Our patient is: · 60 years old · HTN · CKD · Atypical chest pain · Dyslipidemia The article addressed that management includes thorough history regarding any symptoms suggestive of cardiovascular disease and proper examination including a baseline 12-lead ECG, transthoracic echo in suspected valvular, pericardial or pulmonary hypertension is suspected to exclude any symptoms that may hinder cardiac stress investigations. Chronic kidney disease is associated with increased cardiovascular risk and mortality. Standard evaluation begins with a detailed clinical history and examination as mentioned Diagnostic approaches: · Exercise stress testing · Stress echocardiography · Exercise and pharmacological myocardial perfusion scintigraphy According to my practice, all kidney transplant potential recipients are evaluated initially by ECG and Echocardiography, Cardiological consultation is done in most cases especially those with CAD, valvular diseases, arrhythmias and pulmonary HTN.
Mohamed Ghanem
2 years ago
A comprehensive clinical history, physical examination, and baseline 12-lead ECG, are the first steps in the process Exercise stress ECG : Limited in the advanced CKD population, with low sensitivity of 36% (particularly in those receiving dialysis).
Due to vascular, neurological or musculoskeletal comorbidities, and the catabolic/cachexic metabolic state associated with CKD EXERCISE STRESS ECHOCARDIOGRAPHY AND DOBUTAMINE STRESS ECHOCARDIOGRAPHY:
ESE sensitivity has been reported ranging from 71 to 97% with specificity ranging from 64 to 90%.
Limitations : Reduced exercise capacity (deconditioning) Impaired chronotropic response Abnormal baseline ECG and left ventricular hypertrophy. Pharmacological stress echocardiography:
Sensitivity : 80 (64–90) %
Specificity : 89 (79–94) % Limitations : Blunted chronotropic response Left ventricular hypertrophy Microvascular disease potentially can be missed Myocardial perfusion scintigraphy :
Sensitivity : 69 (48–85)%
Specificity : 77 (59–89)%
Limitations : False negative results in multi-vessel disease due to balanced ischemia.
In Our Practice :
Basal ECG and ECHO >> anay indication for coronary angiography , Iwill proceed after cardiology consultation
Normal ECG and ECHO : so ECHo with dobutamin or Myocardial perfusion scintigraphy .
Theepa Mariamutu
2 years ago
Myocardial ischemia assessment in chronic kidney disease: challenges and pitfalls
Summarise the management of the case presented in this article
Please reflect on your practice explaining how you would manage this case in your hospital setting
Bedside investigations:
clinical history and examination
Baseline 12-lead ECG.
Specific Cardiac evaluation
Exercise Stress Ecg
limited in the advanced CKD population, with poor sensitivity, as deconditioning leads to reduced exercise capacity.
CKD patients have also been shown to have impaired heart rate response to exercise, and the frequently abnormal baseline ECG in CKD patients.
In advanced CKD patients, the ST segment changes at stress were shown to be not significantly different between non-severe CAD and severe CAD group.
Exercise Stress Echocardiography and Dobutamine Stress Echocardiography
Exercise stress echocardiography is better than the standard Stress ECG in ruling out CAD.
allows assessment of ventricular size and function, aortic and mitral valvular calcification, Left ventricular hypertrophy (LVH), and potentially CFR.
Dobutamine and dipyridamole stress echocardiography Technique detects inducible myocardial ischemia based on detection of wall motion abnormalities, thus, would detect significant epicardial CAD, not microvascular disease. Abnormal DSE results in CKD patients have been associated with poorer prognosis for cardiac events and overall mortality.
Myocardial Perfusion scintigraphy
Exercise and pharmacological myocardial perfusion scintigraphy (MPS) have sensitivity of 87and 89%, and specificity of 73 and 75%, respectively, in detecting >50% coronary artery stenosis in patients without advanced CKD.
has High false negative result in detecting ischemia in people with significant triple vessel CAD, as in the CKD population.
Cardiovascular Magnetic Resonance
Cardiovascular magnetic resonance (CMR) with gadolinium contrast has not been widely utilized clinically in the CKD population Due to the concern of nephrogenic systemic fibrosis
In our practice will do: 12 lead ECG, stress ECG and Echo will be done. If any cardiac abnormality, consultation of cardiologist and possible coronary angiography plus PCI will be considered.
Nazik Mahmoud
2 years ago
This patient need to be evaluated for myocardial ischemia it done by resting ECG and Echocardiography then they did stress ECG to induce ischemia or arrhythmia,if the patient physical cannot tolerate the exercise pharmacological stress ECHO it will do the job ,if the result is positive for ischemia then myocardial perfusion imaging will be done,
In our transplant center in Sudan we did the same
Fatima AlTaher
2 years ago
CV complications are the leading cause for morbidity and mortality in CKD patients with MI being the commonest cause of death in those population. CAD in renal patients has is related to both traditional and non traditional risk factors . Traditional risk factors as HPN , DM , obesity, dyslipidemia and smoking while non traditional risk factors as uremic toxins , endothelial dysfunction and chronic inflammation.
CAD could occur at macro vascular level and affected by athermanous plaque size and stability or occur at microvascular level related to endothelial dysfunction. Clinical presentation of CAD in renal patients is the same as general population, but investigations and diagnosis are less specific and less sensitive in CKD patients. Investigations for CAD and their limitation in CKD
1- Standard ECG : simple , non invasive test can diagnose chamber enlargement, arrythmia and current or past MI and ischemia . in CKD , base line changes caused by HPN usually present and may mask new ischemic manifestations.
2- Exercise ECG : usually limited sensitivity due to deconditioning and poor HR response due to uremic autonomic neuropathy
3-Echo : non invasive, very valuable in assessing myocardial function expressed as EF, diagnos chamber enlargement, regional wall hypokinesia consistent with ischemia limitation
Dobutamine stress echo : used for diagnosis of induced ischemia indicating underly epicardial CAD with sensitivity reaching 85 % in non renal population but its sensitivity is lower in CKD and kidney transplant recipient may be due to blunted chronotropic effect in those patients. Also LVH that’s commonly present in CKD patients masks the stress induced wall motion abnormalities.
Despite these limitations , abnormal stress echo is associated with poor outcome and increased mortality in renal patients. 4- Exercise and pharmacological myocardial perfusion scientigraphy : has sensitivity and specificity of 87 and 75 % respectively to diagnose CAD with stenosis> 50% in non renal patients. Abnormal MPI in CKD patients us associated with increased mortality Drawbacks of MPI
have high rate of false negative results in CKD patients due to balanced ischemia and blunted heart rate response to stress due to uremic autonomic neuropathy. 5-Cardiac magnetic resonance (CMR) with gadolinium contrast :
is not widely used in CKD patients due to risk of nephrogenic systemic sclerosis. Conclusion
All myocardial investigations are of limited sensitivity and specificity in CKD patients so assessing the myocardial condition should include combination of different investigations with exercise stress testing are very important to express functional capacity of the patients.
In our hospital
we start with non invasive investigations as ECG and trans thoracic echo ,if abnormal or in presence of other risk factors as DM , obesity ,age >50 y we proceed to dobutamine stress echo study . in cases of wall motion abnormalities suggesting ischmia , we perform CT coronary angiography . While if cardiomyopathy was detected we proceed with CT coronary angiography to diagnose underlying CAD and cardiac MRI to exclude infiterating diseases.
dina omar
2 years ago
*Management of presenting case: This patient is 60 years, ESRD ,HTN, dyslipidemic , has atypical chest pain; For CAD evaluation:
History taking and analysis of chest pain ( Type, Time, relation to meals or exertion
ECG, stress ECG ( although less sensitive in Chronic kidney disease patients), cardiac enzymes
Exercise stress echocardiography & dobutamine stressECHO: also; of limited value in CKD population , dobutamine stress is mostly used as a prognostic test in advanced CKD patients. Its sensitivity up to 97% with specificity reaches 90% . It assess the ventricular size and function, aortic and mitral valvular calcification, LVH.
Myocardial perfusion scintigraphy:Abnormal test usually associated with cardiac insult and high mortality rate in CKD patients. it has 75% specificity in tracing CA stenosis in patients not in late stages of CKD .MPS has high false -ve result in detecting ischemia in people with significant 3 vessel CAD, as in the CKD population, because of homogeneous tracer uptake due to balanced ischemia. Reversible defects of inducible M .ischemia was associated with 6 folds increased risk of MI and almost fourfold risk of cardiac death. So, CA is best used for diagnosis and possible therapeutic stenting. fixed defects was associated with 5 times increase risk of sudden cardiac death.
5. Cardiac MRI with gadolinium: not preferred in advanced CKD patients due to risk of nephrogenic systemic fibrosis which resembles scleroderma potentially fatal disease. Dobutamine stress CMR is safer in the pre-renal transplant patients.
In my practice will do : basal ECG, stress ECG and Echo, cardiac enzymes If, any abnormality cardiology consultation :possible coronary angiography
Ahmed Omran
2 years ago
MANAGEMENT includes:
-A detailed clinical history history and examination of cardiovascular system.
-Exercise stress test: It is characterized by poor sensitivity in CKD patients ;more in dialysis patients due to reduced exercise capacity.
-Exercise stress and dobutamine stress echocardiography.
-Myocardial perfusion scintigraphy.
-Cardiovascular MR.
Hospital management:
-Full history and cardiovascular examination
-Cardiology consultation.
-ECG :rest & exercise.
-Coronary angiogram.
-Lab work up : Cardiac enzymes, lipid profile, Pro BNP, urinalysis &urine albumin, CRP and homocysteine.
Mohamed Fouad
2 years ago
Myocardial ischemia assessment in chronic kidney disease: challenges and pitfalls
Coronary artery disease is the leading cause of mortality and morbidity in the chronic kidney disease (CKD) population and often presents with atypical symptoms. CKD patients have both traditional and non-traditional cardiac risk factors. In the CKD population, CAD is often multi-vessel and causes silent or asymptomaticmyocardial ischemia Current diagnostic investigations of myocardial ischemia in CKD lack sensitivity and specificity or may have adverse effects.
Case review:
A 60-year-old female patient CKD stage V secondary to chronic glomerulonephritis presented with atypical chest discomfort at rest. She has history of controlled HTN on ARBS and beta blockers,she also has dyslipidemia but no history of DM.No family history of CAD.No smoking.
Evaluation for cardiovascular disease:
Diagnostic evaluation starts with a thorough clinical history and examination and a baseline 12-lead ECG.Cardiovascular examination, especially to exclude uncontrolled hypertension or significant aortic stenosis is important prior to cardiac stress investigation.
EXERCISE STRESS ECG In patients with normal renal function, exercise stress test (EST) with ECG has a low to moderate sensitivity and specificity 68 and 77% respectively. EST is further limited in the advanced CKD population, with poor sensitivity of 36% (13) (especially those undergoing dialysis), as deconditioning leads to reduced exercise capacity (14). Deconditioning can be due to vascular, neurological ormusculoskeletal comorbidities, and the catabolic/cachexic metabolic state associated with CKD. CKD patients have also been shown to have impaired heart rate response to exercise.
EXERCISE STRESS ECHOCARDIOGRAPHY AND DOBUTAMINE STRESS ECHOCARDIOGRAPHY
Its sensitivity has been reported rang- ing from 71 to 97% with specificity ranging from 64 to 90%. The addition of echocardiography allows assessment of ven- tricular size and function, aortic and mitral valvular calcification, left ventricular hypertrophy (LVH). Dobutamine and dipyridamole stress echocardiography (DSE) technique detects inducible myocardial ischemia based on detec- tion of wall motion abnormalities, thus, would detect significant epicardial CAD, not microvascular disease.
MYOCARDIAL PERFUSIONSCINTIGRAPHY
Exercise and pharmacological myocardial perfusion scintigraphy (MPS) havesensitivity of 87and 89%,and specificity of 73and 75%, respectively,in detecting >50% coronary artery stenosis in patients without advanced CKD(26). Exercise MPS in the advanced CKD population has the same limitation as EST and ESE.
Cardiovascular magnetic resonance (CMR) with gadolinium contrast has not been widely utilized clinically in the CKD population due to the concern of nephrogenic systemic fibrosis (NSF)
In the current case we recommend ESE, to exclude inducible myocardial ischemia, inducible arrhythmia, and to assess exercise capacity and symptoms objectively. Resting echocardiography is useful to exclude significant aortic stenosis prior to exercise stress and to visually assess the degree of LVH.
Asmaa Khudhur
2 years ago
Myocardial ischemia assessment in chronic kidney disease: challenges and pitfalls.
In those with chronic kidney disease (CKD), cardiovascular disease (CVD) is the main cause of mortality and a significant cause of morbidity. One of the main causes of death in people with CKD is myocardial ischemia. Both epicardial and microvascular CAD can result in myocardial ischemia.
Coronary artery disease is quite common in the CKD population and is present in young CKD patients as well as those with early renal failure .
CAD is frequently multi-vessel and produces silent or asymptomatic myocardial ischemia in the CKD population .Even individuals with early-stage CKD have been found to have asymptomatic epicardial CAD .and those with CAD had a greater rate of significant adverse cardiac events .While the prevalence of high-risk plaque in patients with CKD was similar to that in the group without CKD .Kawai et al. found that patients with mild CKD had a higher prevalence of severe epicardial CAD than those without CKD .suggesting that the issue is more likely related to coronary stenosis than plaque stability.
diagnostic assessment
An extensive clinical history, physical exam, baseline 12-lead ECG, and diagnostic evaluation are the first steps in the process. Prior to conducting a cardiac stress test, it is crucial to perform a cardiovascular examination, especially to rule out uncontrolled hypertension or substantial aortic stenosis.
EXERCISE STRESS ECG
Exercise stress test (EST) with ECG has a low to moderate sensitivity and specificity in patients with normal renal function, even when appropriate exercise capacity and 85% heart rate are obtained.
As deconditioning reduces exercise capacity, EST is further constrained in the advanced CKD population, with poor sensitivity of 36% (particularly in those receiving dialysis).
Deconditioning can result from comorbidities in the vascular, nervous, or musculoskeletal systems as well as the catabolic/cachexic metabolic state linked to CKD. Exercise heart rate response in CKD patients has also been demonstrated to be hindered, and routine stress testing is made more difficult by their usually aberrant baseline ECGs (typically brought on by hypertension).
EXERCISE STRESS ECHOCARDIOGRAPHY AND DOBUTAMINE STRESS ECHOCARDIOGRAPHY
Exercise stress echocardiography (ESE) can diagnose and rule out CAD more effectively than a normal stress ECG. Its specificity ranges from 64 to 90%, and its sensitivity has been reported to be between 71 and 97%. However, the same physiological limits that apply to EST mentioned above limit the efficacy of ESE in the CKD population.
Aortic and mitral valve calcification, left ventricular hypertrophy (LVH), and maybe CFR can all be assessed with the addition of echocardiography. Although many echocardiography laboratories do not routinely conduct this due to technological challenges, CFR assessment by Doppler echocardiography in the left anterior descending artery has been demonstrated to be a determinant of cardiac events in CKD patients in the absence of obstructive epicardial CAD.
Dobutamine and dipyridamole stress echocardiography (DSE) approach would detect severe epicardial CAD, not microvascular disease, because it detects inducible myocardial ischemia based on detection of wall motion abnormalities.
A worse prognosis for cardiac events and overall mortality has been linked to abnormal DSE values in CKD patients.
Blunted chronotropic response to exercise in the CKD population may be associated with a worsened prognosis for the heart as a whole.
MYOCARDIAL PERFUSION SCINTIGRAPHY
In patients without severe CKD, exercise and pharmacological myocardial perfusion scintigraphy (MPS) have sensitivity and specificity values of 87 and 89% and 73 and 75%, respectively, for diagnosing >50% coronary artery stenosis. The same limitations that apply to EST and ESE apply to exercise MPS in the advanced CKD population, i.e., linked to insufficient exercise performance and chronotropic incompetence.
Due to the high rate of false negative results from balanced ischemia, normal myocardial perfusion as evaluated by SPECT may not be associated with a favourable prognosis in the CKD group as opposed to the normal population.
Concurrent lowered CFR and LVH may also be important.
However, it has been demonstrated that aberrant MPS findings in CKD patients are linked to a higher incidence of cardiac events and mortality.
A nearly fivefold higher risk of cardiac mortality was linked to the existence of permanent abnormalities.
CARDIOVASCULAR MAGNETIC RESONANCE:
Due to the risk of nephrogenic systemic fibrosis (NSF), cardiovascular magnetic resonance (CMR) with gadolinium contrast has not been widely used clinically in the CKD population. Because of the uncommon but severe side effect of NSF, CKD patients are unable to use gadolinium chelates. NSF causes a permanent and potentially fatal hardening of the skin and internal organs that resembles scleroderma.
Pediatric patients with severe CKD have been investigated to assess early heart impairment using cardiovascular magnetic resonance spectroscopy. The safety of dobutamine stress CMR in the prerenal transplant population has been established.
Wee Leng Gan
2 years ago
Assessment of Exercise Intolerance in Patients with Pre-Dialysis CKD with Cardiopulmonary Function Testing: Translation to Everyday Practice.
2) Exercise stress echocardiography
Sensitivity and specificity possibly similar to DSE.
Practical issues
Reduced exercise capacity (deconditioning)
Impaired chronotropic response Abnormal baseline ECG and left ventricular hypertrophy
3) Pharmacological stress echocardiography
Sensitivity 80 (64–90)%
Specificity 89 (79–94) %
Practical issues
Blunted chronotropic response
Left ventricular hypertrophy
Microvascular disease potentially can be missed
4) Myocardial perfusion scintigraphy
Sensitivity 69 (48–85)%
Specificity 77 (59–89)%
Practical issues
False negative results in multi-vessel disease due to balanced ischemia.
5) Dobutamine stress CMR
Research ongoing for specificity and sensitivity.
Practical issues
Blunted chronotropic response.
Microvascular disease potentially can be missed.
MPS has sensitivity of 69% (confidence interval 48–85) and specificity of 77% (confidence interval 59–89) in diagnosing inducible myocardial ischemia in the pre-renal transplant population. Abnormal MPS results in CKD patients have been shown to be associated with a higher incidence of cardiac events and mortality. Blunted heart rate response in CKD patients during stress myocardial perfusion imaging has been reported to be associated with increased mortality.
Cardiovascular magnetic resonance (CMR) with gadolinium contrast has not been widely utilized clinically in the CKD population due to the concern of nephrogenic systemic fibrosis
Hinda Hassan
2 years ago
Summarise the management of the case presented in this article
This lady with CKD5, with HTN and DM, presented with suspected coronary artery disease. They started by thorough clinical history and examination and abase line12 lead ECG. Resting echocardiography is useful in assessing presence of aortic stenosis and LVH prior to cardiac stress investigation. In advanced CKD patients, stress tests have limited role in detecting CAD. Stress tests include: 1- Exercise ECG but the ST segment changes at stress were not different between non-severe and severe CAD in advanced CKD patients. Furthermore it is limited by the reduced exercise capacity and impaired chronotropic response. 2- exercise echocardiography stress test is limited by the reduced exercise capacity , the impaired chronotropic response and the abnormal baseline ECG and left ventricular hypertrophy 3- The dipyridamole and dobutamine stress echocardiography (Pharmacological stress echocardiography) is often recommended as a screening test in advanced CKD patients but it has reduced accuracy due to again blunted chronotropic response, LVH and the possibility of missing microvascular disease 4- Myocardial perfusion scintigraphy limited by false negative results in multi-vessel disease due to balanced ischemia 5- Dobutamine stress CMR limited by blunted chronotropic response and the possibility of missing microvascular disease Exercise tolerance are useful in pre transplant workup to exclude inducible myocardial ischemia, arrhythmia and exercise capacity.
Please reflect on your practice explaining how you would manage this case in your hospital setting
First we do thorough history, looking for risk factors and then a meticulous cardiovascular examination. Resting ECG and echocardiography are mandatory in all cases. Those with risk factors were referred for cardiac clearance and possible dobutamine stress tests.
Ahmed Abd El Razek
2 years ago
Management:
Detailed history taking is required for this 60 year old woman, with variable risk factors including age, CKD stage 5, hypertensive, dyslipdaemic.
Criteria of atypical chest pain, onset of hypertension and duration, hypertension is also controlled or not .Lifestyle is it active or sedentary, diet and salt intake.
Steps done:
Baseline line ECG,
Stress ECG, not preferred in CKD
Baseline echocardiography.
Stress echocardiography, inconvenient in CKD
Myocardial perfusion scintigraphy, has limitations in CKD.
Cardiovascular magnetic resonance imaging, not done in CKD patients for fear of nephrogenic systemic fibrosis related to gadolinium use.
In our hospital, detailed history is necessary in this setting, cardiological consultation is a must, exclusion of other causes of chest pain is mandatory (muscle spasm for example),history of drug abuse to be clarified , steps would be start by cardiac enzymes as a baseline (although might be misleading ),baseline ECG , baseline echocardiography ,if positive coronary PCI and stenting may be of help.
Besides lifestyle modification and restricted salt fat diet.
Alyaa Ali
2 years ago
First question
60 years old , female
1.Full clinical history and examination
CKD Stage 5 , HTN , not DM, not smoker , no family history of premature CAD, LDL 3.2 mmol/l
Cardiovascular examination to exclude uncontrolled HTN or severe aortic stiffness
2 . Diagnostic evaluation
A) Baseline 12 lead ECG
B) Exercise stress ECG had poor sensitivity(36%) in advanced CKD patients due to reduced exercise capacity, impaired chronotropic response , abnormal Baseline ECG in CKD patients due to HTN
C) Exercise stress echocardiography : it is better than stress ECG
In diagnosis CAD but also had same limitations as it
It allows assessment of ventricular size and function , valve calcification, LVH , CFR
It also detects inducible myocardial ischaemia by detection of wall motion abnormalities
It detects epicardial CAD but miss microvascular CAD
D) Myocardial perfusion Scintegraphy
It has the same limitations as EST and ESE in CKD patients
It has high false negative result in detecting ischaemia in people with significant triple vessel CAD
CKD patients with normal perfusion still had a three times higher cardiac death rate than those with normal MPS and no CKD may be due to concurrent CFR and LVH
E) Cardiovascular magnetic resonance
Not used in CKD patients due to gadolinium induced nephrogenic systemic fibrosis
Recommendation was to use exercise stress Echo and resting Echo
Second question
Clinical history and examination
Baseline ECG
Resting ECHO
coronary angiography
CARLOS TADEU LEONIDIO
2 years ago
Summarise the management of the case presented in this article
The article reviews the different strategies for studying Coronary Artery Disease (CAD), a disease that is highly prevalent in the CKD population. – exercise stress ECG – exercise stress echocardiography and dobutamine stress echocardiography – myocardial perfusion scintigraphy – cardiovascular magnetic resonance We can see that all these strategies have a decrease in their sensitivity when compared to the general population, but accompanied by an increase in their specificity. There is no clear superiority of one strategy over another, however, exercise tolerance has shown greater importance both for prognosis and for the assessment of capacity and symptoms, to the point of being recommended by the article for perioperative renal transplant patients. Thus, in the case described, the patient underwent exercise stress echocardiography, aiming to exclude inducible myocardial ischemia, inducible arrhythmia, and to assess exercise capacity and symptoms objectively.
