CHD Screening in Kidney and Liver Transplant Candidates: Key Points

Cheng XS, VanWagner LB, Costa SP, et al.
Emerging Evidence on Coronary Heart Disease Screening in Kidney and Liver Transplantation Candidates: A Scientific Statement From the American Heart Association. Circulation 2022;Oct 17:[Epub ahead of print].

The following are key points to remember from this American Heart Association scientific statement about emerging evidence on coronary heart disease (CHD) screening in kidney and liver transplantation candidates:

  1. For decades, controversy regarding best practices for CHD screening prior to kidney and liver transplantation has existed, and practices vary widely among institutions. This document reviews evidence from the past decade related to CHD management and screening in these populations, proposes reasonable approaches for clinical practice, and identifies areas for future investigation.
  2. Aside from CHD, kidney and liver transplant candidates are at risk for cardiac conditions including heart failure, pulmonary hypertension, and arrhythmias. Therefore, every patient undergoing transplant evaluation should be screened for cardiac symptoms and have a 12-lead electrocardiogram (ECG) and transthoracic echocardiogram (TTE). All patients with symptomatic cardiac disease or with significant non-CHD findings (such as valve disease or evidence of pulmonary hypertension) should be referred to cardiology. Involvement of a dedicated cardiologist and interdisciplinary collaboration including transplant anesthesiologists is recommended, particularly for high-risk and complex cases. Notably, liver transplant surgery is associated with much more intense hemodynamic stresses than kidney transplant surgery.
  3. The writing group recommends stress echocardiography (SE) as the modality of choice for ischemia evaluation prior to kidney transplant. Reasons for this include reasonable sensitivity and specificity (0.73 and 0.88, respectively, as compared with 0.66 and 0.73 for myocardial perfusion scintigraphy [MPS]), lack of radiation exposure, and ability to provide dynamic structural information. Dobutamine SE may not be feasible in all patients, such as those with uncontrolled hypertension. Though positron emission tomography (PET) may perform better, data in this population are limited. Local expertise should be considered when choosing a modality for CHD screening.
  4. For kidney transplant candidates undergoing evaluation for CHD, a direct-to-catheterization approach with a cardiologist’s guidance is recommended only in very select circumstances, such as left ventricular ejection fraction (LVEF) <40% with regional wall motion abnormalities.
  5. Among kidney transplant candidates without known CHD, it is reasonable to defer evaluation for myocardial ischemia in a low-risk subset meeting the following criteria: age <60 years, lack of CHD equivalents (diabetes, peripheral arterial disease, cerebrovascular disease), duration of dialysis <5 years, and lack of silent infarct on ECG.
  6. The benefits of re-evaluation for CHD while a patient is wait-listed for kidney transplant remain unclear. The ongoing CARSK trial (Canadian-Australasian Randomized Trial of Screening Kidney Transplant Candidates), which has randomized wait-listed candidates to surveillance CHD screening versus no surveillance, should help to clarify.
  7. The ISCHEMIA-CKD trial did not demonstrate a benefit of invasive coronary angiography and revascularization over guideline-directed medical therapy (GDMT) for CHD with moderate to severe ischemia on noninvasive testing. Notably, this study was not specifically designed to address the utility of revascularization in the pre-transplant population. The writing group recommends individualizing decisions regarding revascularization, considering the risks of procedural complications and the need for dual antiplatelet therapy (DAPT), which usually delays active listing for transplant, as it increases risk of perioperative bleeding.
  8. GDMT for CHD in dialysis-dependent patients is somewhat controversial, as randomized trials have not demonstrated benefits of statins, and data on optimal blood pressure management for cardiovascular risk reduction are limited. However, based in part on practices in ISCHEMIA-CKD, the writing group recommends considering moderate- or high-intensity statins, aspirin, and renin-angiotensin-aldosterone system (RAAS) blockers in all kidney transplant candidates. Kidney transplant candidates with LVEF <40% should be treated with a beta-blocker and a RAAS blocker.
  9. Nonalcoholic steatohepatitis (NASH) is the second-leading and fastest-growing indication for liver transplant in the United States and is an independent risk factor for obstructive CHD and adverse liver transplant outcomes. Most liver transplant candidates should undergo evaluation for CHD; exceptions may include those <40 years of age and with <2 CHD risk factors (such as smoking, dyslipidemia, and hypertension).
  10. The writing group recommends anatomic assessment for CHD with coronary computed tomography angiography (CCTA) or invasive coronary angiography for most liver transplant candidates. CCTA has an excellent negative predictive value in the general population. Resting vasodilation in patients with cirrhosis limits the predictive accuracy of MPS, though vasodilator PET has not yet been adequately studied in this population and appears promising. In patients with kidney disease, the risk of contrast-induced nephropathy with CCTA or invasive angiography must be considered. Prior to invasive angiography, the risk of bleeding due to coagulopathy must be considered, and a multidisciplinary discussion should address management plans for obstructive CHD if present.
  11. In patients wait-listed for liver transplant, re-evaluation of CHD risk with reassessment of risk factors, ECG, and TTE should be performed at least annually, with repeat anatomic or functional testing considered on a case-by-case basis.
  12. In liver transplant candidates with obstructive CHD, the approach to revascularization should be individualized based on CHD severity, degree of liver dysfunction, and local expertise. Percutaneous coronary intervention (PCI) with drug-eluting stents (DES) may be performed safely in patients with stable end-stage liver disease with a short course of DAPT (3-6 months). Coronary artery bypass grafting (CABG) carries prohibitive risk in patients with advanced liver disease (Child-Turcotte-Pugh [CTP] score >7 or Model for End-Stage Liver Disease score >13), though combined CABG-liver transplantation has been performed rarely, and PCI with DES with a very short DAPT course (1 month) may be considered. Routine revascularization may present undue risk in patients with advanced cirrhosis, so revascularization should be performed only after a patient is deemed to be an otherwise acceptable transplant candidate. Patients with unrevascularizable CHD with significant myocardial ischemic burden are at prohibitively high risk for liver transplant.
  13. In liver transplant candidates with CTP class A or B cirrhosis and clinical CHD, statins are recommended for secondary prevention, with close monitoring of liver chemistries and markers of rhabdomyolysis. Aspirin should be considered on a case-by-case basis. Liver transplant candidates on DAPT should receive proton-pump inhibitors to reduce risk of gastrointestinal bleeding.

Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Cardiovascular Care Team, Diabetes and Cardiometabolic Disease, Dyslipidemia, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Pulmonary Hypertension and Venous Thromboembolism, Vascular Medicine, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Nonstatins, Novel Agents, Statins, Acute Heart Failure, Pulmonary Hypertension, Interventions and Imaging, Interventions and Vascular Medicine, Angiography, Computed Tomography, Echocardiography/Ultrasound, Nuclear Imaging, Hypertension

Keywords: Arrhythmias, Cardiac, Aspirin, Blood Pressure, Computed Tomography Angiography, Coronary Angiography, Coronary Artery Bypass, Coronary Disease, Diagnostic Imaging, Drug-Eluting Stents, Dyslipidemias, Echocardiography, Electrocardiography, End Stage Liver Disease, Gastrointestinal Hemorrhage, Heart Failure, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Hypertension, Hypertension, Pulmonary, Kidney Transplantation, Liver Cirrhosis, Liver Transplantation, Mass Screening, Myocardial Ischemia, Myocardial Revascularization, Non-alcoholic Fatty Liver Disease, Percutaneous Coronary Intervention, Perfusion Imaging, Platelet Aggregation Inhibitors, Positron Emission Tomography Computed Tomography, Radiation Exposure, Renal Insufficiency, Chronic, Renin-Angiotensin System, Rhabdomyolysis, Risk Factors, Secondary Prevention, Vasodilation, Ventricular Function, Left

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