Kidney or liver transplantation candidates with an LV ejection fraction <50%, evidence of ischemic LV dilation, exercise-induced hypotension, angina, or demonstrable ischemia in the distribution of multiple coronary arteries should be referred to a cardiologist for evaluation and long-term management according to American College of Cardiology Foundation (ACCF)/American Heart Association (AHA) guidelines for the general population (Class I, Level of Evidence B). It may be reasonable for each program to identify a primary cardiology consultant for questions related to potential kidney or liver transplantation candidates (Class IIb, Level of Evidence C).

8. Coronary revascularization. Coronary revascularization before transplantation surgery should be considered in patients who meet the criteria outlined in the 2011 ACCF/AHA Guidelines for Coronary Artery Bypass Graft Surgery (CABG) (Class I, Level of Evidence B). CABG is probably recommended in preference to percutaneous coronary intervention (PCI) to improve survival in patients with multivessel CAD and diabetes mellitus (Class IIa, Level of Evidence B). Without symptomatic or survival indications, routine prophylactic coronary revascularization is not recommended in patients with stable CAD prior transplantation surgery (Class III, Level of Evidence B).

9. PCI. In patients in whom coronary revascularization with PCI is appropriate for mitigation of cardiac symptoms and who need transplantation surgery in the subsequent 12 months, a strategy of balloon angioplasty or bare-metal stent (BMS) placement followed by 4-12 weeks of dual antiplatelet therapy is probably indicated (Class IIa, Level of Evidence B). In patients who have received drug-eluting stent (DES) and who must undergo urgent surgical procedures that mandate the discontinuation of thienopyridine therapy, it is reasonable to continue aspirin if at all possible and to restart the thienopyridine as soon as possible (Class IIa, Level of Evidence C). In cases when urgent surgery must be performed in patients taking aspirin and thienopyridines after coronary stent placement and who are at high risk for bleeding complications, a strategy of stopping the thienopyridine 5 days before surgery and continuing aspirin perioperatively may be reasonable. The thienopyridine should be restarted as soon as possible postoperatively (Class IIb, Level of Evidence B). It may be reasonable to perform kidney transplantation surgery without interruption of clopidogrel therapy if the risk of bleeding is low (Class IIb, Level of Evidence C). Transplantation surgery within 3 months of BMS placement and within 12 months of DES placement is not recommended, particularly if the anticipated time of post-stent dual antiplatelet therapy will be shortened (Class III, Level of Evidence B). Transplantation surgery is not recommended within 4 weeks of coronary revascularization with balloon angioplasty (Class III, Level of Evidence B).

10. Perioperative beta-blocker therapy. Among patients already taking beta-adrenergic blockers before renal transplantation, continuing the medication perioperatively and postoperatively is recommended to prevent rebound hypertension and tachycardia (Class I, Level of Evidence A). Among patients being considered for renal transplantation with clinical markers of cardiac risk (diabetes mellitus, prior known coronary heart disease, prior heart failure, extracardiac atherosclerosis) and those with unequivocal myocardial ischemia on preoperative stress testing, it is reasonable to initiate beta-blockers preoperatively and to continue them postoperatively provided that dose titration is done carefully to avoid bradycardia and hypotension (Class IIa, Level of Evidence C). Perioperative initiation of beta-blockers in beta-blocker–naïve patients may be considered in kidney transplantation candidates with established coronary heart disease or two or more cardiovascular risk markers to protect against perioperative cardiovascular events if dosing is titrated and monitored (Class IIb, Level of Evidence C). However, initiating beta-blocker therapy in beta-blocker–naïve patients the night before and/or the morning of noncardiac surgery is not recommended (Class III, Level of Evidence A).

Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Pulmonary Hypertension and Venous Thromboembolism, Atherosclerotic Disease (CAD/PAD), Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Acute Heart Failure, Pulmonary Hypertension, Interventions and Coronary Artery Disease, Interventions and Imaging, Echocardiography/Ultrasound, Hypertension, Sleep Apnea

Keywords: Coronary Artery Disease, Kidney Transplantation, Myocardial Ischemia, Hypotension, Electrocardiography, Sleep Apnea Syndromes, Tachycardia, Percutaneous Coronary Intervention, Liver Transplantation, Tomography, Heart Failure, Hypertension, Pulmonary, Bradycardia, Coronary Artery Bypass, Hypertension, Echocardiography


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