Please reflect on your practice explaining how you would manage this case in your hospital setting
Due to the organization of the health system, it is more difficult to carry out strategies to evaluate exercise tolerance, being restricted to more specific cases. The most common, due to greater ease in the system, is the performance of myocardial perfusion scintigraphy, leaving the evaluation of exercise tolerance for more specific cases.
Eusha Ansary
2 years ago
Summary:
A 60-year-old woman with stage 5 chronic kidney disease (CKD) due to glomerulonephritis presented with atypical chest discomfort at rest. She is hypertensive with two antihypertensives, nno diabetic, non smoker and no family history of premature CAD.
Here evaluation done by
1. Exercise stress ECG
2. Exercise stress echocardiography and dobutamine stress echocardiography
3. Myocardial perfusion scintigraphy
4. Cardiovascular magnetic resonance
In our practice, this high risk case coronary angiogram is the choice.
Hamdy Hegazy
2 years ago
Summarise the management of the case presented in this article
This is a 60-y old female patient with high risk factors for IHD that include being CKD-5 , Hypertension, high cholesterol. She doesn’t have family history of CAD and she doesn’t smoke. She presented with atypical chest pain and tightness, so IHD should be ruled out because of her high-risk factors. Cardiac evaluation in this case includes the following: 1- Clinical: History and examination 2- Cardiac investigations: A- 12 lead ECG. B- Exercise stress ECG: its sensitivity and specificity in CKD patients are lower than general population without CKD (36% vs 70%).
C- Exercise stress ECHO: is better than ES-ECG in detecting myocardial ischemia (7.9 +ve likelihood ratio vs 3.5 +ve likelihood ratio). Sensitivity and specificity in detecting myocardial ischemia in CKD patients around 70%. ECHO is beneficial in detecting ventricular size and function and assess valves especially aortic and mitral. D- Dobutamine and Dipyridamole stress ECHO: it can detect inducible myocardial ischaemia by wall motion abnormalities, howver it detects only epicardial IHD not microvacular CAD., its sensitivity and specificity around 85%, it is recommended as a screening test in CKD patients. Limitations in CKD: CKD patients show a blunted chronotropc response and they didn’t achieve 85% maximal predicted HR despite use of atropine, reduced sensitivity because of thick myocardium, can’t detect microvascular CAD. E- Myocardial perfusion Scintigraphy (MPS exercise or pharmacological): its sensitivity and specificity in detecting inducible ischaemia in CKD is around 70% compared to around 85% in those without CKD. MPS in CKD showed high false negative results in detecting myocardial ischemia in triple vessel disease patients because of homogenous tracer uptake. Limitation of exercise induced studies (exercise induced ECG, ECHO, MPS) in CKD patients: 1- Exercise intolerance in CKD. 2- LVH 3- Chronotropic incompetence. F- Cardiac MRI: 1- With Gadolinium contrast is usually avoided in CKD patients (GFR below 30) for fear of NSF (Nephrogenic systemic fibrosis). 2- BOLD-CMR (blood oxygen level dependent cardiac MR): can detect epicardial and microvascular CAD.
Please reflect on your practice explaining how you would manage this case in your hospital setting Risk stratification is assessed initially by the renal team which include proper clinical history (HTN, DM, hypercholesterolemia, smoking, cardiac symptoms, family history of IHD) and examination (age, body weight, BP, HR, fluid status, cardiac examination), routine blood investigations, 12 lead ECG, chest X-ray, and ECHO. high risk patients, usually will be referred to cardiology team which they usually decide to go for further assessment like MPS and may subsequently advice for coronary angiography is there was evidence if reversible ischemia. We don’t do exercise induced studies and we don’t do cardiac MR.
Jamila Elamouri
2 years ago
EXERCISE STRESS ECG
In patients with normal renal function, exercise stress test (EST) with ECG has a low to moderate sensitivity and specificity.
It has poor sensitivity of 36%, (especially those undergoing dialysis), due to reduced exercise capacity of these patients.
CKD patients have also been shown to have impaired heart rate response to exercise, and the frequently abnormal baseline ECG in CKD patients interfere with the interpretation of standard stress testing.
EXERCISE STRESS ECHOCARDIOGRAPHY AND DOBUTAMINE STRESS ECHOCARDIOGRAPHY
Exercise stress echocardiography (ESE) is better than the standard stress ECG in ruling in CAD and ruling out CAD. Its sensitivity has been reported ranging from 71 to 97% with specificity ranging from 64 to 90%.
Dobutamine and dipyridamole stress echocardiography (DSE) technique detects inducible myocardial ischemia based on detection of wall motion abnormalities, thus, would detect significant epicardial CAD, not microvascular disease.
It is often recommended as a screening test in advanced CKD patients.
LVH with small intracavitary volume, commonly found in CKD patients, obscures the detection of wall motion abnormalities at stress, thus, significantly reducing the sensitivity of the test in detecting inducible myocardial ischemia in CKD population.
Microvascular CAD is difficult to appreciate given the focus on regional wall motion abnormality and likely to be missed.
Abnormal DSE has been associated with poorer prognosis for cardiac events and overall mortality.
Negative stress echocardiography results, on the other hand, have been shown to be associated with low incidence of major adverse cardiac events.
Exercise and pharmacological myocardial perfusion scintigraphy
(MPS) have sensitivity of 87 and 89%, and specificity of 73 and 75%, respectively, in detecting >50% coronary artery stenosis in patients without advanced CKD.
abnormal MPS results in CKD patients have been shown to be associated with a higher incidence of cardiac events and mortality.
Blunted heart rate response in CKD patients during stress myocardial perfusion imaging has been reported to be associated with increased mortality.
CARDIOVASCULAR MAGNETIC RESONANCE
CMR carries risk of gadolinium induced nephrogenic systemic fibrosis in CKD with GFR < 30. It has been studied to assess early cardiac dysfunction in pediatric population with advanced CKD. Dobutamine stress CMR was shown to be safe in the pre-renal transplant population
Recommendation:
ESE is recommended to exclude inducible myocardial ischemia, and arrhythmia, as well, as to assess exercise capacity and symptoms objectively.
Resting echocardiography is useful to exclude significant aortic stenosis prior to exercise stress and to visually assess the degree of LVH.
in my practice the management of this case will includes:
tough history and clinical examination
rest ECG
cardiac enzymes
CXR
Echo cardiography
evaluation of Bpr control
AMAL Anan
2 years ago
Summarise the management of the case presented in this article
60 years old female , chronic kidney disease stages, atypical chest discomfort, known history of hypertension and no family history of coronary antry diseases.
– diagnostic evaluation.- by..-
1- exercise stress ECG ( sensitively 68% and specificity 77%, most chronic Kidney disease pt had impaired heart rate response to exercise
2- exercise stress echocardiography and dobutamine stress echocardiography:
Allow assessment of CFR by Doppler echocardiography on left anterior descending artery where negative means ion incidence of major cardiac events.
3- myocardial perfusion scintigraphy..-
Abnormal MPS in chronic kidney disease means high incidence of cardiac events and mortality.
4- cardiovascular magnetic resonance –
Please reflect on your practice explaining how you would manage this case in your hospital setting:
Comprehensive history From patient-to detect underlying risk factor
Examination general- vital sign
X-rays, ECG cardiac enzymes.
Echo cardrography.
Amna Khalifa
2 years ago
Summarize the management of the case presented in this article
A 60-year-old woman
stage 5 chronic kidney disease (CKD)
native disease (glomerulonephritis)
presented with atypical chest discomfort at rest.
Past history of hypertension treated with an angiotensin converting enzyme inhibitor and a beta blocker
Hyperlipidemia
She has no diabetes mellitus, no family history of premature CAD, and does not smoke. Management of this case as per the article
Diagnostic evaluation:
1. clinical history 2. and examination 3. and a baseline 12-lead ECG. 4. Cardiovascular examination, especially to exclude uncontrolled hypertension or significant aortic stenosis
5. cardiac stress investigation EXERCISE STRESS ECG
Has poor sensitivity in CKD 36%, esp in dialysis patients attributed to
1-deconditioning in such population which leads to reduced exercise capacity.
Deconditioning can be due to vascular, neurological or musculoskeletal comorbidities, and the catabolic/cachexic metabolic state associated with CKD.
2-CKD patients have also been shown to have impaired heart rate response to exercise ,
3- The frequently abnormal baseline ECG in CKD patients (often secondary to hypertension) hampers the interpretation of standard stress testing.
In advanced CKD patients, the ST segment changes at stress were shown to be not significantly different between non-severe CAD and severe CAD group, despite a longer treadmill exercise time in the non-severe group
EXERCISE STRESS ECHOCARDIOGRAPHY
The addition of echocardiography allows assessment of ventricular size and function, aortic and mitral valvular calcification, left ventricular hypertrophy (LVH), and potentially CFR.
CFR measurement by Doppler echocardiography in the left anterior descending artery has been shown to be a determinant of cardiac events in CKD patients in the absence of obstructive epicardial CAD. HOWEVER this is not performed routinely technical difficulties.
DOBUTAMINE STRESS ECHOCARDIOGRAPHY
Dobutamine and dipyridamole stress echocardiography (DSE) technique detects inducible myocardial ischemia based on detection of wall motion abnormalities, thus, would detect significant epicardial CAD, not microvascular disease.
DSE had moderate sensitivity of 80% in detecting inducible myocardial ischemia in renal transplant candidates
Several mechanisms may explain the reduced accuracy of DSE in the advanced CKD population
Though It is often recommended as a screening test in advanced CKD patients.
Abnormal DSE results in CKD patients have been associated with poorer prognosis for cardiac events and overall mortality
DSE had moderate sensitivity of 80% in detecting inducible myocardial ischemia in renal transplant candidates
Several mechanisms may explain the reduced accuracy of DSE in the advanced CKD population.
1-The majority of advanced CKD patients had a blunted chronotropic response, thus, did not achieve 85% maximal predicted heart rate despite the use of atropine
2-The thick myocardium due to LVH with small intracavitary volume, commonly found in CKD patients, obscures the detection of wall motion abnormalities at stress,
3- Microvascular CAD is difficult to appreciate given the focus on regional wall motion abnormality and likely to be missed.
Due to the above , significantly reducing the sensitivity of stress echocardiography in detecting inducible myocardial ischemia in CKD population.
Abnormal DSE results in CKD patients have been associated with poorer prognosis for cardiac events and overall mortality.
Negative stress echocardiography results, on the other hand, have been shown to be associated with low incidence of major adverse cardiac
MYOCARDIAL PERFUSION SCINTIGRAPHY
Exercise and pharmacological myocardial perfusion scintigraphy (MPS) have sensitivity of 87 and 89%, and specificity of 73 and 75%, respectively, in detecting >50% coronary artery stenosis in patients without advanced CKD
Exercise MPS in the advanced CKD population has the same limitation as EST and ESE, i.e., related to the inadequate exercise performance and chronotropic incompetence
MPS has sensitivity of 69% and specificity of 77% in diagnosing inducible myocardial ischemia in the pre-renal transplant population.
MPS has false negative result in detecting ischemia in people with significant triple vessel CAD, as in the CKD population, because of homogeneous tracer uptake due to “balanced ischemia
CKD with normal MPS still had a three times higher cardiac death rate than those with normal MPS and no CKD
abnormal MPS results in CKD patients have been shown to be associated with a higher incidence of cardiac events and mortality
presence of reversible defects of inducible myocardial ischemia was associated with six fold increased risk of myocardial infarction and almost fourfold risk of cardiac death
The presence of fixed defects was associated with a nearly fivefold increased risk of cardiac death
Blunted heart rate response in CKD patients during stress myocardial perfusion imaging has been reported to be associated with increased mortality CARDIOVASCULAR MAGNETIC RESONANCE
Cardiovascular magnetic resonance (CMR) with gadolinium contrast is avoided due to its association with nephrogenic systemic fibrosis (NSF) in CKD patients. However, Cardiovascular magnetic resonance spectroscopy has been studied to assess early cardiac dysfunction in pediatric population with advanced CKD . and Dobutamine stress CMR was shown to be safe in the pre-renal transplant population
The author recommended Resting echocardiography to exclude significant aortic stenosis prior to exercise stress followed by ESE, to exclude inducible myocardial ischemia, inducible arrhythmia, and to assess exercise capacity and symptoms objectively.
Please reflect on your practice explaining how you would manage this case in your hospital setting
I would manage as follow: after full history and physical exam, including vital signs, and rule out other causes of chest pain either muscular or infectious. will request lab. including renal function and cardiac enzymes and troponin. and CXR. ECG and will refer to the cardiologist and arrange resting Echo and as per the cardiologist advise will either proceed to stress echo or myocardial perfusion. if any is positive then will discuss with the patient to proceed to coronary angio and the risk of contrast nephropathy will be explained and in such case he is already stage 5 so he will require to be initiated on dialysis post procedure most likely.
however saving life is more important than saving kidneys, and he will be added on tx waiting list.
Abdullah Raoof
2 years ago
Q1 -Summarise the management of the case presented in this article.
Cardiovascular disease is the leading cause in CKD population . it has high prevalence in CKD patient even in young and even in early stages of CKD . Of note CKD patient has both traditional and non traditional risk factors. CAD in CKD patient is often multi vessel and could be silent . CAD in CKD patient may be caused by microvascular dysfunction and epicardial obstruction .
Cardiovascular evaluation of patient with CKD involves .
1- EXERCISE STRESS ECG.
In CKD patient this test has poor sensitivity of 36%, usually due to reduced exercise capacity because of deconditioning .
Deconditioning is due to
A. vascular,
B. neurological or
C. musculoskeletal comorbidities,
D. the catabolic/cachexic metabolic state associated with CKD.
The presence of blunted chronotropic response in CKD patient ( could be part of metabolic autonomic dysfunction ) and the presence of baseline ECG changes (LVH ) may make interpretation is difficult .
2- EXERCISE STRESSECHOCARDIOGRAPHYANDDOBUTAMINESTRESS ECHOCARDIOGRAPHY.
It Is better than the stress ECG with a sensitivity of about 85%. This method detects wall motion abnormalities induced by ischemia. had asensitivityof85% and a specificity of 89% . It is the recommended as a screening test in advanced CKD patients. As in other stress tests the presence of blunted chronotropic response and LVH reduces its sensitivity. Abnormal DSE is associated with high cardiovascular event and mortality. Of note blunted exercise response is associated with poor cardiac prognosis.
3- MYOCARDIAL PERFUSIONSCINTIGRAPHY
Exercise and pharmacological myocardial perfusion scintigraphy (MPS) have sensitivity of 88 %, and specificity of 74 % . has same limitation as any exercise test .
It has high false negative in detecting triple vessel disease. Because of (( balanced ischemia)). Normal myocardial perfusion measured by SPECT may not be associated with excellent prognosis in CKD population. But abnormal MPS results in CKD patients have been Shown to be associated with a higher incidence of cardiac events and mortality.
4- CARDIOVASCULARMAGNETICRESONANCE
It is not used widely because of gadalonium induce nephrogenic systemic fibrosis (NSF) in patient with CKD. Dobutamine stress CMR was shown to be safe in the pre-renal transplant population.
RECOMMENDATION
Exercise tolerance has utmost importance both for prognosis and symptoms capacity and has implication in the case of peri operative risk assessment.
Therefore ,we recommend ESE to the case vignette described, to exclude inducible myocardial ischemia ,inducible arrhythmia, and to assess exercise capacity and symptoms objectively.
Resting Echocardiography is useful to exclude significant aortic stenosis Prior to exercise stress and to visually assess the degree of LVH.
Q2- Please reflect on your practice explaining how you would manage this case in your hospital setting.
This patient has ESRD on HD. His age more than 50 Y ,with other cardiovascular risk. presented as atypical chest pain .
I will considered this patient as a high risk.
My management will be
1- Detailed history ( risk factors, symptoms and cardiovascular complication )
2- Examination (pulse, blood pressure, precordium, and peripheral pulses)
3- Baseline investigation – Resting ECG, Resting echo, CXR, cardiac enzyme.
4- As this patient has more than 50y old this patient will need coronary angiography, but this decision should be shared with cardiologist.
Hoon Loi Chong
2 years ago
· Summarise the management of the case presented in this article This is a 60-yrear-old female with: 1. Chronic kidney disease (CKD), stage 5 2. Congestive heart failure (CHF) 3. Hypertension 4. Dyslipidaemia This patient presented with resting atypical chest discomfort. Given a remarkable history of advanced CKD and significant risk factors for cardiovascular disease (CVD), coronary artery disease (CAD) will be a concern of her resting atypical chest discomfort. Detailed clinical history with physical examination and laboratory evaluation which includes a complete 12-lead ECG, complete blood count (CBC), thyroid functions, liver function tests, renal function tests with electrolytes, cardiac enzymes and NT-proBNP level, etc, are important. Imaging studies such as stress echocardiography, CT angiography, myocardial perfusion scintigraphy (MPS) and cardiac MRI are useful clinical tools in CAD diagnosis. However, the clinical utility of CT angiography and cardiac MRI in advanced CKD patients in CAD diagnosis has been limited due to the concern of contrast-induced nephropathy (CIN) and nephrogenic systemic fibrosis (NSF), respectively. Robust studies have shown that stress echocardiography (sensitivity: 80%, specificity: 89%) is performing better than MPS (sensitivity: 69%, specificity: 77%). Since autonomic dysfunction is common in CKD hosts, a blunted chronotropic response is expected during Dobutamine and Dipyridamole stress echocardiography (DSE) testing. Therefore, exercise stress echocardiography (ESE) will comparatively outshine DES in the diagnosis of CAD in CKD hosts.
Please reflect on your practice explaining how you would manage this case in your hospital setting.
Typical clinical symptoms (precordial chest pain, chest tightness with heavy, compressing sensation, or exercise intolerance), abnormal ECG findings with serial evolutional changes plus progressively elevated cardiac enzymes (CK, CK-MB and Troponin I) denote ischemic change of the myocardium and should prompt immediate consultation of cardiologist for percutaneous coronary intervention (PCI). Other laboratory investigations such as CBC, serum electrolytes and NT-proBNP level are reasonable as they help to rule out infection, cardiac dysrhythmia, and congestive heart failure (CHF) that may also lead to such patient’s presentation. If the surveys are all unrevealing, further imaging studies are needed to elucidate the cause of this patient’s resting atypical chest discomfort, with CAD being the particular cause of concern owing to the patient’s remarkable cardiovascular risk factors and advanced CKD status. Stress echocardiography, CT angiography, MPS and cardiac MRI are useful clinical tools in CAD diagnosis. However, the clinical utility of CT angiography and cardiac MRI in advanced CKD patients in CAD diagnosis has been limited due to the concern of contrast-induced nephropathy (CIN) and nephrogenic systemic fibrosis (NSF), respectively. Literatures have shown that stress echocardiography has a better sensitivity and specificity if compared to MPS (80% and 89% versus 69% and 77%, respectively). However, in host with advanced CKD, exercise stress echocardiography (ESE) will perform better than Dobutamine and Dipyridamole stress echocardiography (DSE) as there is an expected blunted chronotropic response caused by autonomic dysfunction in CKD hosts. Therefore, ESE is preferred over DSE.
Dalia Ali
2 years ago
Myocardialischemiaassessmentinchronickidney disease:challenges and pitfalls
Cardiovascular disease(CVD)is the most common cause of death in CKD patients
Myocardial ischemia can be caused by both epicardial and microvascularCAD. CAD is often multi-vessel and causes either
1-silent
2-Asymptomatic myocardial ischemia
STRATEGIES AND EVIDENCE
DIAGNOSTIC EVALUATION
1-EXERCISE STRESS ECG
In patients with normal renal function, exercise stress test (EST) with ECG has a low to moderate sensitivity and specificity, 68±16% and 77±17%, respectively, even when adequate exercise capacity and 85% heart rate is achieved.
EST is limited in the advanced CKD population, with poor sensitivity of 36% (13) (especially those undergoing dialysis), due to reduced exercise capacity .this limitation occurs as the result of vascular, neurological or musculoskeletal comorbidities, and the catabolic metabolic state associated with CKD. CKD patients have also been shown to have impaired heart rate response to exercise and the frequently abnormal baseline ECG in CKD patients ( hypertension)
segment changes at stress were shown to be not significantly different between non-severe CAD and severe CAD group
2-EXERCISE STRESS ECHOCARDIOGRAPHY AND DOBUTAMINE STRESS ECHOCARDIOGRAPHY
Exercise stress echocardiography (ESE) is better than the standard stressECGin ruling inCAD. The sensitivity ranging from 71 to 97% with specificity ranging from 64 to 90% (17).The use of ESE in CKD population remains limited due to the same exercise intolerance that occurs in ECG test.The echocardiography is mandatory for the assessment of ventricular size and function, aortic and mitral valvular calcification, left ventricular hypertrophy (LVH), and potentially CFR.
Dobutamine and dipyridamole stress echocardiography (DSE) technique detects myocardial ischemia based on detection of wall motion abnormalities, So it detect significant epicardial CAD, not microvascular disease.
Abnormal DSE results in CKD patients have been associated
with poorer prognosis for cardiac events and overall mortality.
3- MYOCARDIAL PERFUSION SCINTIGRAPHY
Exercise and pharmacological myocardial perfusion scintigraphy (MPS) have sensitivity of 87 and 89%, and specificity of 73 and 75%, respectively, in detecting >50% coronary artery stenosis in patients without advanced CKD
Again Exercise MPS in the advanced CKD population has the same limitation as EST and ESE, i.e., related to the inadequate exercise tolerance and chronotropic incompetence
abnormal MPS results in CKD patients have been
shown to be associated with a higher incidence of cardiac events and mortality.
myocardial ischemia was associated with sixfold increased risk of myocardial infarction and almost fourfold risk of cardiac death.The fixed ischemic defects associated with fivefold increased risk of cardiac death.myocardial perfusion abnormalities significantly predicted cardiac events in CKD patients independently of eGFR and left ventricular ejection fraction.
4-CARDIOVASCULAR MAGNETIC RESONANCE
Cardiovascular magnetic resonance (CMR) with gadolinium contrast is contraindicated in the CKD patient due to the risk of nephrogenic systemic fibrosis. NSF manifests as a hardening of the skin and internal organs resembling scleroderma, which is irreversible and potentially fatal. Cardiovascular magnetic resonance spectroscopy has been
studied to assess early cardiac dysfunction in pediatric population with advanced CKD
mai shawky
2 years ago
ESKD patient with hypertension, dyslipidemia and chest pain during rest (with fear and concern to have coronary artery diseases) Diagnostic evaluation:
· History regrading chest pain, timing, relation to meals and exertion, other symptoms of peripheral vascular disease. manifestations of heart failure as peripheral edema, dyspnea and congestive symptoms.
· Cardiovascular examination, especially HR and ABP to exclude uncontrolled hypertension or significant aortic stenosis.
· start with Baseline 12-lead ECG then proceed to Cardiac stress investigation.
a. Exercise stress ECG: has low sensitivity in CKD patient (36%) due to abnormal basal ecg and Impaired heart rate response to exercise in addition abnormal ST segment changes at stress were shown to be not significant between non-severe CAD and severe CAD group.
b. Exercise stress echocardiography and dobutamine stressECHO:
· limited value in CKD population
· Dipyridamole and dobutamine stress is often recommended as a screening test in advanced CKD patients.
· Several mechanisms explain the reduced accuracy of DSE in the advanced CKD due to blunted response of the hypertrophied ventricles to dobutamine stimulation.,
· Thick myocardium due to LVH with small intracavitary volume, commonly found in CKD patients, obscures the detection of wall motion abnormality.
c. Myocardial perfusion scintigraphy:
· Exercise and pharmacological myocardial perfusion scintigraphy (MPS) have 87% sensitivity and 75% specificity in detecting >50% coronary artery stenosis in patients without advanced CKD.
· Abnormal MPS results in CKD patients have been shown to be associated with a higher risk of cardiac events and mortality.
· Presence of reversible defects of inducible myocardial ischemia was associated with six fold increased risk of myocardial infarction and almost fourfold risk of cardiac death. this indicates referral to coronary angio for better diagnostic accuracy and possibility of therapeutic stenting.
· The presence of fixed defects was associated with a nearly 5 times higher risk of sudden cardiac death.
· Cardiac MRI: not preferred in advanced or borderline CKD population due to the concern of nephrogenic systemic fibrosis.
our practice in pediatrics is just basal ecg and echo. this is due to less prevalence of cardiovascular diseases among our young patients.
Giulio Podda
2 years ago
Summarise the management of the case presented in this article
60-year-old women with CKD (stage V) presented with atypical chest pain needs evaluation for coronary artery disease (CAD). She has an high cardiovascular risk in view of advanced CKD and history of hypertension. I would assess the history of the present complain (type of pain”Constricitive” “pressure type chest pain”, any SOB, any radiation of the pain, nausea,vomiting or any sweating etc). However I have to consider that CKD is often multivessel and causes silent or asymptomatic MI. I would arrange an e.cg.and blood test (Troponin baseline and 6 or 12 hours etc). Depend on e.c.g. and troponin results may require a coronary angiogram. In terms of diagnostic evaluation: EXERCISE STRESS ECG (EST) has a low modrate sensitivity and specificity in normal renal function (68 +/-_16% and 77 +/-17%), respectively, even when adequate exercise capacity and 85% heart rate is achieved . EST is further limited in advanced CKD population, with poor sensitivity of 36% (especially those on dialysis). HD patient have reduced exercise capacity, as deconditioning results. Deconditioning can be due to vascular, neurological ormusculoskeletal comorbidities, and the catabolic/cachexic metabolic state associated with CKD leads to reduced exercise capacity EXERCISE STRESSECHOCARDIOGRAPHYANDDOBUTAMINESTRESS ECHOCARDIOGRAPHY (ESE) is better than the standard stress ECG in ruling in CAD (Positive likelihood ratio ESE 7.94 versus EST 3.57) and ruling out CAD (Negative likelihood ratio ESE 0.19 versus EST 0.38). However,the utilityof ESE in CKD population remains limited due to the same physical reasons as EST limitations. Its sensitivity ranges from 71 to 97% with specificity ranging from 64 to 90% . It is possible to assess the ven tricular size and function, aortic and mitral valvular calcification, left ventricular hypertrophy (LVH), and potentially CFR with the addition of echocardiography. The use of the Doppler echocardiography in the left anterior allows the measurement of the CFR measurement by Dobutamine and dipyridamole stress echocardiography (DSE) technique detects inducible myocardial ischemia based on detection of wall motion abnormalities. DSE detect significant epicardial CAD, not microvascular disease. A meta analysis showed that dipyridamole and dobu- tamine stress echocardiography had a sensitivity of 85% and 86% respectively, and a specificity of 89% and 86%, respectively, in detecting myocardial ischemia in the non-renal population. Overall, DSE has moderate sensitivity of 80% in detecting inducible myocardial ischemia in renal transplant candidates in view of blunted chronotropic response and thick myocardium which obscures the detection of wall motion abnormalities at stress, thus, significantly reducing the sensitivity of stress echocardiography in detecting inducible myocardial ischemia in CKD population. MYOCARDIAL PERFUSIONSCINTIGRAPHY (MPS) Exercise MPS in the advanced CKD population has the same limitation as EST and ESE in view of the inadequate exercise performance and chronotropic incompetence. MPS has a sensitivity of 87and 89%, and specificity of 73and 75%, respectively, in detecting >50% coronary artery stenosis in patients without advanced CKD. MPS has sensitivity of 69% and specificity of 77% in diagnosing inducible myocardial ischemia in the pre-renal transplant population. Unlike the normal population a normal myocardial perfusion in CKD population may not be associated with excellent prognosis and this could be explained in view of the high-false negative result from balanced ischemia. MPS has high false negative result in detecting ischemia in people with significant triple vessel CAD, as in the CKD population, because of homogeneous tracer uptake due to balanced ischemia. CARDIOVASCULARMAGNETICRESONANCE (CMR) with gadolinium. It is not widely used as it may induce nephrogenic systemic fibrosis. Gadolinium may induece rare but serius side effect such as hardening of the skin and internal organs resembling scleroderma (potentially lethal), which is irreversible and potentially fatal. Dobutamine stress CMR was shown to be safe in the pre-renal transplant population
Please reflect on your practice explaining how you would manage this case in your hospital setting
In the first instance we have to take the history of the present complain. Will need a baseline e.c.g and if any dynamic changes (ST elevation or STdepression) and bllod test confirm a cardiac event (Raise troponin) will need an urgent cardiology review and coronary angiogram. We need to know if the patient has risk factors for cardiac event rather than hypertension and CKD (smoking, diabetes, dyslipidemia, and family history of cardiac disease). If the patient has no acute cardiac event (Myocardial infarction, iscahemia etc) prior to the transplant I would arrange an exercise tolerance for prognosis, symptoms capacity and perioperative risk assessment (in his case transplant). I would request a baseline e.c.g and baseline resting ECHO to exclude valve disease (for e.g. aortic stenosis) and to assess LVH. Exercise stress ECHO to exclude inducible myocardial ischemia, inducible arrhythmia, to assess exercise capacity If the patient is at high risk I would arrande a DSE and as above mentione if patient has dymanic e.c.g changes (MI cardiac iscahemia than Coronary angiography
Zahid Nabi
2 years ago
Management
Silent CAD is quite common in CKD patients and while doing transplant work up in this population of patient this fact should always be kept in mind.
The patient in this case Vignette is considered high risk being 60 years of age having CKD and hypertensive. Her symptoms are of atypical chest pain and she would require a base line ECG and cardiac stress evaluation that could be stress ECG MPS or Doubutamine stress Echo.A base line echo should be done to rule out aortic stenosis before proceeding for these tests. Each test has its own pitfalls as these have quite low sensitivity and specificity.
In patients with normal renal function, exercise stress test (EST) with ECG has a low to moderate sensitivity and specificity, 68 ± 16% and 77 ± 17%, respectively, even when adequate exercise capacity and 85% heart rate is achieved.
EST is further limited in the advanced CKD population, with poor sensitivity of 36% (especially those undergoing dialysis), as deconditioning leads to reduced exercise capacity. Deconditioning can be due to vascular, neurological or musculoskeletal comorbidities, and the catabolic/cachexic metabolic state associated with CKD.
Exercise stress echocardiography (ESE) is better than the standard stress ECG in ruling in CAD (Positive likelihood ratio ESE 7.94 versus EST 3.57) and ruling out CAD (Negative likelihood ratio ESE 0.19 versus EST 0.38).Its sensitivity has been reported ranging from 71 to 97% with specificity ranging from 64 to 90%. However, the utility of ESE in CKD population remains limited due to the same physical reasons as EST limitations above.
Dobutamine and dipyridamole stress echocardiography (DSE) technique detects inducible myocardial ischemia based on detection of wall motion abnormalities, thus, would detect significant epicardial CAD, not microvascular disease.
Overall, DSE had moderate sensitivity of 80% (confidence interval 64–90) in detecting inducible myocardial ischemia in renal transplant candidates.
The majority of advanced CKD patients had a blunted chronotropic response, thus, did not achieve 85% maximal predicted heart rate despite the use of atropine, significantly reducing the sensitivity of DSE in detecting myocardial ischemia The thick myocardium due to LVH with small intra- cavitary volume, commonly found in CKD patients, obscures the detection of wall motion abnormalities at stress, thus, significantly reducing the sensitivity of stress echocardiography in detecting inducible myocardial ischemia in CKD population. Microvascular CAD is difficult to appreciate given the focus on regional wall motion abnormality and likely to be missed.
Exercise and pharmacological myocardial perfusion scintigraphy (MPS) have sensitivity of 87 and 89%, and specificity of 73 and 75%, respectively, in detecting >50% coronary artery stenosis in patients without advanced CKD. Exercise MPS in the advanced CKD population has the same limitation as EST and ESE, i.e., related to the inadequate exercise performance and chronotropic incompetence.
A systematic review in 2011 showed that MPS has sensitivity of 69% (confidence interval 48–85) and specificity of 77% (confidence interval 59–89) in diagnosing inducible myocardial ischemia in the pre-renal transplant population. MPS has high false negative result in detecting ischemia in people with significant triple vessel CAD, as in the CKD population, because of homogeneous tracer uptake due to “balanced ischemia”
we at our center will send this patient for MPS after baseline echo and ECG are ok.We will consider coronary angio depending upon MPS result , obviously our Cardialogist will be the one following these patients
Reem Younis
2 years ago
Summarise the management of the case presented in this article DIAGNOSTIC EVALUATION
-Thorough clinical history and examination ( exclude uncontrolled hypertension or significant aortic stenosis )
-Baseline 12-lead ECG.
-Cardiac stress investigations . EXERCISE STRESS ECG
In patients with normal renal function, exercise stress test (EST) with ECG has a low to moderate sensitivity and specificity.EST is further limited in the advanced CKD population, with poor sensitivity , as deconditioning leads to reduced exercise capacity .
CKD patients have also been shown to have impaired heart rate response to exercise , and the frequently abnormal baseline ECG in CKD patients . In advanced CKD patients, the ST segment changes at stress were shown to be not significantly different between non-severe CAD and severe CAD group . EXERCISE STRESS ECHOCARDIOGRAPHY AND DOBUTAMINE STRESS ECHOCARDIOGRAPHY
Exercise stress echocardiography (ESE) is better than the standard
Stress ECG in ruling in CAD and ruling out CAD.
The addition of echocardiography allows assessment of ventricular size and function, aortic and mitral valvular calcification, Left ventricular hypertrophy (LVH),and potentially CFR.
Dobutamine and dipyridamole stress echocardiography(DSE) Technique detects inducible myocardial ischemia based on detection of wall motion abnormalities, thus, would detect significant epicardial CAD, not microvascular disease. Abnormal DSE results in CKD patients have been associated With poorer prognosis for cardiac events and over all mortality. MYOCARDIAL PERFUSIONSCINTIGRAPHY
Exercise and pharmacological myocardial perfusion scintigraphy (MPS) have sensitivity of 87and 89%,and specificity of 73 and 75%, respectively, indetecting >50% coronary artery stenosis in patients without advanced CKD.
MPS has High false negative result in detecting ischemia in people with significant triple vessel CAD ,as in the CKD population . CARDIOVASCULAR MAGNETIC RESONANCE
Cardiovascular magnetic resonance(CMR) with gadolinium con-Trast has not been widely utilized clinically in the CKD population Due to the concern of nephrogenic systemic fibrosis (NSF).
-In this case ,ESE is recommend to exclude inducible myocardial ischemia, inducible arrhythmia, and to assess exercise capacity and symptoms objectively.
Resting echocardiograph is useful to exclude significant aortic stenosis prior to exercise stress and to visually assess the degree of LVH. Please reflect on your practice explaining how you would manage this case in your hospital setting
-Detailed history and full clinical examination.
-ECG ,Chest x-ray ,cardiac enzymes and other laboratory tests.
-Cardiac consultation for further evaluation of the patient.
CKD patients have increased risk of cardiovascular morbidity and mortality, so renal transplant recipients must be evaluated properly before proceeding for transplant .
Evaluated by:
-proper history taking
-Full examination especially cardiac ( pulse , bp , auscultation)
-12- lead ECG and ECHO
-stress test
Diagnostic approaches:
*Exercise stress testing:
it is limited in advanced CKD patients and sensitivity about 36% due to reduced exercise capacity.
* Exercise stress echocardiography:
is an alternative to the stress ECG for diagnosing CAD
Its sensitivity ranging from 71 to 97% and specificity ranging from 64 to 90%.
But exercise intolerance and deconditioning in CKD are limiting its use .
*Exercise and pharmacological myocardial perfusion scintigraphy :
They can detect more than 50% of coronary artery stenosis in pt without advanced CKD with
sensitivity of 87 and 89% with specificity of 73 and 75%, respectively, .
In my practice
kidney transplant candidates must be assessed by :
-Good history taking
-Examination with assessment of all risk (obesity, smoking …
-ECG and ECHO
-stress ECG
If any abnormalities we are referring to tertiary center for coronary angio
Marius Badal
2 years ago
Summarise the management of the case presented in this article
The patient in this case presentation has traditional cardiovascular diseases risk factors like for example hypertension, and dyslipidemia and she is over 60 years of age with atypical cardiovascular pain during rest. Cardiovascular disease has been the leading cause of death in patients with no kidney disease and in those with kidney disease the cardiovascular diseases increase significantly. Myocardial ischemia has been the leading cause of morbidity and mortality in CKD, but its presentation has been atypical. The atypical presentation causes worries to both patients and physicians. Since it is challenging to diagnose these patients, it is advisable that a proper history be taken, and a deep clinical assessment must be made. Studies like EKG and ECHO are vital due to the information that can be received like heart dynamics, hypertrophy and muscle dyskinesias, etc. The stress cardiac evaluation that can help to facilitate a better understanding of cardiovascular evaluation are: 1) Stress EKG exercise: patient with CKD is difficult to evaluate because of their physical challenges. Its sensitivity is poor like 35-36%. 2) Stress ECHO exercise: has similar problems as the stress EKG but better in giving details like cardiac EF, LVH, valve pathologies, heart necrosis, etc. 3) Stress ECHO with medications like dobutamine and dipyridamole. This test is valuable by giving information to patients who cannot do any activity. It will provide details on inducible myocardial ischemia based on wall motion activity or inactivity. Its sensitivity is about 80% while the specificity is 89%. 4) Myocardial scintigraphy. It is a radiopharmacology study that allows one to see the anatomy of the heart and any other abnormalities. An abnormal study is related to poor prognosis and mortality. 5) Cardiovascular magnetic resonance.
Please reflect on your practice explaining how you would manage this case in your hospital setting
To manage this patient adequately the following must be done. 1) Detailed history that is an interview 2) Detailed physical examination 3) To do an investigation like EKG at resting and repeat in 6 hours to see any abnormal changes. 4) Echocardiogram to see patient baseline function. 5) Start cardioprotective medications to ensure further cardiovascular damage etc 6) Refer the patient to a cardiologist 7) Ensure blood pressures are controlled 8) Ensure proper dialysis and fluid control to prevent fluid overload 9) Ensure metabolic control and calcium and phosphorus levels are at normal levels.
10) Blood studies like lipids, chemistry, and cardiac enzymes. etc.
Huda Saadeddin
2 years ago
Cardiovascular disease (CVD) is the leading cause of mortality and a major cause of morbidity in the CKD population. Myocardial ischemia is a major cause of death in CKD patients. Myocardial ischemia can be caused by both epicardial and microvascular CAD.
patients with mild CKD had higher prevalence of severe epicardial CAD compared to those without CKD (8),thus,suggesting that the problem relates to coronary stenosis rather than plaque stability.
EXERCISE STRESS ECG
EST is further limited in the advanced CKD population, with poor sensitivity of 36% (13) (especially those undergoing dialysis), as deconditioning leads to reduced exercise capacity (14). Deconditioning can be due to vascular, neurological or musculoskeletal comorbidities, and the catabolic/cachexic metabolic state associated with CKD.
EXERCISE STRESS ECHOCARDIOGRAPHY AND DOBUTAMINE STRESS ECHOCARDIOGRAPHY
Exercise stress echocardiography (ESE) is better than the standard stress ECG in ruling in CAD (Positive likelihood ratio ESE 7.94 versus EST 3.57) and ruling out CAD (Negative likelihood ratio ESE 0.19 versus EST 0.38) (16). Its sensitivity has been reported ranging from 71 to 97% with specificity ranging from 64 to 90% (17). However, the utility of ESE in CKD population remains limited due to the same physical reasons as EST limitations Abnormal DSE results in CKD patients have been associated with poorer prognosis for cardiac events and overall mortality.
Negative stress echocardiography results, on the other hand, have been shown to be associated with low incidence of major adverse cardiac events (21).
Blunted chronotropic response with exercise in CKD population may relate to poorer overall cardiac prognosis.
Managmanet of this old ckd patient proper hx and physical examination
labs including cardiac enzymes ,cbc,hga1c ,ecg ,echo ,stress ecg and exercise stress echo
Cardiology follow up medical treatment with asa statins and his anti hypertensive
Rahul Yadav rahulyadavdr@gmail.com
2 years ago
Summarize the management of the case presented in this article
The patient presented in the case has traditional cardiovascular risk factors like hypertension, borderline dyslipidemia, age of 60 years with history of atypical chest pain at rest.
In view of above findings and presence of CKD stage 5, she needs further evaluation as cardiovascular disease is the leading cause of morbidity and mortality is these subsets of patients.
CKD patients often have multi-vessel CAD and can cause asymptomatic myocardial ischemia and the case presented here is genuinely worried about CAD.
Diagnostic evaluation starts with proper clinical examinations and 12 Lead ECG.
ECHO to rule out Aortic stenosis and Left Ventricular hypertrophy before ordering Stress cardiac investigations.
Stress cardiac evaluation with their potential implications and limitations as below:
1. Exercise Stress ECG(EST): Exercise capacity is poor in patients with CKD (especially those on dialysis) in view of inactivity, deconditioning, catabolic state and sarcopenia. Also, frequent presence of baseline abnormal ECG, impaired heart response to exercise, EST has poor sensitivity (36%) in these subsets of patients.
2. Exercise Stress Echocardiography (ESE): ESE has similar limitations due to reduced exercise capacity as mentioned above but better than EST in ruling in (better LE+ ratio of ESE versus EST) and rulling out (Lesser LE- ratio of ESE versus EST) CAD. In addition, it can estimate Ejection Fraction, LVH, valvular calcifications, Aortic stenosis and coronary flow reserve.
3. Dobutamine and Dipyridamole (Pharmacological) Stress ECHO: It bypasses the exercise limitations in these subsets of patients but have similar limitations due to CKD (like blunted chronotropic response and left ventricular hypertrophy limiting spatial resolution of positive findings). It would detect inducible myocardial ischemia based on wall motion abnormality and overall moderate sensitivity (80%) and specificity (89%) in CKD patients. Abnormal DSE is related to poor prognosis and overall mortality. Microvascular disease is likely to be missed due to more focus on wall motion abnormality during DSE.
4. Myocardial Perfusion Scintigraphy: Exercise/Pharmacological MPS has false negative results in case of triple vessel disease due to balanced ischemia which is not uncommon in patients with advanced CKD. Abnormal MPS in CKD patients have been associated with higher incidence of cardiac events and myocardial ischemia.
5. Cardiovascular Magnetic Resonance: Utility is limited due to risk of NSF caused by gadolinium contrast usage in CKD patients
6. Non-Contrast Blood oxygen level dependent (BOLD) CMR: It’s a new technique utilized to assess ischemia by assessing myocardial oxygenation in few human studies and initial results are promising. This needs to be further tested.
Authors of this article in light of above information recommends clinical examination (Heart sounds/murmurs),12 lead ECG,ECHO(assessing LVH,AS) and DSE to rule out inducible myocardial ischemia by assessing wall motion abnormality in this case.
Please reflect on your practice explaining how you would manage this case in your hospital setting
Clinical Examination
Evaluation of non-traditional cardiovascular risk factors like Hb, Serum Vitamin D3/Calcium/Phosphate/Intact PTH/Urinary Spot Albumin creatinine ratio
12 Lead ECG (for arrythmias)
ECHO to evaluate for Ventricular function, Left Ventricular Hypertrophy and Aortic Stenosis
DSE to rule out inducible/reversible myocardial ischemia by picking wall motion abnormality, exercise tolerance and prognosis (In view of age around 60 years with hypertension and history of atypical chest pain at rest)
If DSE s/o of abnormality, Coronary angiogram and proceed
Cardiology referral for as mentioned above
Mu'taz Saleh
2 years ago
Please reflect on your practice explaining how you would manage this case in your hospital setting
1- more history about her chest pain and associated symptoms
2- comprehensive physical examination ( fluid overload , arrhythmia , murmurs , peripheral pulses
3- ECG , CXR , cardiac enzymes
4- Echo : assessment of EF , Hypokinesia , Valvular disease , LVH
5- labs for non traditional risk factors ( Ca , PO4 , PTH , CBC , Iron SAT , Protienurea , Urea
6- consult cardiologist
7- EST and consider ESE ( if available )
Summarise the management of the case presented in this article :
DIAGNOSTIC EVALUATION:
Clinical history
Examination
A baseline 12-lead ECG.
resting echo
Cardiovascular examination, primarily to exclude uncontrolled hypertension or significant aortic stenosis, is essential before cardiac stress investigation.
2-EXERCISE STRESS ECHOCARDIOGRAPHY AND DOBUTAMINE STRESS ECHOCARDIOGRAPHY : Reduced exercise capacity(deconditioning)
Impaired chronotropic response
Abnormal baseline ECG and leftventricular hypertrophy
3- Myocardial perfusion scintigraphy : Blunted chronotropic response
Left ventricular hypertrophy Micro vascular disease potentially can be missed
4-CARDIOVASCULAR MAGNETIC RESONANCE : False negative results in multi-vessel disease due to balanced ischemia
Radwa Ellisy
2 years ago
Coronary artery diseases are prevalent in CKD patients even with early stages.
Evaluation could be done:
I- stress tests
– Initially, clinical evaluation using 12- lead ECG and echocardiography to exclude stenosis before stress testing
– Exercise testing has a low to moderate sensitivity and specificity in patients with normal kidney function even after reaching 85% of heart rate exercise.
– In advanced CKD patients has a poorer sensitivity as 36%.
II- MYOCARDIAL PERFUSION SCINTIGRAPHY
– In non-advanced CKD patients, scintigraphy studies (using either pharmacological or exercise induction) could detect coronary artery stenosis more than 50% with sensitivity 87 and specificity 73%.
– In pretransplant patients with reversible perfusion defects have fourfold increase in cardiac events, and patients with fixed defects have a 5-fold increase in cardiac events.
– Patients with blunted response have increased risk for mortality.
Limitations in advanced CKD:
§ Chronotropic incompetence
§ Exercise intolerance.
§ High false negative results in detecting ischemia in multivessel coronary artery disease due to balanced ischemia causing homogenous uptake.
§ With normal MPS, Advanced CKD patients have a 3-time cardiac death more non CKD patient.
III- Exercise stress echocardiography:
– Exercise stress echocardiography (ESE) is more sensitive and specific than stress ECG.
– Provide structural and functional assessment.
– Assessment of CFR in the left anterior descending artery (main determinant of cardiac events)
IV- Dobutamine and dipyridamole stress echocardiography (DSE)
– It detects inducible myocardial ischemia. It could assess significant epicardial diseases rather than microvascular disease.
– It is recommended as a screening test in advanced CKD patients.
– Abnormal DSE is associated with poor outcomes
Limitation:
– Blunted chronotropic response.
– Difficulty assessing wall motion abnormalities due to LVH and reduced intracavitary volume
V- CARDIOVASCULAR MAGNETIC RESONANCE
– it is of limited used due to nephrogenic systemic fibrosis which occur in advanced CKD patients.
– CMR spectroscopy could be used for diagnosis early cardiac dysfunction in pediatric patients with advanced CKD.
– Dobutamine CMR could be used safely in advanced CKD patients.
reflection in my practice:
in pretransplant evaluation:
detailed history and physical examination
ECG, ECHO
dobutamine stress test
+/- coronary angiography if indicated
Manal Malik
2 years ago
2-reflect on your practice explaining how you would manage this case in your hospital setting
more detail history needed in this case like more history about GN,is associtted with nephrotic or not because as we konw the degree of protienurea corealate with cvs events.
ask about any symptoms of ischemia such as intermittent cauldication.
ask about other risk factor such as stress at work.
ask about other cvs symptom such as S.O.B on exertion….
clinical exainmation
general examination such as anaemia
check the Bp (controlled or not)
fluid status (euovolmic or hypervolumic)
CVS ;
pluse
perherial pluse
carotidplue(bruit).
examine for any murmur or sign of HF.
lowe limb for oedema
LAB
full chemistry and CBC.
lipid profile HAIC
cardiac enzyme
RESTING ECG
RESTING ECHO to role out any aortic stenosis and LVH.
CARDILOGY REFERAL
Thank You, but you have not reflected on the practice in Sudan. I know that you are immunologist, but at least you can ask your nephrology colleagues.
Manal Malik
2 years ago
1 Summary of Myocardial ischemia assessment in chronic kidney disease: challenges and pitfallsThe major cause of CVS death in ckd is myocardial ischemia and usually is multi vessel,micro vascular CAD has been associated with reduced survival.
Diagnostic evulation based on history,clinical examination and12 lead ECG. Exercise stress ECG
Has low to moderate sensitivity and specificity in patients with normal renal function but has limited poor sensitivity of 36% in advanced ckd population especially in dialysis patients due to vascular or musculoskeletal comorbidity and catabolic state associated with ckd.
unable to interpenetrated stress test in advanced ckd due to abnormal baseline response to exercise ,st segment changes at stress in advanced ckd more show no significant different between sever CAD and non sever CADin longer treadmill exercise time in the non sever group. EXercise stress Echocardiography and Dobutamine Stress Echocardiography
Exercise stress Echo is better than stress ECG in diagnosis CAD.
71 to 97% sensitivity range of ESE and specificity ranging from 64 to 90 %.
ESE is limited in ckd patients due to above mention physical reason as in exercise stress ECG.
CFR is measurement by Doppler echo cardiology in the left antior descending artyery is most cause of cardiac event in ckd patients and can not performed routinely due to technical difficulties . Dobutamine and dipyridamole stress echo
DSE detects ineducable myocardial ischemia based on detection of wall motion abnormalities so detect significant epicardial CAD,not microvascular disease..
Ametanalysis in 2008 showed dipyridmole and dioubtamine stress echo cardology has high sensitivity and specifcity in detecting myocardial ischemia in non renal patients.
it is recommented screening test in advanced ckd patients.
abnormal MPS in ckd patients associated with higher incidence of cardiac events and mortality.
some of studies showed that in pre-transplant patients the presence of reversible defect of ineducable myocardial ischemia was associated with 6 fold increased of risk of myocardial infraction and 4 fold risk of cardiac death.
The presence of fixed defect was associated five fold increased risk of cardiac death . Cardiovascular magnetic resonance
CMR with gadolinum contrast has not been used in ckd patients due to NSF.
CVS magnetic resoance spectoscopy has been studies to assess early cardiac dysfunction in padetartic population with advanced ckd.
doutamine stress CMR safe in pre renal transplant recipient Recommendation
iExerscise tolerence iscrucial in perioperative risk assessment.
in renal transplantESE is recommended to exclude ineducable myocardial ischemia ,ineducable arrhythmia and exercise capcity,
Resting echo is mandatory to exculde aortic stenosis and degree of LVH prior to exercise stress test. ) iew / Download
Summarise the management of the case presented in this article
A 60-year-old female with CKD and atypical chest pain needs evaluation for coronary artery disease (CAD) in view of high risk of cardiovascular morbidity and mortality in this patient population.
The various aspects of evaluation in such patients include:
1) Detailed history
2) A thorough clinical examination including pulse, blood pressure and cardiovascular examination.
3) A baseline 12-lead ECG
4) Non-invasive testing
5) Coronary angiography
The diagnostic approach involves the following tests:
1) Exercise stress ECG: In CKD patients, although the specificity is high (94%), its sensitivity is very low (36%) due to poor exercise capacity and an impaired chronotropic response. Abnormal baseline ECG and left ventricle hypertrophy further reduce its usefulness. The ECG changes between non-severe and severe CAD patients have not been found to be significantly different.
2) Stress Echocardiography (Exercise Stress Echocardiography, ESE and Dobutamine/ Dipyridamole Stress Echocardiography, DSE): The usefulness of ESE is also low in CKD patients due to poor exercise capacity, impaired chronotropic response and left ventricular hypertrophy. The sensitivity and specificity of DSE in CKD patients is 80% and 89% respectively. The sensitivity is less than the non-renal population due to blunted chronological response, presence of left ventricle hypertrophy obscuring wall motion abnormality detection and chances of missing microvascular disease. Abnormal DSE results are associated with poor outcomes.
3) Myocardial Perfusion Scintigraphy (MPS) – Exercise and pharmacological stress associated: It is done using SPECT and has low sensitivity and specificity (69% and 77%) with false negative results in patients with triple vessel disease due to balanced ischemia (homogeneous tracer uptake). Exercise MPS has limitations due to inadequate exercise performance and chronotropic incompetence. Perfusion defect on stress only signifies myocardial ischemia. A reversible defect is associated with 6 times increased risk of myocardial infarction and 4 times increased risk of cardiac death. A fixed defect is associated with 5 times increased risk of cardiac death. Even a normal MPS has 3 times increased risk of cardiac death.
4) Cardiovascular Magnetic Resonance (CMR): It has not been used in CKD patients due to increased risk of nephrogenic systemic fibrosis.
In the index case, patient was advised exercise stress echocardiography (ESE) after a resting echocardiography.
Please reflect on your practice explaining how you would manage this case in your hospital setting
In our unit, a CKD-ESRD patient being planned for kidney transplant is assessed in association with cardiologist by:
· Thorough history: especially for risk factors like age more than 50 years, diabetes, hypertension, obesity, smoking history, dyslipidemia etc)
· Physical examination: especially pulses, blood pressure, cardiovascular examination
· Initial evaluation for all patients: ECG and baseline Echocardiography
· Dobutamine Stress Echocardiography (DSE) in high-risk individuals.
· Coronary angiography in symptomatic patients, or a DSE suggesting ischemia.
# Case presentation management :
60 years old female with CKD S 5 due to GN .
no cardiac risk factors a part from hypertension and CKD ( not diabetic , cholesterol 5 mmoL/L , and LdL 3.2 mmoL/L, and does not smoke, no family history )
presented with atypical chest pain and worried about to have CAD .
# measures of treatment of the case ?
Exercise ECG testing :
with reduce sensitivity and specificity in CKD patients a round 36% in comparing to non-CKD patients ,( about 68% +/-16% for sensitivity , and 77% +/- 17% for specificity ) .
CKD patient have reduce exercise capacity , due to vascular, neurological, muscloskeletal comorbidities, (osteodystrophy, osteoporosis) and their sequel.
another limitation of ECG in CKD patients is that , there is abnormal ECG changes secondary to HTN, and this affect interpretation of standard stress test.
also in advance CKD, ST segment stress test changes, not significantly different between sever, non-sever CAD, even with long time exercise.
2.Exercise stress Echocardiograghy and Dobutamine stress Echocardiograghy:
Better (than exercise ECG in specificity and sensitivity, and detection of abnormal wall motion ischemia) in ruling in CAD with +ve likelihood ratio of 7.94 comparing to 3.57 in E_ECG test, also in ruling out with -ve likelihood of 0.19, versus 0.38 in E_ECG tset .
Have the sensitivity of 71-97% and specificity of 64-90% .
Benifit is to assess ventricular size and function, aortic and mitral valve calcification, LVH, and potential CFR.
limitations: in CKD patients due to physical reasons mentioned before.
3.Dobutamine and pyridamole stress ECHO :
Detect inducible myocardial ischemia, wall motion abnormality, and epicardial CAD.
In metanalysis done in 2008, show specificity of 85% and specificity of 89% for dobutamine, and sensitivity of 86% , specificity of 86% for pyridamole, in detecting myocardial ischemia,
It is recommended as screening test in CKD, and pre-transplant candidates.
Limitation, thick wall of ventricle obscure detection of wall motion abnormality.
Abnormal DES associated with poor prognosis, and overall mortality.
4.MPS, myocardial perfusion scintigraphy :
Exercise and pharmacological, sensitivity (87%and 89%) and specificity, (73%and 75%) respectively.
used in detecting > 50% of coronary artery stenosis in patients without advance CKD .
Exercise MPS in advance CKD have some limitation, as EST,and ESE, which is related to limited capacity, and chronotropic incompetance.
Abnormal MPS, in CKD, patients associated with higher incidence of cardiac events and increased mortality.
5.Cardiovascular magnetic resonance :
CMR with gadolinium, not widely used, in CKD, due to concern of nephrogenic systemic fibrosis, NSF.
CMR spectroscopy, assess early cardiac dysfunction, in advance CKD.
CMR deputamine stress test , safe in pre-renal kidney transplantation.
In conclusion : ESE is recommended, to assess inducible myocardial ischemia, arrythmia, and to assess exercise capacity, and symptoms.
Resting ECHO. to exclude significant aortic stenosis, prior to exercise and to assess degree of LVH.
# In my facility :
$ inpatient general and routine investigation and imaging for detection of any abnormality that related to our CKD patient , and to apply cardioprotective measures according to the guidelines, and to refer to cardilogist for invasive and non-invasive techniques to diagnose and manage defects.
$ in our dialysis center we become more specific in categorization of the dialysis patients , to delay, prevent, and prevent as quick as possible patient at risk, includinf scanned ECG, and ECHO, with followup by cardiologist, as well as intervention cardilogy .
DIAGNOSTIC EVALUATION
1st step; bedside evaluation
A thorough clinical history and examination
and a baseline 12-lead ECG, exclusion of uncontrolled hypertension or significant aortic stenosis
2nd step; cardiac stress investigation
EXERCISE STRESS ECG
Deconditioning problems in the advanced CKD population render EST of limited use with a sensitivity of 36%
EXERCISE STRESS ECHOCARDIOGRAPHY
Because of the same physical reasons as EST limitations, its use in CKD population is still limited. nevertheless, it allows assessment of ventricular size and function, valvular calcification, left ventricular hypertrophy (LVH), and potentially CFR.
DOBUTAMINE STRESS ECHOCARDIOGRAPHY
DSE has a reduced accuracy in the advanced CKD population and of moderate sensitivity of 80% (confidence interval 64–90) in detecting inducible myocardial ischemia in renal transplant candidates however, It may be recommended as a screening test in advanced CKD patients.
MYOCARDIAL PERFUSION SCINTIGRAPHY
It can see more than 50% coronary artery stenosis in patients without advanced CKD with 87 % sensitivity and 89 % specificity. however, it has the same limitation as EST in the advanced CKD population.
CARDIOVASCULAR MAGNETIC RESONANCE( CONTRAST ENHANCED)
Its use in CKD population should be limited as the contrast media used may result in a severe condition (NSF).
So for this 60-year-old woman with stage 5CKD who presented with atypical chest discomfort at rest, and worried about (CAD). She
has hypertension .with no DM, no family history of premature CAD, and does not smoke.
I would recommend ESE to detect possible ischemia and to asses her ventricles regarding LVH after completing her bedside evaluation.
Please reflect on your practice explaining how you would manage this case in your hospital setting
history of exertional dyspnea
Clinical examination
Resting ECG
Cardiac enzymes
CXR- abdominal U/S
Cardiology consultation if further investigations are needed.
Thank You, I’m sure you can add more reflection on your practice. You work up potential recipients in your clinic. Please add more
Wadia Elhardallo
2 years ago
Summarise the management of the case presented in this article
In general: cardiac evaluation starts with history, clinical examination then investigation. Is Important for risk stratification of the patients and identifications of possible contraindication to stress studies such as significant aortic stenosis and uncontrolled hypertension.
Exercise stress ECG
In patients with normal renal function, exercise stress test (EST) with ECG has a low to moderate sensitivity 68 ± 16% and specificity 77 ± 17%.EST is further limited in the advanced CKD population, with poor sensitivity of 36%.In advanced CKD patients, the ST segment changes at stress were shown to be notsignificantly different between non-severe CAD and severe CAD group
Exercise stress echocardiography and dobutamine stress echocardiography
Exercise stress echocardiography (ESE) is better than the standard stress ECG in detecting and excluding CAD Its sensitivity has been reported ranging from 71 to 97% with specificity ranging from 64 to 90%. But they share the same limitation by physical activity and exercise intolerance in CKD population. The echocardiography allows assessment of ventricular size and function, aortic and mitral valvular calcification, left ventricular hypertrophy (LVH).
Dobutamine and dipyridamole stress echocardiography (DSE) technique detects inducible myocardial ischemia based on detection of wall motion abnormalities, so they detect significant epicardial CAD, not microvascular disease. It has relitaivly high sensitivity 80 (64–90) % and specificity 89 (79–94) % in CKD population so It is often recommended as a screening test in advanced CKD patients. Abnormal DSE results in CKD patients have been associated with poorer prognosis for cardiac events and overall mortality.
Myocardial Perfusion Scintigraphy
Exercise and pharmacological myocardial perfusion scintigraphy (MPS) have sensitivity of 87 and 89%, and specificity of 73 and 75%, respectively, in detecting >50% coronary artery stenosis in patients without advanced CKD .Exercise MPS in the
advanced CKD population has the same limitation as EST and ESE. MPS has high false negative result in detecting ischemia in people with significant triple vessel CAD, as in the CKD population, because of homogeneous tracer uptake due to balanced ischemia. abnormal MPS results in CKD patients have been shown to be associated with a higher incidence of cardiac events and mortality. The presence of fixed defects was associated with a nearly fivefold increased risk of cardiac death
Cardiovascular Magnetic Resonance
Cardiovascular magnetic resonance (CMR) with gadolinium contrast not used in CKD population due risk of nephrogenic systemic fibrosis (NSF) Dobutamine stress CMR was shown to be safe in the pre-renal transplant population.
*The lady is having risk factors for CAD (traditional) Age, HTN, Hyperlipidaemia and most importantly atypical chest discomfort. she might have other risk factors when assessed by further investigation.
When screening for CAD They depend mainly on:
Exercise stress ECG: which is better than the standard stress ECG in ruling in CAD, but in CKD patients its limited by exercise tolerance and fatigability. When compared sensitivity its reduced from 68 % normal people to 36% in CKD.
Echocardiography: allows assessment of ventricular size and function, aortic and mitral valvular calcifications left ventricular hypertrophy (LVH).
Please reflect on your practice explaining how you would manage this case in your hospital setting
Start assessment with: detailed history, clinical examination, investigate as possible all risk factors * traditional + non-traditional (including dialysis duration if on dialysis)
Standard 12 lead ECG,Echocardiography for ALL.
MDT with cardiologist for risk stratification and further steps individualized according to each patient’s condition.
Summarise the management of the case presented in this article
– 60 y old male chronic kidney disease stage five with atypical chest pain and onARBS and B blockers with no family history of coronary artery disease.
– for diagnosis :-
* execise stress test:
studies shown poor sensitivity in advanced kidneys diseases especially those who under dialysis.
Chronic kidney disease patients have poor response to exercise inform of impaired heart rate with abnormal baseline ECG. * exercise stress Ecchocardiography and dobutamine stress echocardiography:
helps in assessment of assessments of ventricular size and function s valve calcification (mitral and aortic) and measurement of Coronary flows reserve in left anterior descending artery , while dobatamine and dipyridamole stress has 85% sensitivity and 89% specificity and recommended as a screening test in patients with advanced coronary artery disease .
Abnormal DSE has poor prognosis with high mortality while negative one had low adverse cardiac events. * myocardial perfusion scientigraphy :-
studies shown MPS has false negative result in detecting ischemia in patient with triple vessels diseases. While abnormal MPS has increased incidence of cardiac diseases with increased mortality.
* cardiovascular magnetic resonance :-
CMR with gadolinium contrast carried risk of nephrogenic systemic fibrosis while dobutamine stress CMR safe in pre-renal transplant recipients.
Please reflect on your practice explaining how you would manage this case in your hospital setting:
– full history regarding risk factors traditional and non-traditional).
– examination.
– Investigation.- cardiac enzymes- lipid profiles-lives enzymes – CBC – chest X-rays.
– ECG -ecchocardiography.
-Cardiology consultation.. For assessment and choice of different modalities of cardiac investigation and plan of management.
Thank you, please explain the cardiac investigations in more detail
Ghalia sawaf
2 years ago
DIAGNOSTIC EVALUATION according to the article
clinical history and examination
a baseline12 leadECG.
Cardiovascular examination
Exercise stress ECG
low to moderate sensitivity and specificity
the frequently abnormal baseline ECG in CKD patients (often secondary to hypertension) hampers the interpretation of standard stress testing.
the ST segment changes at stress were shown to be not significantly different between non-severe CAD and severe CAD group
5. Exercise stress ECHOCARDIOGRAPHY low to moderate sensitivity and specificity
imited due to the same physical reasons as EST limitations above.
6. Dobutamin stress ECHOCARDIOGRAPHY
based on detection of wall motion abnormalities ,thus, would detect significant epicardial CAD, not microvascular disease
7.MPI SCINTIGRAPH
have sensitivity of 87and89%, and specificity of 73 and 75% ,respectively ,indetecting>50% coronary artery stenosis in patients without advanced CKD
False negative results in multi-vessel disease due to balance dischemia
8. Cardiovascular magnetic resonance
with gadolinium contrast has not been widely utilized clinically in the CKD population due to the concern of nephrogenicsy stemicfibrosis(NSF)(4
Dobutamine stress CMR was shown to be safe in the pre-renaltransplant population
In our practice
History and examination
Echo cardiogram
ECG
our Hospital is lacking of MPI
SO we perform cardiologist to make decision about ICA
echo doppler to rule out atherosclerotic vascular disease
A 60-year-old woman with stage 5 chronic kidney disease (CKD) from glomerulonephritis presented with atypical chest discomfort at rest. She is worried about coronary artery disease (CAD). She has hypertension treated with an angiotensin converting enzyme inhibitor and a beta blocker. Her total cholesterol is 5 mmol/L with low-density lipoprotein of 3.2 mmol/L. She has no diabetes mel[1]litus, no family history of premature CAD, and does not smoke. How should she be evaluated?
Management of the case starts with a thorough clinical history about presenting symptoms, risk factors for CAD, traditional and non-traditional and symptoms of complications of CAD specifically heart failure and arrythmias and examination and a baseline 12-lead ECG.
Cardiovascular examination, especially to exclude uncontrolled hypertension, heart failure or significant aortic stenosis is important prior to cardiac stress investigation.
Then, if there is no contra indication, will go for cardiac stress investigations. These investigations have a lot of limitations in CKD patients as discussed below.
Exercise stress ECG
Has a low to moderate sensitivity and specificity of 68% and 77% respectively, even when adequate exercise capacity and 85% heart rate is achieved. EST is further limited in the advanced CKD population, with poor sensitivity of 36% specially those undergoing dialysis. This because of deconditioning which leads to reduced exercise capacity. Deconditioning can be due to vascular, neurological or musculoskeletal comorbidities, and the catabolic/cachexic metabolic state associated with CKD.
EXERCISE STRESS ECHOCARDIOGRAPHY AND DOBUTAMINE STRESS ECHOCARDIOGRAPHY
Exercise stress echocardiography (ESE) is better than the standard stress ECG in ruling in CAD (Positive likelihood ratio ESE 7.94 versus EST 3.57) and ruling out CAD (Negative likelihood ratio ESE 0.19 versus EST 0.38). Its sensitivity has been reported ranging from 71 to 97% with specificity ranging from 64 to 90%. However, the utility of ESE in CKD population remains limited due to the same physical reasons as EST limitations above. The addition of echocardiography allows assessment of Ventricular size and function, aortic and mitral valvular calcification, left ventricular hypertrophy (LVH), and potentially CFR.
MYOCARDIAL PERFUSION SCINTIGRAPHY
Exercise and pharmacological myocardial perfusion scintigraphy (MPS) have sensitivity of 87 and 89%, and specificity of 73 and 75%, respectively, in detecting >50% coronary artery stenosis in patients without advanced CKD. Exercise MPS in the advanced CKD population has the same limitation as EST and ESE, i.e related to the inadequate exercise performance and chronotropic incompetence.
CARDIOVASCULAR MAGNETIC RESONANCE
Cardiovascular magnetic resonance (CMR)with gadolinium contrast has not been widely utilized clinically in the CKD population due to the concern of nephrogenic systemic fibrosis (NSF). The use of Gadolinium chelates is prohibitive in CKD patients Due to the rare but serious side effect of NSF. NSF manifests as a Hardening of the skin and internal organs resembling scleroderma, which is irreversible and potentially fatal.
In this case we recommend ESE, to exclude inducible myocardial ischemia, inducible arrhythmia, and to assess exercise capacity and symptoms objectively. Resting echocardiography is useful to exclude significant aortic stenosis prior to exercise stress and to visually assess the degree of LVH.
Please reflect on your practice explaining how you would manage this case in your hospital setting
In our hospital setting, this case needs full history, including presenting symptoms analysis, risk factors for CAD and initial targeted examination of her cardiovascular systems. Then initial 12 leads ECG, routine lab including cardiac enzymes and Chest x ray. Since presentation is with chest pain in patient with multiple risk factors for CAD, cardiologist involvement to decide further investigations and management of the case is needed. If acute coronary syndrome is diagnosed such case will be primarily under cardiology care with follow up from nephrology for kidney issues.
DIAGNOSTIC EVALUATION
* clinical history
* Clinical examination
* Cardiovascular examination
* Assess fluid overload , Urea , hemoglobin vitamin D, calcium, phosphate, PTH ,Alb , Chol , TG, and proteinuria .
* Assess Inflammatory state
* Resting ECG
* Resting echocardiography
** Exercise stress ECG ( poor sensitivity , Deconditioning due to vascular, neurological or musculoskeletal comorbidities, catabolic/cachexic metabolic state that leads to reduced exercise capacity )
** Exercise stress echocardiography ( high Sensitivity and Specificity , limitations due to the same physical reasons )
Dobutamine stress echocardiography
( recommended in advanced CKD patients)
** Myocardial perfusion scintigraphy
( high false negative result in triple vessel CAD, and CKD )
** Cardiovascular magnetic resonance ( risk of Nnephrogenic systemic fibrosis , assess early cardiac dysfunction in pediatric population with advanced CKD
# In our practice for assessment this patient we do cardiovascular examination , Chest X ray , resting ECG , resting echocardiography , assest PAD , MPI and Consult cardiologist .
· Summarise the management of the case presented in this article
This patient has many risk factors for CVD: her age, hypertension, advanced chronic kidney disease, dyslipidaemia, and maybe proteinuria due to GN.
But she the good thing that she is not smoker, not diabetic, and has no family history of CVD.
1) We need more detailed history of type of pain, exacerbating and relieving factors, distribution and localization.
2) Good clinical examination for chest, abdomen, to role out extracardiac cause of pain, and cardiac examination for JVP and murmurs to role out valve lesion, and exclude uncontrolled hypertension.
4) I will not go for Exercise stress ECG because of : Reduced exercise capacity, Impaired chronotropic response, and abnormal base line ECG.
5) Exercise Stress Echocardiography and Dobutamine Stress Echocardiography also the same as ESE in advanced kidney disease.
6) Exercise Myocardial perfusion scintigraphy in the advanced chronic kidney disease patient has the sane limitation as EST and ESE.
7) Cardiovascular magnetic resonance with gadolinium is contraindicated due to risk of rare but fatal nephrogenic systemic fibrosis.
· Please reflect on your practice explaining how you would manage this case in your hospital setting
After excluding extracardiac causes, I would consult the cardiologist to evaluate ECG and Echo and possible to do Exercise Stress Echo, if it is strongly suggestive of CVD and needs Angiography, I will discuss with the patient the risk and benefit of coronary angiography.
Thank you, but this is a short reflection on your practice
Ban Mezher
2 years ago
CVD is the main cause of mortality in CKD patients even in young patients. Assessment of patient with suspected coronary disease may include:
detailed history, thorough CV system examination, and resting ECG.
Exercise stress ECG but it has low sensitivity and specificity in CKD patients especially in advanced stages.
Exercise stress ECHO: its benefit in CKD patients limited due to reconditioning, impaired heart rate response and presence of abnormalities in baseline ECG. But ECHO can assess ventricular function & size, presence of valvular calcification, LVH & CFR. Dobutamine stress ECHO can detect inducible ischemia in CKD patients with sensitivity reaching 80%( reduced in advanced CKD stage). Reducing sensitivity in CKD patients may be due to LVH with small ventricular cavity, and blunted heart rate response. Positive result of stress ECHO associated with poor CV risk while negative results associated with low frequency of major cardiac events.
MPS: both exercise & pharmacological MPS have moderate sensitivity & specificity in detection of CVD when there is >50% stenosis( in patients without CKD). Among CKD patients, the sensitivity is reduced more due to exercise intolerance & poor heart rate response. MPS has good false negative results in diagnosis of ischemia due to 3 vessels disease with CKD due to balance ischemia & abnormal MPS associated with increased frequency of cardiac events & death.
CMR: due to using go gadolinium in MRI that can cause NSF it is not used widely among CKD patients. In pediatric CMR spectroscopy can be used to assess early cardiac dysfunction & dobutamine stress CMR can be used safely in CKD patients.
Combination of BOLD-CMR & non contrast whole-heart MRC angiography can assess myocardial ischemia in patients with advanced CKD stage.
In conclusion for this CKD patient ESE recommended to exclude inducible ischemia, inducible arrhythmia, in addition to assessing exercise capacity.
In my hospital we can assess CKD patients with resting ECG, resting ECHO and pharmacological stress ECHO in addition to clinical history & examination.
Chronic kidney disease is associated with increase cardiovascular risk and cardiovascular mortality.
Renal transplant candidate awaiting for kidney transplantation should be stratified for cardiovascular risk and evaluated carefully before proceeding into transplantation surgery. Cardiovascular evaluation of renal transplant candidate passes through a multidisciplinary approach including endocrinologist, pulmonologist, nephrologist and cardiologist.
Standard evaluation begins with a detailed clinical history and examination, a baseline 12-lead ECG and transthoracic echocardiography in patient with suspected underlying LVH, valvular, pericardial disease or pulmonary hypertension.
Diagnostic approaches:
– Exercise stress testing is the initial testing in exercise tolerating patients however it is limited in the advanced CKD population, with poor sensitivity of 36% as deconditioning leads to reduced exercise capacity.The stress induced ST segment changes in patients with advanced CKD, were shown to be not indicative of the severity of CAD, non-severe CAD a VS severe CAD group.
– Exercise stress echocardiography is an alternative or complementary option to the standard stress ECG in ruling in CAD and ruling out CAD). Its sensitivity has been reported ranging from 71 to 97% with specificity ranging from 64 to 90%.However, deconditioning of CKD population and exercise intolerance limits its use.
– Dobutamine and dipyridamole stress echocardiography technique detects inducible myocardial ischemia based on detection of wall motion abnormalities.Dipyridamole and dobutamine stress echocardiography had a sensitivity of 85and 86%, respectively, and a specificity of 89% and 86% , respectively, in detecting myocardial ischemia in the non-renal population. In renal population, a systematic review of 11 DSE studies with 690 potential renal transplant recipients reported that DSE had moderate sensitivity of 80% in detecting inducible myocardial ischemia. Abnormal DSE results in CKD patients have been associated with poorer prognosis for cardiac events and overall mortality.
– Exercise and pharmacological myocardial perfusion scintigraphy have sensitivity of 87 and 89%, and specificity of 73 and 75%, respectively, in detecting >50% coronary artery stenosis in patients without advanced CKD. Exercise MPS is limited for the same reasons of exercise intolerance in CKD population. A systematic review in 2011 showed that MPS has sensitivity of 69% and specificity of 77% in diagnosing inducible myocardial ischemia in the pre-renal transplant population. A meta analysis of 12 studies of prerenal transplant patients showed that the presence of reversible defects of inducible myocardial ischemia was associated with sixfold increased risk of myocardial infarction and almost fourfold risk of cardiac death. The presence of fixed defects was associated with a nearly fivefold increased risk of cardiac death.
In my practice, kidney transplant candidates with traditional risk factors of cardiovascular complications (smokers, diabetic, obese, hypertensive, dyslipidemic) are evaluated initially with ECG and Echocardiography followed by stress exercise testing and in cases with findings suggestive of underlying ischemia, patients are sent to cardiac catheterization.
Cardiovascular disease accounts for almost half the deaths of patient with esrd (20% to coronary artery disease )
Screening is indicated is symptomatic patient
Symptoms mabay typical and may atypical(silent -arrythmias _exertional dyspnea_weakness _ syncope)
Our patient is 60 year old female with hypertension and without family
history of cad
She asked to be investigated for cad
First thing to do is Ecg(cad changes as general population)
Second to do echocardiography for the patient to exclude valvular heart disease(especially aortic stenosis )
Then a non invasive test should be done
There are multiple tests with deffirence in sensitivity and specificity summarised as follow :
1_excesice stress test :
It is of moderate sensitivity and specificity
Many patients couldn’t reach the wanted heart rate due to exercise intolerance
Other probleme is basic ecg changes due to hypertension which could affect the interpretation of standard stress testing .
2_ Exercise echocardiography:
It is of better sensitivity and specificity compare to exercise test alone
The echocardiography could give us information about valvular lesions and cardiac wall movment with stress, however similar problems like exercise test are present (exercise intoleranc and other interpretation).
3_dobutamin stress echocardiography:
May solves the problemes with exercise sterss test with better sensitivity and specificity compare to stress test ,however cause it depends on cardiac wall abnormality ,it is ability to detect microvascular lesions is limited.
Cariac waa thickness due to LVH may reduce it’s sensitivity.
4_myocardial perfusion scintigraphy :
Althoug have tow methods to do
Throughout excersie or pharmacological
It is of good sensitivity with less specificity percentage.
Same problems in exercise test
The test has ahigh prevelance of false negative results.
5_cardiovascular magnitic resonance :
Of no clinical use cause due to concern of nephrogenic systemic fibrosis .
Please reflect on your practice explaining how you would manage this case in your hospital setting
First thing i will do ecg and echocardiography
Correct anemia if present
Add aspirin with monitoring of bleeding .
Correct mbd especially if the patient takes unneeded calcium containing drug.
Blood control to goal of 130/80
A cardiologist must be consulted
We don’t have mps
So the best choice in my center will be stress echocardiography cause it is available and cheap as primary noninvasive test.
The cardiologist opinion is also important
A detail clinical history history and cardiovascular examination.
Exercise stress test. It has a poor sensitivity among CKD population especially those on dialysis due to deconditioning effect that reduce their exercise capacity.
Exercise stress echocardiography and dobutamine stress echocardiography.
Myocardial perfusion scintigraphy.
Cardiovascular magnetic resonance.
How to mangment in hospital:
Full clinical history and cardiovascular examination
Clinical history, cardiovascular examination and baseline ECG to exclude severe aortic stenosis and uncontrolled HTN before proceeding to cardiac stress investigations. Exercise stress ECG:
Has several limitations in CKD patients due to:
Poor sensitivity especially in those on dialysis because of deconditioning that limits exercise capacity due to associated comorbidities and catabolic state.
Impaired heart rate response to exercise
Abnormal baseline ECG often due to HTN making interpretation of stress testing difficult
Severe and non-severe CAD in CKD patients have similar ST segment changes
Exercise stress echocardiography (ESE) and dobutamine stress echocardiography (DSE):
ESE is more sensitive than exercise stress ECG but its use in CKD patients is limited due to the limited exercise capacity.
Echocardiography provide information about ventricular size and function, valvular calcifications, left ventricular hypertrophy (LVH) and potential coronary flow reserve.
DSE detects significant epicardial CAD but not microvascular disease as it detects wall motion abnormalities resulting from inducible ischemia.
DSE has lower accuracy in CKD patients due to
The poor chronotropic response which fails to reach 85% of predicted heart rate resulting in reduced sensitivity in detecting myocardial ischemia.
Presence of LVH in CKD patients limiting the detection of induced wall motion abnormalities
Abnormal DSE in CKD patients is associated with poor prognosis for cardiac events and mortality.
However, DSE is recommended as screening test in advanced CKD population. Myocardial perfusion scintigraphy (MPS):
Exercise MPS is limited in CKD patients due to the decreased exercise capacity and poor chronotropic response
Has sensitivity of 69% and specificity of 77% in diagnosing inducible myocardial ischemia in pre-transplant patients.
Associated with high false negative results in triple vessel CAD in CKD patients due to “balanced ischemia” that cause homogenous uptake of tracer.
A study showed that CKD patients with normal MPS have three times higher rate of cardiac death than non-CKD patients with normal MPS, this may be due to reduced coronary flow reserve, LVH with increased baseline myocardial blood flow and peripheral endothelial dysfunction in CKD patients.
Abnormal MPS results in CKD patients are associated with higher incidence of cardiac events and mortality.
Blunted heart rate response in CKD patients during stress MPI is associated with increased mortality. Cardiovascular magnetic resonance (CMR):
Its use is limited in CKD patients due to the associated risk of nephrogenic systemic fibrosis which is irreversible and potentially fatal.
New non-contrast blood oxygen level dependent CMR technique and non-contrast whole heart MR coronary angiography are potential for assessing myocardial ischemia in CKD patients and need further studies.
In our practice:
This patient is considered at high risk for CAD and presenting with atypical chest pain, we will do serial resting ECG and cardiac enzymes to exclude active cardiac condition.
Resting echocardiography to assess ventricular size and function
She will be referred to cardiologist who will ask for Dobutamine stress echocardiography, if positive or non-conclusive (predicted heart rate wasn’t reached), she will have coronary angiography after informing her about the risk of contrast induced nephropathy.
Given data:
Age 60 years, female, stage 5 ckd, presented with atypial chest dyscomfort.
Evaluation:
History – examination (BP, cardiovascular system) to exclude accelerated hypertension and aortic stenosis) – ECG- exercise stress echo.
In my hospital, I wll assess the same way as described here. one other thing, I will do s. Troponin I level to exclude acute MI during initial presentation
Thank you for your reply; please explain more. You need also to structure your summary
Jamila Elamouri
2 years ago
• Summarise the management of the case presented in this article. EXERCISE STRESS ECG
In patient with normal renal function, EST has a low to moderate sensitivity and specificity, even when adequate exercise capacity and 85% heart rate is achieved. EST limited further in advanced kidney disease, with poor sensitivity (36%). Because deconditioning leads further to decrease exercise capacity. Deconditioning occurs as a result to vascular, neurological or musculoskeletal comorbidities,
and the catabolic/cachexic metabolic state associated with CKD. CKD patients have also been shown to have impaired heart rate response to exercise, and abnormal baseline ECG which interfere with EST interpretation. In advanced CKD patients, the ST segment changes at stress were shown to be not significantly different between non-severe CAD and severe CAD group, despite a longer treadmill exercise time in the non-severe group. EXERCISE STRESS ECHOCARDIOGRAPHY AND DOBUTAMINE STRESS ECHOCARDIOGRAPHY
Exercise stress echocardiography (ESE) is better than the standard stress ECG in ruling in CAD and ruling out CAD. However, the utility of ESE in CKD population remains limited due to the same physical reasons as EST limitations above.
The addition of echocardiography allows assessment of ventricular size and function, aortic and mitral valvular calcification, left ventricular hypertrophy (LVH), and potentially CFR. CFR measurement by Doppler echocardiography in the left anterior descending artery has been shown to be a determinant of cardiac events in CKD patients in the absence of obstructive epicardial CAD, but, it is not performed routinely by many echocardiography laboratories due to technical difficulties.
Dobutamine and dipyridamole stress echocardiography (DSE)technique detects inducible myocardial ischemia based on detection of wall motion abnormalities, thus, would detect significant epicardial CAD, not microvascular disease.
It is often recommended as a screening test in advanced CKD patients.
The majority of advanced CKD patients had a blunted chronotropic response, and even with the use of atropine they do not reach 85% maximal predicted heart rate, which further reduce the DSE sensitivity in detecting myocardial ischemia. Additionally, LVH with small intracavitary volume, obscures the detection of wall motion abnormalities at stress, thus, reduce the sensitivity of stress echocardiography.
Abnormal DSE results in CKD patients have been associated with poorer prognosis for cardiac events and overall mortality. Negative stress echocardiography results, on the other hand, have been shown to be associated with low incidence of major adverse cardiac events. Blunted chronotropic response with exercise in CKD population may relate to poorer overall cardiac prognosis. MYOCARDIAL PERFUSION SCINTIGRAPHY
Exercise and pharmacological myocardial perfusion scintigraphy (MPS) have sensitivity of 87 and 89%, and specificity of 73 and 75%, respectively, in detecting >50% coronary artery stenosis in patients without advanced CKD. MPS has high false negative result in detecting ischemia in people with significant triple vessel CAD, as in the CKD population, because of homogeneous tracer uptake due to “balanced ischemia. abnormal MPS results in CKD patients have been shown to be associated with a higher incidence of cardiac events and mortality. CARDIOVASCULAR MAGNETIC RESONANCE
Cardiovascular magnetic resonance (CMR) with gadolinium contrast has not been widely utilized clinically in the CKD population due to the concern of nephrogenic systemic fibrosis (NSF).
my work up to this patient will include ECG, Echo, SET
Please reflect on your practice explaining how you would manage this case in your hospital setting
IT is cardiologist decision according to the patient’s risk
Our patient is:
· 60 years old
· HTN
· CKD
· Atypical chest pain
· Dyslipidemia
The article addressed that management includes thorough history regarding any symptoms suggestive of cardiovascular disease and proper examination including a baseline 12-lead ECG, transthoracic echo in suspected valvular, pericardial or pulmonary hypertension is suspected to exclude any symptoms that may hinder cardiac stress investigations.
Chronic kidney disease is associated with increased cardiovascular risk and mortality.
Standard evaluation begins with a detailed clinical history and examination as mentioned
Diagnostic approaches:
· Exercise stress testing
· Stress echocardiography
· Exercise and pharmacological myocardial perfusion scintigraphy
According to my practice, all kidney transplant potential recipients are evaluated initially by ECG and Echocardiography, Cardiological consultation is done in most cases especially those with CAD, valvular diseases, arrhythmias and pulmonary HTN.
A comprehensive clinical history, physical examination, and baseline 12-lead ECG, are the first steps in the process
Exercise stress ECG : Limited in the advanced CKD population, with low sensitivity of 36% (particularly in those receiving dialysis).
Due to vascular, neurological or musculoskeletal comorbidities, and the catabolic/cachexic metabolic state associated with CKD
EXERCISE STRESS ECHOCARDIOGRAPHY AND DOBUTAMINE STRESS ECHOCARDIOGRAPHY:
ESE sensitivity has been reported ranging from 71 to 97% with specificity ranging from 64 to 90%.
Limitations : Reduced exercise capacity (deconditioning) Impaired chronotropic response Abnormal baseline ECG and left ventricular hypertrophy.
Pharmacological stress echocardiography:
Sensitivity : 80 (64–90) %
Specificity : 89 (79–94) %
Limitations : Blunted chronotropic response Left ventricular hypertrophy Microvascular disease potentially can be missed
Myocardial perfusion scintigraphy :
Sensitivity : 69 (48–85)%
Specificity : 77 (59–89)%
Limitations : False negative results in multi-vessel disease due to balanced ischemia.
In Our Practice :
Basal ECG and ECHO >> anay indication for coronary angiography , Iwill proceed after cardiology consultation
Normal ECG and ECHO : so ECHo with dobutamin or Myocardial perfusion scintigraphy .
Myocardial ischemia assessment in chronic kidney disease: challenges and pitfalls
Summarise the management of the case presented in this article
Please reflect on your practice explaining how you would manage this case in your hospital setting
Bedside investigations:
Specific Cardiac evaluation
Exercise Stress Ecg
Exercise Stress Echocardiography and Dobutamine Stress Echocardiography
Myocardial Perfusion scintigraphy
Cardiovascular Magnetic Resonance
In our practice will do: 12 lead ECG, stress ECG and Echo will be done. If any cardiac abnormality, consultation of cardiologist and possible coronary angiography plus PCI will be considered.
This patient need to be evaluated for myocardial ischemia it done by resting ECG and Echocardiography then they did stress ECG to induce ischemia or arrhythmia,if the patient physical cannot tolerate the exercise pharmacological stress ECHO it will do the job ,if the result is positive for ischemia then myocardial perfusion imaging will be done,
In our transplant center in Sudan we did the same
CV complications are the leading cause for morbidity and mortality in CKD patients with MI being the commonest cause of death in those population. CAD in renal patients has is related to both traditional and non traditional risk factors . Traditional risk factors as HPN , DM , obesity, dyslipidemia and smoking while non traditional risk factors as uremic toxins , endothelial dysfunction and chronic inflammation.
CAD could occur at macro vascular level and affected by athermanous plaque size and stability or occur at microvascular level related to endothelial dysfunction. Clinical presentation of CAD in renal patients is the same as general population, but investigations and diagnosis are less specific and less sensitive in CKD patients.
Investigations for CAD and their limitation in CKD
1- Standard ECG : simple , non invasive test can diagnose chamber enlargement, arrythmia and current or past MI and ischemia . in CKD , base line changes caused by HPN usually present and may mask new ischemic manifestations.
2- Exercise ECG : usually limited sensitivity due to deconditioning and poor HR response due to uremic autonomic neuropathy
3-Echo : non invasive, very valuable in assessing myocardial function expressed as EF, diagnos chamber enlargement, regional wall hypokinesia consistent with ischemia
limitation
Dobutamine stress echo : used for diagnosis of induced ischemia indicating underly epicardial CAD with sensitivity reaching 85 % in non renal population but its sensitivity is lower in CKD and kidney transplant recipient may be due to blunted chronotropic effect in those patients. Also LVH that’s commonly present in CKD patients masks the stress induced wall motion abnormalities.
Despite these limitations , abnormal stress echo is associated with poor outcome and increased mortality in renal patients.
4- Exercise and pharmacological myocardial perfusion scientigraphy : has sensitivity and specificity of 87 and 75 % respectively to diagnose CAD with stenosis> 50% in non renal patients. Abnormal MPI in CKD patients us associated with increased mortality
Drawbacks of MPI
have high rate of false negative results in CKD patients due to balanced ischemia and blunted heart rate response to stress due to uremic autonomic neuropathy.
5-Cardiac magnetic resonance (CMR) with gadolinium contrast :
is not widely used in CKD patients due to risk of nephrogenic systemic sclerosis.
Conclusion
All myocardial investigations are of limited sensitivity and specificity in CKD patients so assessing the myocardial condition should include combination of different investigations with exercise stress testing are very important to express functional capacity of the patients.
In our hospital
we start with non invasive investigations as ECG and trans thoracic echo ,if abnormal or in presence of other risk factors as DM , obesity ,age >50 y we proceed to dobutamine stress echo study . in cases of wall motion abnormalities suggesting ischmia , we perform CT coronary angiography . While if cardiomyopathy was detected we proceed with CT coronary angiography to diagnose underlying CAD and cardiac MRI to exclude infiterating diseases.
*Management of presenting case: This patient is 60 years, ESRD ,HTN, dyslipidemic , has atypical chest pain; For CAD evaluation:
5. Cardiac MRI with gadolinium: not preferred in advanced CKD patients due to risk of nephrogenic systemic fibrosis which resembles scleroderma potentially fatal disease. Dobutamine stress CMR is safer in the pre-renal transplant patients.
MANAGEMENT includes:
-A detailed clinical history history and examination of cardiovascular system.
-Exercise stress test: It is characterized by poor sensitivity in CKD patients ;more in dialysis patients due to reduced exercise capacity.
-Exercise stress and dobutamine stress echocardiography.
-Myocardial perfusion scintigraphy.
-Cardiovascular MR.
Hospital management:
-Full history and cardiovascular examination
-Cardiology consultation.
-ECG :rest & exercise.
-Coronary angiogram.
-Lab work up : Cardiac enzymes, lipid profile, Pro BNP, urinalysis &urine albumin, CRP and homocysteine.
Myocardial ischemia assessment in chronic kidney disease: challenges and pitfalls
Coronary artery disease is the leading cause of mortality and morbidity in the chronic kidney disease (CKD) population and often presents with atypical symptoms. CKD patients have both traditional and non-traditional cardiac risk factors. In the CKD population, CAD is often multi-vessel and causes silent or asymptomaticmyocardial ischemia Current diagnostic investigations of myocardial ischemia in CKD lack sensitivity and specificity or may have adverse effects.
Case review:
A 60-year-old female patient CKD stage V secondary to chronic glomerulonephritis presented with atypical chest discomfort at rest. She has history of controlled HTN on ARBS and beta blockers,she also has dyslipidemia but no history of DM.No family history of CAD.No smoking.
Evaluation for cardiovascular disease:
Diagnostic evaluation starts with a thorough clinical history and examination and a baseline 12-lead ECG.Cardiovascular examination, especially to exclude uncontrolled hypertension or significant aortic stenosis is important prior to cardiac stress investigation.
EXERCISE STRESS ECG In patients with normal renal function, exercise stress test (EST) with ECG has a low to moderate sensitivity and specificity 68 and 77% respectively. EST is further limited in the advanced CKD population, with poor sensitivity of 36% (13) (especially those undergoing dialysis), as deconditioning leads to reduced exercise capacity (14). Deconditioning can be due to vascular, neurological ormusculoskeletal comorbidities, and the catabolic/cachexic metabolic state associated with CKD. CKD patients have also been shown to have impaired heart rate response to exercise.
EXERCISE STRESS ECHOCARDIOGRAPHY AND DOBUTAMINE STRESS ECHOCARDIOGRAPHY
Its sensitivity has been reported rang- ing from 71 to 97% with specificity ranging from 64 to 90%. The addition of echocardiography allows assessment of ven- tricular size and function, aortic and mitral valvular calcification, left ventricular hypertrophy (LVH).
Dobutamine and dipyridamole stress echocardiography (DSE) technique detects inducible myocardial ischemia based on detec- tion of wall motion abnormalities, thus, would detect significant epicardial CAD, not microvascular disease.
MYOCARDIAL PERFUSIONSCINTIGRAPHY
Exercise and pharmacological myocardial perfusion scintigraphy (MPS) havesensitivity of 87and 89%,and specificity of 73and 75%, respectively,in detecting >50% coronary artery stenosis in patients without advanced CKD(26). Exercise MPS in the advanced CKD population has the same limitation as EST and ESE.
Cardiovascular magnetic resonance (CMR) with gadolinium contrast has not been widely utilized clinically in the CKD population due to the concern of nephrogenic systemic fibrosis (NSF)
In the current case we recommend ESE, to exclude inducible myocardial ischemia, inducible arrhythmia, and to assess exercise capacity and symptoms objectively. Resting echocardiography is useful to exclude significant aortic stenosis prior to exercise stress and to visually assess the degree of LVH.
Myocardial ischemia assessment in chronic kidney disease: challenges and pitfalls.
In those with chronic kidney disease (CKD), cardiovascular disease (CVD) is the main cause of mortality and a significant cause of morbidity. One of the main causes of death in people with CKD is myocardial ischemia. Both epicardial and microvascular CAD can result in myocardial ischemia.
Coronary artery disease is quite common in the CKD population and is present in young CKD patients as well as those with early renal failure .
CAD is frequently multi-vessel and produces silent or asymptomatic myocardial ischemia in the CKD population .Even individuals with early-stage CKD have been found to have asymptomatic epicardial CAD .and those with CAD had a greater rate of significant adverse cardiac events .While the prevalence of high-risk plaque in patients with CKD was similar to that in the group without CKD .Kawai et al. found that patients with mild CKD had a higher prevalence of severe epicardial CAD than those without CKD .suggesting that the issue is more likely related to coronary stenosis than plaque stability.
diagnostic assessment
An extensive clinical history, physical exam, baseline 12-lead ECG, and diagnostic evaluation are the first steps in the process. Prior to conducting a cardiac stress test, it is crucial to perform a cardiovascular examination, especially to rule out uncontrolled hypertension or substantial aortic stenosis.
EXERCISE STRESS ECG
Exercise stress test (EST) with ECG has a low to moderate sensitivity and specificity in patients with normal renal function, even when appropriate exercise capacity and 85% heart rate are obtained.
As deconditioning reduces exercise capacity, EST is further constrained in the advanced CKD population, with poor sensitivity of 36% (particularly in those receiving dialysis).
Deconditioning can result from comorbidities in the vascular, nervous, or musculoskeletal systems as well as the catabolic/cachexic metabolic state linked to CKD. Exercise heart rate response in CKD patients has also been demonstrated to be hindered, and routine stress testing is made more difficult by their usually aberrant baseline ECGs (typically brought on by hypertension).
EXERCISE STRESS ECHOCARDIOGRAPHY AND DOBUTAMINE STRESS ECHOCARDIOGRAPHY
Exercise stress echocardiography (ESE) can diagnose and rule out CAD more effectively than a normal stress ECG. Its specificity ranges from 64 to 90%, and its sensitivity has been reported to be between 71 and 97%. However, the same physiological limits that apply to EST mentioned above limit the efficacy of ESE in the CKD population.
Aortic and mitral valve calcification, left ventricular hypertrophy (LVH), and maybe CFR can all be assessed with the addition of echocardiography. Although many echocardiography laboratories do not routinely conduct this due to technological challenges, CFR assessment by Doppler echocardiography in the left anterior descending artery has been demonstrated to be a determinant of cardiac events in CKD patients in the absence of obstructive epicardial CAD.
Dobutamine and dipyridamole stress echocardiography (DSE) approach would detect severe epicardial CAD, not microvascular disease, because it detects inducible myocardial ischemia based on detection of wall motion abnormalities.
A worse prognosis for cardiac events and overall mortality has been linked to abnormal DSE values in CKD patients.
Blunted chronotropic response to exercise in the CKD population may be associated with a worsened prognosis for the heart as a whole.
MYOCARDIAL PERFUSION SCINTIGRAPHY
In patients without severe CKD, exercise and pharmacological myocardial perfusion scintigraphy (MPS) have sensitivity and specificity values of 87 and 89% and 73 and 75%, respectively, for diagnosing >50% coronary artery stenosis. The same limitations that apply to EST and ESE apply to exercise MPS in the advanced CKD population, i.e., linked to insufficient exercise performance and chronotropic incompetence.
Due to the high rate of false negative results from balanced ischemia, normal myocardial perfusion as evaluated by SPECT may not be associated with a favourable prognosis in the CKD group as opposed to the normal population.
Concurrent lowered CFR and LVH may also be important.
However, it has been demonstrated that aberrant MPS findings in CKD patients are linked to a higher incidence of cardiac events and mortality.
A nearly fivefold higher risk of cardiac mortality was linked to the existence of permanent abnormalities.
CARDIOVASCULAR MAGNETIC RESONANCE:
Due to the risk of nephrogenic systemic fibrosis (NSF), cardiovascular magnetic resonance (CMR) with gadolinium contrast has not been widely used clinically in the CKD population. Because of the uncommon but severe side effect of NSF, CKD patients are unable to use gadolinium chelates. NSF causes a permanent and potentially fatal hardening of the skin and internal organs that resembles scleroderma.
Pediatric patients with severe CKD have been investigated to assess early heart impairment using cardiovascular magnetic resonance spectroscopy. The safety of dobutamine stress CMR in the prerenal transplant population has been established.
Assessment of Exercise Intolerance in Patients with Pre-Dialysis CKD with Cardiopulmonary Function Testing: Translation to Everyday Practice.
Components of Exercise intolerance tests
1) Exercise stress ECG
Sensitivity 36 (21–54)%
Specificity 91 (83–96%
Practical issues
Reduced exercise capacity (deconditioning)
Impaired chronotropic response Abnormal baseline ECG and left ventricular hypertrophy
2) Exercise stress echocardiography
Sensitivity and specificity possibly similar to DSE.
Practical issues
Reduced exercise capacity (deconditioning)
Impaired chronotropic response Abnormal baseline ECG and left ventricular hypertrophy
3) Pharmacological stress echocardiography
Sensitivity 80 (64–90)%
Specificity 89 (79–94) %
Practical issues
Blunted chronotropic response
Left ventricular hypertrophy
Microvascular disease potentially can be missed
4) Myocardial perfusion scintigraphy
Sensitivity 69 (48–85)%
Specificity 77 (59–89)%
Practical issues
False negative results in multi-vessel disease due to balanced ischemia.
5) Dobutamine stress CMR
Research ongoing for specificity and sensitivity.
Practical issues
Blunted chronotropic response.
Microvascular disease potentially can be missed.
MPS has sensitivity of 69% (confidence interval 48–85) and specificity of 77% (confidence interval 59–89) in diagnosing inducible myocardial ischemia in the pre-renal transplant population. Abnormal MPS results in CKD patients have been shown to be associated with a higher incidence of cardiac events and mortality. Blunted heart rate response in CKD patients during stress myocardial perfusion imaging has been reported to be associated with increased mortality.
Cardiovascular magnetic resonance (CMR) with gadolinium contrast has not been widely utilized clinically in the CKD population due to the concern of nephrogenic systemic fibrosis
This lady with CKD5, with HTN and DM, presented with suspected coronary artery disease. They started by thorough clinical history and examination and abase line12 lead ECG. Resting echocardiography is useful in assessing presence of aortic stenosis and LVH prior to cardiac stress investigation. In advanced CKD patients, stress tests have limited role in detecting CAD. Stress tests include:
1- Exercise ECG but the ST segment changes at stress were not different between non-severe and severe CAD in advanced CKD patients. Furthermore it is limited by the reduced exercise capacity and impaired chronotropic response.
2- exercise echocardiography stress test is limited by the reduced exercise capacity , the impaired chronotropic response and the abnormal baseline ECG and left ventricular hypertrophy
3- The dipyridamole and dobutamine stress echocardiography (Pharmacological stress echocardiography) is often recommended as a screening test in advanced CKD patients but it has reduced accuracy due to again blunted chronotropic response, LVH and the possibility of missing microvascular disease
4- Myocardial perfusion scintigraphy limited by false negative results in multi-vessel disease due to balanced ischemia
5- Dobutamine stress CMR limited by blunted chronotropic response and the possibility of missing microvascular disease
Exercise tolerance are useful in pre transplant workup to exclude inducible myocardial ischemia, arrhythmia and exercise capacity.
First we do thorough history, looking for risk factors and then a meticulous cardiovascular examination. Resting ECG and echocardiography are mandatory in all cases. Those with risk factors were referred for cardiac clearance and possible dobutamine stress tests.
Management:
Detailed history taking is required for this 60 year old woman, with variable risk factors including age, CKD stage 5, hypertensive, dyslipdaemic.
Criteria of atypical chest pain, onset of hypertension and duration, hypertension is also controlled or not .Lifestyle is it active or sedentary, diet and salt intake.
Steps done:
Baseline line ECG,
Stress ECG, not preferred in CKD
Baseline echocardiography.
Stress echocardiography, inconvenient in CKD
Myocardial perfusion scintigraphy, has limitations in CKD.
Cardiovascular magnetic resonance imaging, not done in CKD patients for fear of nephrogenic systemic fibrosis related to gadolinium use.
In our hospital, detailed history is necessary in this setting, cardiological consultation is a must, exclusion of other causes of chest pain is mandatory (muscle spasm for example),history of drug abuse to be clarified , steps would be start by cardiac enzymes as a baseline (although might be misleading ),baseline ECG , baseline echocardiography ,if positive coronary PCI and stenting may be of help.
Besides lifestyle modification and restricted salt fat diet.
First question
60 years old , female
1.Full clinical history and examination
CKD Stage 5 , HTN , not DM, not smoker , no family history of premature CAD, LDL 3.2 mmol/l
Cardiovascular examination to exclude uncontrolled HTN or severe aortic stiffness
2 . Diagnostic evaluation
A) Baseline 12 lead ECG
B) Exercise stress ECG had poor sensitivity(36%) in advanced CKD patients due to reduced exercise capacity, impaired chronotropic response , abnormal Baseline ECG in CKD patients due to HTN
C) Exercise stress echocardiography : it is better than stress ECG
In diagnosis CAD but also had same limitations as it
It allows assessment of ventricular size and function , valve calcification, LVH , CFR
It also detects inducible myocardial ischaemia by detection of wall motion abnormalities
It detects epicardial CAD but miss microvascular CAD
D) Myocardial perfusion Scintegraphy
It has the same limitations as EST and ESE in CKD patients
It has high false negative result in detecting ischaemia in people with significant triple vessel CAD
CKD patients with normal perfusion still had a three times higher cardiac death rate than those with normal MPS and no CKD may be due to concurrent CFR and LVH
E) Cardiovascular magnetic resonance
Not used in CKD patients due to gadolinium induced nephrogenic systemic fibrosis
Recommendation was to use exercise stress Echo and resting Echo
Second question
Clinical history and examination
Baseline ECG
Resting ECHO
coronary angiography
The article reviews the different strategies for studying Coronary Artery Disease (CAD), a disease that is highly prevalent in the CKD population.
– exercise stress ECG
– exercise stress echocardiography and dobutamine stress echocardiography
– myocardial perfusion scintigraphy
– cardiovascular magnetic resonance
We can see that all these strategies have a decrease in their sensitivity when compared to the general population, but accompanied by an increase in their specificity. There is no clear superiority of one strategy over another, however, exercise tolerance has shown greater importance both for prognosis and for the assessment of capacity and symptoms, to the point of being recommended by the article for perioperative renal transplant patients.
Thus, in the case described, the patient underwent exercise stress echocardiography, aiming to exclude inducible myocardial ischemia, inducible arrhythmia, and to assess exercise capacity and symptoms objectively.
Due to the organization of the health system, it is more difficult to carry out strategies to evaluate exercise tolerance, being restricted to more specific cases. The most common, due to greater ease in the system, is the performance of myocardial perfusion scintigraphy, leaving the evaluation of exercise tolerance for more specific cases.
Summary:
A 60-year-old woman with stage 5 chronic kidney disease (CKD) due to glomerulonephritis presented with atypical chest discomfort at rest. She is hypertensive with two antihypertensives, nno diabetic, non smoker and no family history of premature CAD.
Here evaluation done by
1. Exercise stress ECG
2. Exercise stress echocardiography and dobutamine stress echocardiography
3. Myocardial perfusion scintigraphy
4. Cardiovascular magnetic resonance
In our practice, this high risk case coronary angiogram is the choice.
This is a 60-y old female patient with high risk factors for IHD that include being CKD-5 , Hypertension, high cholesterol.
She doesn’t have family history of CAD and she doesn’t smoke.
She presented with atypical chest pain and tightness, so IHD should be ruled out because of her high-risk factors.
Cardiac evaluation in this case includes the following:
1- Clinical: History and examination
2- Cardiac investigations:
A- 12 lead ECG.
B- Exercise stress ECG: its sensitivity and specificity in CKD patients are lower than general population without CKD (36% vs 70%).
C- Exercise stress ECHO: is better than ES-ECG in detecting myocardial ischemia (7.9 +ve likelihood ratio vs 3.5 +ve likelihood ratio). Sensitivity and specificity in detecting myocardial ischemia in CKD patients around 70%. ECHO is beneficial in detecting ventricular size and function and assess valves especially aortic and mitral.
D- Dobutamine and Dipyridamole stress ECHO: it can detect inducible myocardial ischaemia by wall motion abnormalities, howver it detects only epicardial IHD not microvacular CAD., its sensitivity and specificity around 85%, it is recommended as a screening test in CKD patients. Limitations in CKD: CKD patients show a blunted chronotropc response and they didn’t achieve 85% maximal predicted HR despite use of atropine, reduced sensitivity because of thick myocardium, can’t detect microvascular CAD.
E- Myocardial perfusion Scintigraphy (MPS exercise or pharmacological): its sensitivity and specificity in detecting inducible ischaemia in CKD is around 70% compared to around 85% in those without CKD. MPS in CKD showed high false negative results in detecting myocardial ischemia in triple vessel disease patients because of homogenous tracer uptake.
Limitation of exercise induced studies (exercise induced ECG, ECHO, MPS) in CKD patients:
1- Exercise intolerance in CKD.
2- LVH
3- Chronotropic incompetence.
F- Cardiac MRI:
1- With Gadolinium contrast is usually avoided in CKD patients (GFR below 30) for fear of NSF (Nephrogenic systemic fibrosis).
2- BOLD-CMR (blood oxygen level dependent cardiac MR): can detect epicardial and microvascular CAD.
Please reflect on your practice explaining how you would manage this case in your hospital setting
Risk stratification is assessed initially by the renal team which include proper clinical history (HTN, DM, hypercholesterolemia, smoking, cardiac symptoms, family history of IHD) and examination (age, body weight, BP, HR, fluid status, cardiac examination), routine blood investigations, 12 lead ECG, chest X-ray, and ECHO.
high risk patients, usually will be referred to cardiology team which they usually decide to go for further assessment like MPS and may subsequently advice for coronary angiography is there was evidence if reversible ischemia.
We don’t do exercise induced studies and we don’t do cardiac MR.
EXERCISE STRESS ECG
In patients with normal renal function, exercise stress test (EST) with ECG has a low to moderate sensitivity and specificity.
It has poor sensitivity of 36%, (especially those undergoing dialysis), due to reduced exercise capacity of these patients.
CKD patients have also been shown to have impaired heart rate response to exercise, and the frequently abnormal baseline ECG in CKD patients interfere with the interpretation of standard stress testing.
EXERCISE STRESS ECHOCARDIOGRAPHY AND DOBUTAMINE STRESS ECHOCARDIOGRAPHY
Exercise stress echocardiography (ESE) is better than the standard stress ECG in ruling in CAD and ruling out CAD. Its sensitivity has been reported ranging from 71 to 97% with specificity ranging from 64 to 90%.
Dobutamine and dipyridamole stress echocardiography (DSE) technique detects inducible myocardial ischemia based on detection of wall motion abnormalities, thus, would detect significant epicardial CAD, not microvascular disease.
It is often recommended as a screening test in advanced CKD patients.
LVH with small intracavitary volume, commonly found in CKD patients, obscures the detection of wall motion abnormalities at stress, thus, significantly reducing the sensitivity of the test in detecting inducible myocardial ischemia in CKD population.
Microvascular CAD is difficult to appreciate given the focus on regional wall motion abnormality and likely to be missed.
Abnormal DSE has been associated with poorer prognosis for cardiac events and overall mortality.
Negative stress echocardiography results, on the other hand, have been shown to be associated with low incidence of major adverse cardiac events.
Exercise and pharmacological myocardial perfusion scintigraphy
(MPS) have sensitivity of 87 and 89%, and specificity of 73 and 75%, respectively, in detecting >50% coronary artery stenosis in patients without advanced CKD.
abnormal MPS results in CKD patients have been shown to be associated with a higher incidence of cardiac events and mortality.
Blunted heart rate response in CKD patients during stress myocardial perfusion imaging has been reported to be associated with increased mortality.
CARDIOVASCULAR MAGNETIC RESONANCE
CMR carries risk of gadolinium induced nephrogenic systemic fibrosis in CKD with GFR < 30. It has been studied to assess early cardiac dysfunction in pediatric population with advanced CKD. Dobutamine stress CMR was shown to be safe in the pre-renal transplant population
Recommendation:
ESE is recommended to exclude inducible myocardial ischemia, and arrhythmia, as well, as to assess exercise capacity and symptoms objectively.
Resting echocardiography is useful to exclude significant aortic stenosis prior to exercise stress and to visually assess the degree of LVH.
in my practice the management of this case will includes:
tough history and clinical examination
rest ECG
cardiac enzymes
CXR
Echo cardiography
evaluation of Bpr control
60 years old female , chronic kidney disease stages, atypical chest discomfort, known history of hypertension and no family history of coronary antry diseases.
– diagnostic evaluation.- by..-
1- exercise stress ECG ( sensitively 68% and specificity 77%, most chronic Kidney disease pt had impaired heart rate response to exercise
2- exercise stress echocardiography and dobutamine stress echocardiography:
Allow assessment of CFR by Doppler echocardiography on left anterior descending artery where negative means ion incidence of major cardiac events.
3- myocardial perfusion scintigraphy..-
Abnormal MPS in chronic kidney disease means high incidence of cardiac events and mortality.
4- cardiovascular magnetic resonance –
Comprehensive history From patient-to detect underlying risk factor
Examination general- vital sign
X-rays, ECG cardiac enzymes.
Echo cardrography.
A 60-year-old woman
stage 5 chronic kidney disease (CKD)
native disease (glomerulonephritis)
presented with atypical chest discomfort at rest.
Past history of hypertension treated with an angiotensin converting enzyme inhibitor and a beta blocker
Hyperlipidemia
She has no diabetes mellitus, no family history of premature CAD, and does not smoke.
Management of this case as per the article
1. clinical history
2. and examination
3. and a baseline 12-lead ECG.
4. Cardiovascular examination, especially to exclude uncontrolled hypertension or significant aortic stenosis
5. cardiac stress investigation
EXERCISE STRESS ECG
Has poor sensitivity in CKD 36%, esp in dialysis patients attributed to
1-deconditioning in such population which leads to reduced exercise capacity.
Deconditioning can be due to vascular, neurological or musculoskeletal comorbidities, and the catabolic/cachexic metabolic state associated with CKD.
2-CKD patients have also been shown to have impaired heart rate response to exercise ,
3- The frequently abnormal baseline ECG in CKD patients (often secondary to hypertension) hampers the interpretation of standard stress testing.
In advanced CKD patients, the ST segment changes at stress were shown to be not significantly different between non-severe CAD and severe CAD group, despite a longer treadmill exercise time in the non-severe group
EXERCISE STRESS ECHOCARDIOGRAPHY
The addition of echocardiography allows assessment of ventricular size and function, aortic and mitral valvular calcification, left ventricular hypertrophy (LVH), and potentially CFR.
CFR measurement by Doppler echocardiography in the left anterior descending artery has been shown to be a determinant of cardiac events in CKD patients in the absence of obstructive epicardial CAD. HOWEVER this is not performed routinely technical difficulties.
DOBUTAMINE STRESS ECHOCARDIOGRAPHY
Dobutamine and dipyridamole stress echocardiography (DSE) technique detects inducible myocardial ischemia based on detection of wall motion abnormalities, thus, would detect significant epicardial CAD, not microvascular disease.
DSE had moderate sensitivity of 80% in detecting inducible myocardial ischemia in renal transplant candidates
Several mechanisms may explain the reduced accuracy of DSE in the advanced CKD population
Though It is often recommended as a screening test in advanced CKD patients.
Abnormal DSE results in CKD patients have been associated with poorer prognosis for cardiac events and overall mortality
DSE had moderate sensitivity of 80% in detecting inducible myocardial ischemia in renal transplant candidates
Several mechanisms may explain the reduced accuracy of DSE in the advanced CKD population.
1-The majority of advanced CKD patients had a blunted chronotropic response, thus, did not achieve 85% maximal predicted heart rate despite the use of atropine
2-The thick myocardium due to LVH with small intracavitary volume, commonly found in CKD patients, obscures the detection of wall motion abnormalities at stress,
3- Microvascular CAD is difficult to appreciate given the focus on regional wall motion abnormality and likely to be missed.
Due to the above , significantly reducing the sensitivity of stress echocardiography in detecting inducible myocardial ischemia in CKD population.
Abnormal DSE results in CKD patients have been associated with poorer prognosis for cardiac events and overall mortality.
Negative stress echocardiography results, on the other hand, have been shown to be associated with low incidence of major adverse cardiac
MYOCARDIAL PERFUSION SCINTIGRAPHY
Exercise and pharmacological myocardial perfusion scintigraphy (MPS) have sensitivity of 87 and 89%, and specificity of 73 and 75%, respectively, in detecting >50% coronary artery stenosis in patients without advanced CKD
Exercise MPS in the advanced CKD population has the same limitation as EST and ESE, i.e., related to the inadequate exercise performance and chronotropic incompetence
MPS has sensitivity of 69% and specificity of 77% in diagnosing inducible myocardial ischemia in the pre-renal transplant population.
MPS has false negative result in detecting ischemia in people with significant triple vessel CAD, as in the CKD population, because of homogeneous tracer uptake due to “balanced ischemia
CKD with normal MPS still had a three times higher cardiac death rate than those with normal MPS and no CKD
abnormal MPS results in CKD patients have been shown to be associated with a higher incidence of cardiac events and mortality
presence of reversible defects of inducible myocardial ischemia was associated with six fold increased risk of myocardial infarction and almost fourfold risk of cardiac death
The presence of fixed defects was associated with a nearly fivefold increased risk of cardiac death
Blunted heart rate response in CKD patients during stress myocardial perfusion imaging has been reported to be associated with increased mortality
CARDIOVASCULAR MAGNETIC RESONANCE
Cardiovascular magnetic resonance (CMR) with gadolinium contrast is avoided due to its association with nephrogenic systemic fibrosis (NSF) in CKD patients. However, Cardiovascular magnetic resonance spectroscopy has been studied to assess early cardiac dysfunction in pediatric population with advanced CKD . and Dobutamine stress CMR was shown to be safe in the pre-renal transplant population
The author recommended Resting echocardiography to exclude significant aortic stenosis prior to exercise stress followed by ESE, to exclude inducible myocardial ischemia, inducible arrhythmia, and to assess exercise capacity and symptoms objectively.
I would manage as follow:
after full history and physical exam, including vital signs, and rule out other causes of chest pain either muscular or infectious.
will request lab. including renal function and cardiac enzymes and troponin. and CXR.
ECG and will refer to the cardiologist and arrange resting Echo and as per the cardiologist advise will either proceed to stress echo or myocardial perfusion.
if any is positive then will discuss with the patient to proceed to coronary angio and the risk of contrast nephropathy will be explained and in such case he is already stage 5 so he will require to be initiated on dialysis post procedure most likely.
however saving life is more important than saving kidneys, and he will be added on tx waiting list.
Q1 -Summarise the management of the case presented in this article.
Cardiovascular disease is the leading cause in CKD population . it has high prevalence in CKD patient even in young and even in early stages of CKD . Of note CKD patient has both traditional and non traditional risk factors. CAD in CKD patient is often multi vessel and could be silent . CAD in CKD patient may be caused by microvascular dysfunction and epicardial obstruction .
Cardiovascular evaluation of patient with CKD involves .
1- EXERCISE STRESS ECG.
In CKD patient this test has poor sensitivity of 36%, usually due to reduced exercise capacity because of deconditioning .
Deconditioning is due to
A. vascular,
B. neurological or
C. musculoskeletal comorbidities,
D. the catabolic/cachexic metabolic state associated with CKD.
The presence of blunted chronotropic response in CKD patient ( could be part of metabolic autonomic dysfunction ) and the presence of baseline ECG changes (LVH ) may make interpretation is difficult .
2- EXERCISE STRESSECHOCARDIOGRAPHYANDDOBUTAMINESTRESS ECHOCARDIOGRAPHY.
It Is better than the stress ECG with a sensitivity of about 85%. This method detects wall motion abnormalities induced by ischemia. had asensitivityof85% and a specificity of 89% . It is the recommended as a screening test in advanced CKD patients. As in other stress tests the presence of blunted chronotropic response and LVH reduces its sensitivity. Abnormal DSE is associated with high cardiovascular event and mortality. Of note blunted exercise response is associated with poor cardiac prognosis.
3- MYOCARDIAL PERFUSIONSCINTIGRAPHY
Exercise and pharmacological myocardial perfusion scintigraphy (MPS) have sensitivity of 88 %, and specificity of 74 % . has same limitation as any exercise test .
It has high false negative in detecting triple vessel disease. Because of (( balanced ischemia)).
Normal myocardial perfusion measured by SPECT may not be associated with excellent prognosis in CKD population. But abnormal MPS results in CKD patients have been Shown to be associated with a higher incidence of cardiac events and mortality.
4- CARDIOVASCULARMAGNETICRESONANCE
It is not used widely because of gadalonium induce nephrogenic systemic fibrosis (NSF) in patient with CKD. Dobutamine stress CMR was shown to be safe in the pre-renal transplant population.
RECOMMENDATION
Exercise tolerance has utmost importance both for prognosis and symptoms capacity and has implication in the case of peri operative risk assessment.
Therefore ,we recommend ESE to the case vignette described, to exclude inducible myocardial ischemia ,inducible arrhythmia, and to assess exercise capacity and symptoms objectively.
Resting Echocardiography is useful to exclude significant aortic stenosis Prior to exercise stress and to visually assess the degree of LVH.
Q2- Please reflect on your practice explaining how you would manage this case in your hospital setting.
This patient has ESRD on HD. His age more than 50 Y ,with other cardiovascular risk. presented as atypical chest pain .
I will considered this patient as a high risk.
My management will be
1- Detailed history ( risk factors, symptoms and cardiovascular complication )
2- Examination (pulse, blood pressure, precordium, and peripheral pulses)
3- Baseline investigation – Resting ECG, Resting echo, CXR, cardiac enzyme.
4- As this patient has more than 50y old this patient will need coronary angiography, but this decision should be shared with cardiologist.
· Summarise the management of the case presented in this article
This is a 60-yrear-old female with:
1. Chronic kidney disease (CKD), stage 5
2. Congestive heart failure (CHF)
3. Hypertension
4. Dyslipidaemia
This patient presented with resting atypical chest discomfort. Given a remarkable history of advanced CKD and significant risk factors for cardiovascular disease (CVD), coronary artery disease (CAD) will be a concern of her resting atypical chest discomfort. Detailed clinical history with physical examination and laboratory evaluation which includes a complete 12-lead ECG, complete blood count (CBC), thyroid functions, liver function tests, renal function tests with electrolytes, cardiac enzymes and NT-proBNP level, etc, are important. Imaging studies such as stress echocardiography, CT angiography, myocardial perfusion scintigraphy (MPS) and cardiac MRI are useful clinical tools in CAD diagnosis. However, the clinical utility of CT angiography and cardiac MRI in advanced CKD patients in CAD diagnosis has been limited due to the concern of contrast-induced nephropathy (CIN) and nephrogenic systemic fibrosis (NSF), respectively. Robust studies have shown that stress echocardiography (sensitivity: 80%, specificity: 89%) is performing better than MPS (sensitivity: 69%, specificity: 77%). Since autonomic dysfunction is common in CKD hosts, a blunted chronotropic response is expected during Dobutamine and Dipyridamole stress echocardiography (DSE) testing. Therefore, exercise stress echocardiography (ESE) will comparatively outshine DES in the diagnosis of CAD in CKD hosts.
Typical clinical symptoms (precordial chest pain, chest tightness with heavy, compressing sensation, or exercise intolerance), abnormal ECG findings with serial evolutional changes plus progressively elevated cardiac enzymes (CK, CK-MB and Troponin I) denote ischemic change of the myocardium and should prompt immediate consultation of cardiologist for percutaneous coronary intervention (PCI). Other laboratory investigations such as CBC, serum electrolytes and NT-proBNP level are reasonable as they help to rule out infection, cardiac dysrhythmia, and congestive heart failure (CHF) that may also lead to such patient’s presentation. If the surveys are all unrevealing, further imaging studies are needed to elucidate the cause of this patient’s resting atypical chest discomfort, with CAD being the particular cause of concern owing to the patient’s remarkable cardiovascular risk factors and advanced CKD status. Stress echocardiography, CT angiography, MPS and cardiac MRI are useful clinical tools in CAD diagnosis. However, the clinical utility of CT angiography and cardiac MRI in advanced CKD patients in CAD diagnosis has been limited due to the concern of contrast-induced nephropathy (CIN) and nephrogenic systemic fibrosis (NSF), respectively. Literatures have shown that stress echocardiography has a better sensitivity and specificity if compared to MPS (80% and 89% versus 69% and 77%, respectively). However, in host with advanced CKD, exercise stress echocardiography (ESE) will perform better than Dobutamine and Dipyridamole stress echocardiography (DSE) as there is an expected blunted chronotropic response caused by autonomic dysfunction in CKD hosts. Therefore, ESE is preferred over DSE.
Myocardialischemiaassessmentinchronickidney disease:challenges and pitfalls
Cardiovascular disease(CVD)is the most common cause of death in CKD patients
Myocardial ischemia can be caused by both epicardial and microvascularCAD. CAD is often multi-vessel and causes either
1-silent
2-Asymptomatic myocardial ischemia
STRATEGIES AND EVIDENCE
DIAGNOSTIC EVALUATION
1-EXERCISE STRESS ECG
In patients with normal renal function, exercise stress test (EST) with ECG has a low to moderate sensitivity and specificity, 68±16% and 77±17%, respectively, even when adequate exercise capacity and 85% heart rate is achieved.
EST is limited in the advanced CKD population, with poor sensitivity of 36% (13) (especially those undergoing dialysis), due to reduced exercise capacity .this limitation occurs as the result of vascular, neurological or musculoskeletal comorbidities, and the catabolic metabolic state associated with CKD. CKD patients have also been shown to have impaired heart rate response to exercise and the frequently abnormal baseline ECG in CKD patients ( hypertension)
segment changes at stress were shown to be not significantly different between non-severe CAD and severe CAD group
2-EXERCISE STRESS ECHOCARDIOGRAPHY AND DOBUTAMINE STRESS ECHOCARDIOGRAPHY
Exercise stress echocardiography (ESE) is better than the standard stressECGin ruling inCAD. The sensitivity ranging from 71 to 97% with specificity ranging from 64 to 90% (17).The use of ESE in CKD population remains limited due to the same exercise intolerance that occurs in ECG test.The echocardiography is mandatory for the assessment of ventricular size and function, aortic and mitral valvular calcification, left ventricular hypertrophy (LVH), and potentially CFR.
Dobutamine and dipyridamole stress echocardiography (DSE) technique detects myocardial ischemia based on detection of wall motion abnormalities, So it detect significant epicardial CAD, not microvascular disease.
Abnormal DSE results in CKD patients have been associated
with poorer prognosis for cardiac events and overall mortality.
3- MYOCARDIAL PERFUSION SCINTIGRAPHY
Exercise and pharmacological myocardial perfusion scintigraphy (MPS) have sensitivity of 87 and 89%, and specificity of 73 and 75%, respectively, in detecting >50% coronary artery stenosis in patients without advanced CKD
Again Exercise MPS in the advanced CKD population has the same limitation as EST and ESE, i.e., related to the inadequate exercise tolerance and chronotropic incompetence
abnormal MPS results in CKD patients have been
shown to be associated with a higher incidence of cardiac events and mortality.
myocardial ischemia was associated with sixfold increased risk of myocardial infarction and almost fourfold risk of cardiac death.The fixed ischemic defects associated with fivefold increased risk of cardiac death.myocardial perfusion abnormalities significantly predicted cardiac events in CKD patients independently of eGFR and left ventricular ejection fraction.
4-CARDIOVASCULAR MAGNETIC RESONANCE
Cardiovascular magnetic resonance (CMR) with gadolinium contrast is contraindicated in the CKD patient due to the risk of nephrogenic systemic fibrosis. NSF manifests as a hardening of the skin and internal organs resembling scleroderma, which is irreversible and potentially fatal. Cardiovascular magnetic resonance spectroscopy has been
studied to assess early cardiac dysfunction in pediatric population with advanced CKD
ESKD patient with hypertension, dyslipidemia and chest pain during rest (with fear and concern to have coronary artery diseases)
Diagnostic evaluation:
· History regrading chest pain, timing, relation to meals and exertion, other symptoms of peripheral vascular disease. manifestations of heart failure as peripheral edema, dyspnea and congestive symptoms.
· Cardiovascular examination, especially HR and ABP to exclude uncontrolled hypertension or significant aortic stenosis.
· start with Baseline 12-lead ECG then proceed to Cardiac stress investigation.
a. Exercise stress ECG: has low sensitivity in CKD patient (36%) due to abnormal basal ecg and Impaired heart rate response to exercise in addition abnormal ST segment changes at stress were shown to be not significant between non-severe CAD and severe CAD group.
b. Exercise stress echocardiography and dobutamine stress ECHO:
· limited value in CKD population
· Dipyridamole and dobutamine stress is often recommended as a screening test in advanced CKD patients.
· Several mechanisms explain the reduced accuracy of DSE in the advanced CKD due to blunted response of the hypertrophied ventricles to dobutamine stimulation.,
· Thick myocardium due to LVH with small intracavitary volume, commonly found in CKD patients, obscures the detection of wall motion abnormality.
c. Myocardial perfusion scintigraphy:
· Exercise and pharmacological myocardial perfusion scintigraphy (MPS) have 87% sensitivity and 75% specificity in detecting >50% coronary artery stenosis in patients without advanced CKD.
· Abnormal MPS results in CKD patients have been shown to be associated with a higher risk of cardiac events and mortality.
· Presence of reversible defects of inducible myocardial ischemia was associated with six fold increased risk of myocardial infarction and almost fourfold risk of cardiac death. this indicates referral to coronary angio for better diagnostic accuracy and possibility of therapeutic stenting.
· The presence of fixed defects was associated with a nearly 5 times higher risk of sudden cardiac death.
· Cardiac MRI: not preferred in advanced or borderline CKD population due to the concern of nephrogenic systemic fibrosis.
60-year-old women with CKD (stage V) presented with atypical chest pain needs evaluation for coronary artery disease (CAD). She has an high cardiovascular risk in view of advanced CKD and history of hypertension.
I would assess the history of the present complain (type of pain”Constricitive” “pressure type chest pain”, any SOB, any radiation of the pain, nausea,vomiting or any sweating etc). However I have to consider that CKD is often multivessel and causes silent or asymptomatic MI. I would arrange an e.cg.and blood test (Troponin baseline and 6 or 12 hours etc). Depend on e.c.g. and troponin results may require a coronary angiogram.
In terms of diagnostic evaluation:
EXERCISE STRESS ECG (EST) has a low modrate sensitivity and specificity in normal renal function (68 +/-_16% and 77 +/-17%), respectively, even when adequate exercise capacity and 85% heart rate is achieved . EST is further limited in advanced CKD population, with poor sensitivity of 36% (especially those on dialysis). HD patient have reduced exercise capacity, as deconditioning results. Deconditioning can be due to vascular, neurological ormusculoskeletal comorbidities, and the catabolic/cachexic metabolic state associated with CKD leads to reduced exercise capacity
EXERCISE STRESSECHOCARDIOGRAPHYANDDOBUTAMINESTRESS ECHOCARDIOGRAPHY (ESE) is better than the standard stress ECG in ruling in CAD (Positive likelihood ratio ESE 7.94 versus EST 3.57) and ruling out CAD (Negative likelihood ratio ESE 0.19 versus EST 0.38). However,the utilityof ESE in CKD population remains limited due to the same physical reasons as EST limitations. Its sensitivity ranges from 71 to 97% with specificity ranging from 64 to 90% . It is possible to assess the ven tricular size and function, aortic and mitral valvular calcification, left ventricular hypertrophy (LVH), and potentially CFR with the addition of echocardiography. The use of the Doppler echocardiography in the left anterior allows the measurement of the CFR measurement by
Dobutamine and dipyridamole stress echocardiography (DSE) technique detects inducible myocardial ischemia based on detection of wall motion abnormalities. DSE detect significant epicardial CAD, not microvascular disease. A meta analysis showed that dipyridamole and dobu- tamine stress echocardiography had a sensitivity of 85% and 86% respectively, and a specificity of 89% and 86%, respectively, in detecting myocardial ischemia in the non-renal population. Overall, DSE has moderate sensitivity of 80% in detecting inducible myocardial ischemia in renal transplant candidates in view of blunted chronotropic response and thick myocardium which obscures the detection of wall motion abnormalities at stress, thus, significantly reducing the sensitivity of stress echocardiography in detecting inducible myocardial ischemia in CKD population.
MYOCARDIAL PERFUSIONSCINTIGRAPHY (MPS) Exercise MPS in the advanced CKD population has the same limitation as EST and ESE in view of the inadequate exercise performance and chronotropic incompetence. MPS has a sensitivity of 87and 89%, and specificity of 73and 75%, respectively, in detecting >50% coronary artery stenosis in patients without advanced CKD. MPS has sensitivity of 69% and specificity of 77% in diagnosing inducible myocardial ischemia in the pre-renal transplant population. Unlike the normal population a normal myocardial perfusion in CKD population may not be associated with excellent prognosis and this could be explained in view of the high-false negative result from balanced ischemia. MPS has high false negative result in detecting ischemia in people with significant triple vessel CAD, as in the CKD population, because of homogeneous tracer uptake due to balanced ischemia.
CARDIOVASCULARMAGNETICRESONANCE (CMR) with gadolinium. It is not widely used as it may induce nephrogenic systemic fibrosis. Gadolinium may induece rare but serius side effect such as hardening of the skin and internal organs resembling scleroderma (potentially lethal), which is irreversible and potentially fatal. Dobutamine stress CMR was shown to be safe in the pre-renal transplant population
In the first instance we have to take the history of the present complain. Will need a baseline e.c.g and if any dynamic changes (ST elevation or STdepression) and bllod test confirm a cardiac event (Raise troponin) will need an urgent cardiology review and coronary angiogram. We need to know if the patient has risk factors for cardiac event rather than hypertension and CKD (smoking, diabetes, dyslipidemia, and family history of cardiac disease).
If the patient has no acute cardiac event (Myocardial infarction, iscahemia etc) prior to the transplant I would arrange an exercise tolerance for prognosis, symptoms capacity and perioperative risk assessment (in his case transplant).
I would request a baseline e.c.g and baseline resting ECHO to exclude valve disease (for e.g. aortic stenosis) and to assess LVH.
Exercise stress ECHO to exclude inducible myocardial ischemia, inducible arrhythmia, to assess exercise capacity
If the patient is at high risk I would arrande a DSE and as above mentione if patient has dymanic e.c.g changes (MI cardiac iscahemia than Coronary angiography
Management
Silent CAD is quite common in CKD patients and while doing transplant work up in this population of patient this fact should always be kept in mind.
The patient in this case Vignette is considered high risk being 60 years of age having CKD and hypertensive. Her symptoms are of atypical chest pain and she would require a base line ECG and cardiac stress evaluation that could be stress ECG MPS or Doubutamine stress Echo.A base line echo should be done to rule out aortic stenosis before proceeding for these tests. Each test has its own pitfalls as these have quite low sensitivity and specificity.
In patients with normal renal function, exercise stress test (EST) with ECG has a low to moderate sensitivity and specificity, 68 ± 16% and 77 ± 17%, respectively, even when adequate exercise capacity and 85% heart rate is achieved.
EST is further limited in the advanced CKD population, with poor sensitivity of 36% (especially those undergoing dialysis), as deconditioning leads to reduced exercise capacity. Deconditioning can be due to vascular, neurological or musculoskeletal comorbidities, and the catabolic/cachexic metabolic state associated with CKD.
Exercise stress echocardiography (ESE) is better than the standard stress ECG in ruling in CAD (Positive likelihood ratio ESE 7.94 versus EST 3.57) and ruling out CAD (Negative likelihood ratio ESE 0.19 versus EST 0.38).Its sensitivity has been reported ranging from 71 to 97% with specificity ranging from 64 to 90%. However, the utility of ESE in CKD population remains limited due to the same physical reasons as EST limitations above.
Dobutamine and dipyridamole stress echocardiography (DSE) technique detects inducible myocardial ischemia based on detection of wall motion abnormalities, thus, would detect significant epicardial CAD, not microvascular disease.
Overall, DSE had moderate sensitivity of 80% (confidence interval 64–90) in detecting inducible myocardial ischemia in renal transplant candidates.
The majority of advanced CKD patients had a blunted chronotropic response, thus, did not achieve 85% maximal predicted heart rate despite the use of atropine, significantly reducing the sensitivity of DSE in detecting myocardial ischemia The thick myocardium due to LVH with small intra- cavitary volume, commonly found in CKD patients, obscures the detection of wall motion abnormalities at stress, thus, significantly reducing the sensitivity of stress echocardiography in detecting inducible myocardial ischemia in CKD population. Microvascular CAD is difficult to appreciate given the focus on regional wall motion abnormality and likely to be missed.
Exercise and pharmacological myocardial perfusion scintigraphy (MPS) have sensitivity of 87 and 89%, and specificity of 73 and 75%, respectively, in detecting >50% coronary artery stenosis in patients without advanced CKD. Exercise MPS in the advanced CKD population has the same limitation as EST and ESE, i.e., related to the inadequate exercise performance and chronotropic incompetence.
A systematic review in 2011 showed that MPS has sensitivity of 69% (confidence interval 48–85) and specificity of 77% (confidence interval 59–89) in diagnosing inducible myocardial ischemia in the pre-renal transplant population. MPS has high false negative result in detecting ischemia in people with significant triple vessel CAD, as in the CKD population, because of homogeneous tracer uptake due to “balanced ischemia”
we at our center will send this patient for MPS after baseline echo and ECG are ok.We will consider coronary angio depending upon MPS result , obviously our Cardialogist will be the one following these patients
Summarise the management of the case presented in this article
DIAGNOSTIC EVALUATION
-Thorough clinical history and examination ( exclude uncontrolled hypertension or significant aortic stenosis )
-Baseline 12-lead ECG.
-Cardiac stress investigations .
EXERCISE STRESS ECG
In patients with normal renal function, exercise stress test (EST) with ECG has a low to moderate sensitivity and specificity.EST is further limited in the advanced CKD population, with poor sensitivity , as deconditioning leads to reduced exercise capacity .
CKD patients have also been shown to have impaired heart rate response to exercise , and the frequently abnormal baseline ECG in CKD patients . In advanced CKD patients, the ST segment changes at stress were shown to be not significantly different between non-severe CAD and severe CAD group .
EXERCISE STRESS ECHOCARDIOGRAPHY AND DOBUTAMINE STRESS
ECHOCARDIOGRAPHY
Exercise stress echocardiography (ESE) is better than the standard
Stress ECG in ruling in CAD and ruling out CAD.
The addition of echocardiography allows assessment of ventricular size and function, aortic and mitral valvular calcification, Left ventricular hypertrophy (LVH),and potentially CFR.
Dobutamine and dipyridamole stress echocardiography(DSE) Technique detects inducible myocardial ischemia based on detection of wall motion abnormalities, thus, would detect significant epicardial CAD, not microvascular disease. Abnormal DSE results in CKD patients have been associated With poorer prognosis for cardiac events and over all mortality.
MYOCARDIAL PERFUSIONSCINTIGRAPHY
Exercise and pharmacological myocardial perfusion scintigraphy (MPS) have sensitivity of 87and 89%,and specificity of 73 and 75%, respectively, indetecting >50% coronary artery stenosis in patients without advanced CKD.
MPS has High false negative result in detecting ischemia in people with significant triple vessel CAD ,as in the CKD population .
CARDIOVASCULAR MAGNETIC RESONANCE
Cardiovascular magnetic resonance(CMR) with gadolinium con-Trast has not been widely utilized clinically in the CKD population Due to the concern of nephrogenic systemic fibrosis (NSF).
-In this case ,ESE is recommend to exclude inducible myocardial ischemia, inducible arrhythmia, and to assess exercise capacity and symptoms objectively.
Resting echocardiograph is useful to exclude significant aortic stenosis prior to exercise stress and to visually assess the degree of LVH.
Please reflect on your practice explaining how you would manage this case in your hospital setting
-Detailed history and full clinical examination.
-ECG ,Chest x-ray ,cardiac enzymes and other laboratory tests.
-Cardiac consultation for further evaluation of the patient.
CKD patients have increased risk of cardiovascular morbidity and mortality, so renal transplant recipients must be evaluated properly before proceeding for transplant .
Evaluated by:
-proper history taking
-Full examination especially cardiac ( pulse , bp , auscultation)
-12- lead ECG and ECHO
-stress test
Diagnostic approaches:
*Exercise stress testing:
it is limited in advanced CKD patients and sensitivity about 36% due to reduced exercise capacity.
* Exercise stress echocardiography:
is an alternative to the stress ECG for diagnosing CAD
Its sensitivity ranging from 71 to 97% and specificity ranging from 64 to 90%.
But exercise intolerance and deconditioning in CKD are limiting its use .
*Exercise and pharmacological myocardial perfusion scintigraphy :
They can detect more than 50% of coronary artery stenosis in pt without advanced CKD with
sensitivity of 87 and 89% with specificity of 73 and 75%, respectively, .
In my practice
kidney transplant candidates must be assessed by :
-Good history taking
-Examination with assessment of all risk (obesity, smoking …
-ECG and ECHO
-stress ECG
If any abnormalities we are referring to tertiary center for coronary angio
The patient in this case presentation has traditional cardiovascular diseases risk factors like for example hypertension, and dyslipidemia and she is over 60 years of age with atypical cardiovascular pain during rest.
Cardiovascular disease has been the leading cause of death in patients with no kidney disease and in those with kidney disease the cardiovascular diseases increase significantly. Myocardial ischemia has been the leading cause of morbidity and mortality in CKD, but its presentation has been atypical. The atypical presentation causes worries to both patients and physicians. Since it is challenging to diagnose these patients, it is advisable that a proper history be taken, and a deep clinical assessment must be made. Studies like EKG and ECHO are vital due to the information that can be received like heart dynamics, hypertrophy and muscle dyskinesias, etc.
The stress cardiac evaluation that can help to facilitate a better understanding of cardiovascular evaluation are:
1) Stress EKG exercise: patient with CKD is difficult to evaluate because of their physical challenges. Its sensitivity is poor like 35-36%.
2) Stress ECHO exercise: has similar problems as the stress EKG but better in giving details like cardiac EF, LVH, valve pathologies, heart necrosis, etc.
3) Stress ECHO with medications like dobutamine and dipyridamole. This test is valuable by giving information to patients who cannot do any activity. It will provide details on inducible myocardial ischemia based on wall motion activity or inactivity. Its sensitivity is about 80% while the specificity is 89%.
4) Myocardial scintigraphy. It is a radiopharmacology study that allows one to see the anatomy of the heart and any other abnormalities. An abnormal study is related to poor prognosis and mortality.
5) Cardiovascular magnetic resonance.
To manage this patient adequately the following must be done.
1) Detailed history that is an interview
2) Detailed physical examination
3) To do an investigation like EKG at resting and repeat in 6 hours to see any abnormal changes.
4) Echocardiogram to see patient baseline function.
5) Start cardioprotective medications to ensure further cardiovascular damage etc
6) Refer the patient to a cardiologist
7) Ensure blood pressures are controlled
8) Ensure proper dialysis and fluid control to prevent fluid overload
9) Ensure metabolic control and calcium and phosphorus levels are at normal levels.
10) Blood studies like lipids, chemistry, and cardiac enzymes. etc.
Cardiovascular disease (CVD) is the leading cause of mortality and a major cause of morbidity in the CKD population. Myocardial ischemia is a major cause of death in CKD patients. Myocardial ischemia can be caused by both epicardial and microvascular CAD.
patients with mild CKD had higher prevalence of severe epicardial CAD compared to those without CKD (8),thus,suggesting that the problem relates to coronary stenosis rather than plaque stability.
EXERCISE STRESS ECG
EST is further limited in the advanced CKD population, with poor sensitivity of 36% (13) (especially those undergoing dialysis), as deconditioning leads to reduced exercise capacity (14). Deconditioning can be due to vascular, neurological or musculoskeletal comorbidities, and the catabolic/cachexic metabolic state associated with CKD.
EXERCISE STRESS ECHOCARDIOGRAPHY AND DOBUTAMINE STRESS ECHOCARDIOGRAPHY
Exercise stress echocardiography (ESE) is better than the standard stress ECG in ruling in CAD (Positive likelihood ratio ESE 7.94 versus EST 3.57) and ruling out CAD (Negative likelihood ratio ESE 0.19 versus EST 0.38) (16). Its sensitivity has been reported ranging from 71 to 97% with specificity ranging from 64 to 90% (17). However, the utility of ESE in CKD population remains limited due to the same physical reasons as EST limitations Abnormal DSE results in CKD patients have been associated with poorer prognosis for cardiac events and overall mortality.
Negative stress echocardiography results, on the other hand, have been shown to be associated with low incidence of major adverse cardiac events (21).
Blunted chronotropic response with exercise in CKD population may relate to poorer overall cardiac prognosis.
Managmanet of this old ckd patient proper hx and physical examination
labs including cardiac enzymes ,cbc,hga1c ,ecg ,echo ,stress ecg and exercise stress echo
Cardiology follow up medical treatment with asa statins and his anti hypertensive
Summarize the management of the case presented in this article
The patient presented in the case has traditional cardiovascular risk factors like hypertension, borderline dyslipidemia, age of 60 years with history of atypical chest pain at rest.
In view of above findings and presence of CKD stage 5, she needs further evaluation as cardiovascular disease is the leading cause of morbidity and mortality is these subsets of patients.
CKD patients often have multi-vessel CAD and can cause asymptomatic myocardial ischemia and the case presented here is genuinely worried about CAD.
Diagnostic evaluation starts with proper clinical examinations and 12 Lead ECG.
ECHO to rule out Aortic stenosis and Left Ventricular hypertrophy before ordering Stress cardiac investigations.
Stress cardiac evaluation with their potential implications and limitations as below:
1. Exercise Stress ECG(EST): Exercise capacity is poor in patients with CKD (especially those on dialysis) in view of inactivity, deconditioning, catabolic state and sarcopenia. Also, frequent presence of baseline abnormal ECG, impaired heart response to exercise, EST has poor sensitivity (36%) in these subsets of patients.
2. Exercise Stress Echocardiography (ESE): ESE has similar limitations due to reduced exercise capacity as mentioned above but better than EST in ruling in (better LE+ ratio of ESE versus EST) and rulling out (Lesser LE- ratio of ESE versus EST) CAD. In addition, it can estimate Ejection Fraction, LVH, valvular calcifications, Aortic stenosis and coronary flow reserve.
3. Dobutamine and Dipyridamole (Pharmacological) Stress ECHO: It bypasses the exercise limitations in these subsets of patients but have similar limitations due to CKD (like blunted chronotropic response and left ventricular hypertrophy limiting spatial resolution of positive findings). It would detect inducible myocardial ischemia based on wall motion abnormality and overall moderate sensitivity (80%) and specificity (89%) in CKD patients. Abnormal DSE is related to poor prognosis and overall mortality. Microvascular disease is likely to be missed due to more focus on wall motion abnormality during DSE.
4. Myocardial Perfusion Scintigraphy: Exercise/Pharmacological MPS has false negative results in case of triple vessel disease due to balanced ischemia which is not uncommon in patients with advanced CKD. Abnormal MPS in CKD patients have been associated with higher incidence of cardiac events and myocardial ischemia.
5. Cardiovascular Magnetic Resonance: Utility is limited due to risk of NSF caused by gadolinium contrast usage in CKD patients
6. Non-Contrast Blood oxygen level dependent (BOLD) CMR: It’s a new technique utilized to assess ischemia by assessing myocardial oxygenation in few human studies and initial results are promising. This needs to be further tested.
Authors of this article in light of above information recommends clinical examination (Heart sounds/murmurs),12 lead ECG,ECHO(assessing LVH,AS) and DSE to rule out inducible myocardial ischemia by assessing wall motion abnormality in this case.
Please reflect on your practice explaining how you would manage this case in your hospital setting
Clinical Examination
Evaluation of non-traditional cardiovascular risk factors like Hb, Serum Vitamin D3/Calcium/Phosphate/Intact PTH/Urinary Spot Albumin creatinine ratio
12 Lead ECG (for arrythmias)
ECHO to evaluate for Ventricular function, Left Ventricular Hypertrophy and Aortic Stenosis
DSE to rule out inducible/reversible myocardial ischemia by picking wall motion abnormality, exercise tolerance and prognosis (In view of age around 60 years with hypertension and history of atypical chest pain at rest)
If DSE s/o of abnormality, Coronary angiogram and proceed
Cardiology referral for as mentioned above
1- more history about her chest pain and associated symptoms
2- comprehensive physical examination ( fluid overload , arrhythmia , murmurs , peripheral pulses
3- ECG , CXR , cardiac enzymes
4- Echo : assessment of EF , Hypokinesia , Valvular disease , LVH
5- labs for non traditional risk factors ( Ca , PO4 , PTH , CBC , Iron SAT , Protienurea , Urea
6- consult cardiologist
7- EST and consider ESE ( if available )
DIAGNOSTIC EVALUATION:
Cardiac stress investigations :
1-Exercise stress ECG. : Reduced exercise capacity(deconditioning)
Impaired chronotropic response Abnormal baseline ECG and left ventricular hypertrophy
2-EXERCISE STRESS ECHOCARDIOGRAPHY AND DOBUTAMINE STRESS ECHOCARDIOGRAPHY : Reduced exercise capacity(deconditioning)
Impaired chronotropic response
Abnormal baseline ECG and leftventricular hypertrophy
3- Myocardial perfusion scintigraphy : Blunted chronotropic response
Left ventricular hypertrophy Micro vascular disease potentially can be missed
4- CARDIOVASCULAR MAGNETIC RESONANCE : False negative results in multi-vessel disease due to balanced ischemia
Coronary artery diseases are prevalent in CKD patients even with early stages.
Evaluation could be done:
I- stress tests
– Initially, clinical evaluation using 12- lead ECG and echocardiography to exclude stenosis before stress testing
– Exercise testing has a low to moderate sensitivity and specificity in patients with normal kidney function even after reaching 85% of heart rate exercise.
– In advanced CKD patients has a poorer sensitivity as 36%.
II- MYOCARDIAL PERFUSION SCINTIGRAPHY
– In non-advanced CKD patients, scintigraphy studies (using either pharmacological or exercise induction) could detect coronary artery stenosis more than 50% with sensitivity 87 and specificity 73%.
– In pretransplant patients with reversible perfusion defects have fourfold increase in cardiac events, and patients with fixed defects have a 5-fold increase in cardiac events.
– Patients with blunted response have increased risk for mortality.
Limitations in advanced CKD:
§ Chronotropic incompetence
§ Exercise intolerance.
§ High false negative results in detecting ischemia in multivessel coronary artery disease due to balanced ischemia causing homogenous uptake.
§ With normal MPS, Advanced CKD patients have a 3-time cardiac death more non CKD patient.
III- Exercise stress echocardiography:
– Exercise stress echocardiography (ESE) is more sensitive and specific than stress ECG.
– Provide structural and functional assessment.
– Assessment of CFR in the left anterior descending artery (main determinant of cardiac events)
IV- Dobutamine and dipyridamole stress echocardiography (DSE)
– It detects inducible myocardial ischemia. It could assess significant epicardial diseases rather than microvascular disease.
– It is recommended as a screening test in advanced CKD patients.
– Abnormal DSE is associated with poor outcomes
Limitation:
– Blunted chronotropic response.
– Difficulty assessing wall motion abnormalities due to LVH and reduced intracavitary volume
V- CARDIOVASCULAR MAGNETIC RESONANCE
– it is of limited used due to nephrogenic systemic fibrosis which occur in advanced CKD patients.
– CMR spectroscopy could be used for diagnosis early cardiac dysfunction in pediatric patients with advanced CKD.
– Dobutamine CMR could be used safely in advanced CKD patients.
reflection in my practice:
in pretransplant evaluation:
detailed history and physical examination
ECG, ECHO
dobutamine stress test
+/- coronary angiography if indicated
2-reflect on your practice explaining how you would manage this case in your hospital setting
more detail history needed in this case like more history about GN,is associtted with nephrotic or not because as we konw the degree of protienurea corealate with cvs events.
ask about any symptoms of ischemia such as intermittent cauldication.
ask about other risk factor such as stress at work.
ask about other cvs symptom such as S.O.B on exertion….
clinical exainmation
general examination such as anaemia
check the Bp (controlled or not)
fluid status (euovolmic or hypervolumic)
CVS ;
pluse
perherial pluse
carotidplue(bruit).
examine for any murmur or sign of HF.
lowe limb for oedema
LAB
full chemistry and CBC.
lipid profile HAIC
cardiac enzyme
RESTING ECG
RESTING ECHO to role out any aortic stenosis and LVH.
CARDILOGY REFERAL
Thank You, but you have not reflected on the practice in Sudan. I know that you are immunologist, but at least you can ask your nephrology colleagues.
1 Summary of Myocardial ischemia assessment in chronic kidney disease: challenges and pitfallsThe major cause of CVS death in ckd is myocardial ischemia and usually is multi vessel,micro vascular CAD has been associated with reduced survival.
Diagnostic evulation based on history,clinical examination and12 lead ECG.
Exercise stress ECG
Has low to moderate sensitivity and specificity in patients with normal renal function but has limited poor sensitivity of 36% in advanced ckd population especially in dialysis patients due to vascular or musculoskeletal comorbidity and catabolic state associated with ckd.
unable to interpenetrated stress test in advanced ckd due to abnormal baseline response to exercise ,st segment changes at stress in advanced ckd more show no significant different between sever CAD and non sever CADin longer treadmill exercise time in the non sever group.
EXercise stress Echocardiography and Dobutamine Stress Echocardiography
Exercise stress Echo is better than stress ECG in diagnosis CAD.
71 to 97% sensitivity range of ESE and specificity ranging from 64 to 90 %.
ESE is limited in ckd patients due to above mention physical reason as in exercise stress ECG.
CFR is measurement by Doppler echo cardiology in the left antior descending artyery is most cause of cardiac event in ckd patients and can not performed routinely due to technical difficulties .
Dobutamine and dipyridamole stress echo
DSE detects ineducable myocardial ischemia based on detection of wall motion abnormalities so detect significant epicardial CAD,not microvascular disease..
Ametanalysis in 2008 showed dipyridmole and dioubtamine stress echo cardology has high sensitivity and specifcity in detecting myocardial ischemia in non renal patients.
it is recommented screening test in advanced ckd patients.
abnormal MPS in ckd patients associated with higher incidence of cardiac events and mortality.
some of studies showed that in pre-transplant patients the presence of reversible defect of ineducable myocardial ischemia was associated with 6 fold increased of risk of myocardial infraction and 4 fold risk of cardiac death.
The presence of fixed defect was associated five fold increased risk of cardiac death .
Cardiovascular magnetic resonance
CMR with gadolinum contrast has not been used in ckd patients due to NSF.
CVS magnetic resoance spectoscopy has been studies to assess early cardiac dysfunction in padetartic population with advanced ckd.
doutamine stress CMR safe in pre renal transplant recipient
Recommendation
iExerscise tolerence iscrucial in perioperative risk assessment.
in renal transplantESE is recommended to exclude ineducable myocardial ischemia ,ineducable arrhythmia and exercise capcity,
Resting echo is mandatory to exculde aortic stenosis and degree of LVH prior to exercise stress test.
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iew / Download
Thank You, see above
A 60-year-old female with CKD and atypical chest pain needs evaluation for coronary artery disease (CAD) in view of high risk of cardiovascular morbidity and mortality in this patient population.
The various aspects of evaluation in such patients include:
1) Detailed history
2) A thorough clinical examination including pulse, blood pressure and cardiovascular examination.
3) A baseline 12-lead ECG
4) Non-invasive testing
5) Coronary angiography
The diagnostic approach involves the following tests:
1) Exercise stress ECG: In CKD patients, although the specificity is high (94%), its sensitivity is very low (36%) due to poor exercise capacity and an impaired chronotropic response. Abnormal baseline ECG and left ventricle hypertrophy further reduce its usefulness. The ECG changes between non-severe and severe CAD patients have not been found to be significantly different.
2) Stress Echocardiography (Exercise Stress Echocardiography, ESE and Dobutamine/ Dipyridamole Stress Echocardiography, DSE): The usefulness of ESE is also low in CKD patients due to poor exercise capacity, impaired chronotropic response and left ventricular hypertrophy. The sensitivity and specificity of DSE in CKD patients is 80% and 89% respectively. The sensitivity is less than the non-renal population due to blunted chronological response, presence of left ventricle hypertrophy obscuring wall motion abnormality detection and chances of missing microvascular disease. Abnormal DSE results are associated with poor outcomes.
3) Myocardial Perfusion Scintigraphy (MPS) – Exercise and pharmacological stress associated: It is done using SPECT and has low sensitivity and specificity (69% and 77%) with false negative results in patients with triple vessel disease due to balanced ischemia (homogeneous tracer uptake). Exercise MPS has limitations due to inadequate exercise performance and chronotropic incompetence. Perfusion defect on stress only signifies myocardial ischemia. A reversible defect is associated with 6 times increased risk of myocardial infarction and 4 times increased risk of cardiac death. A fixed defect is associated with 5 times increased risk of cardiac death. Even a normal MPS has 3 times increased risk of cardiac death.
4) Cardiovascular Magnetic Resonance (CMR): It has not been used in CKD patients due to increased risk of nephrogenic systemic fibrosis.
In the index case, patient was advised exercise stress echocardiography (ESE) after a resting echocardiography.
In our unit, a CKD-ESRD patient being planned for kidney transplant is assessed in association with cardiologist by:
· Thorough history: especially for risk factors like age more than 50 years, diabetes, hypertension, obesity, smoking history, dyslipidemia etc)
· Physical examination: especially pulses, blood pressure, cardiovascular examination
· Initial evaluation for all patients: ECG and baseline Echocardiography
· Dobutamine Stress Echocardiography (DSE) in high-risk individuals.
· Coronary angiography in symptomatic patients, or a DSE suggesting ischemia.
Thank You, well done
# Case presentation management :
60 years old female with CKD S 5 due to GN .
no cardiac risk factors a part from hypertension and CKD ( not diabetic , cholesterol 5 mmoL/L , and LdL 3.2 mmoL/L, and does not smoke, no family history )
presented with atypical chest pain and worried about to have CAD .
# measures of treatment of the case ?
with reduce sensitivity and specificity in CKD patients a round 36% in comparing to non-CKD patients ,( about 68% +/-16% for sensitivity , and 77% +/- 17% for specificity ) .
CKD patient have reduce exercise capacity , due to vascular, neurological, muscloskeletal comorbidities, (osteodystrophy, osteoporosis) and their sequel.
another limitation of ECG in CKD patients is that , there is abnormal ECG changes secondary to HTN, and this affect interpretation of standard stress test.
also in advance CKD, ST segment stress test changes, not significantly different between sever, non-sever CAD, even with long time exercise.
2.Exercise stress Echocardiograghy and Dobutamine stress Echocardiograghy:
Better (than exercise ECG in specificity and sensitivity, and detection of abnormal wall motion ischemia) in ruling in CAD with +ve likelihood ratio of 7.94 comparing to 3.57 in E_ECG test, also in ruling out with -ve likelihood of 0.19, versus 0.38 in E_ECG tset .
Have the sensitivity of 71-97% and specificity of 64-90% .
Benifit is to assess ventricular size and function, aortic and mitral valve calcification, LVH, and potential CFR.
limitations: in CKD patients due to physical reasons mentioned before.
3.Dobutamine and pyridamole stress ECHO :
Detect inducible myocardial ischemia, wall motion abnormality, and epicardial CAD.
In metanalysis done in 2008, show specificity of 85% and specificity of 89% for dobutamine, and sensitivity of 86% , specificity of 86% for pyridamole, in detecting myocardial ischemia,
It is recommended as screening test in CKD, and pre-transplant candidates.
Limitation, thick wall of ventricle obscure detection of wall motion abnormality.
Abnormal DES associated with poor prognosis, and overall mortality.
4.MPS, myocardial perfusion scintigraphy :
Exercise and pharmacological, sensitivity (87%and 89%) and specificity, (73%and 75%) respectively.
used in detecting > 50% of coronary artery stenosis in patients without advance CKD .
Exercise MPS in advance CKD have some limitation, as EST,and ESE, which is related to limited capacity, and chronotropic incompetance.
Abnormal MPS, in CKD, patients associated with higher incidence of cardiac events and increased mortality.
5.Cardiovascular magnetic resonance :
CMR with gadolinium, not widely used, in CKD, due to concern of nephrogenic systemic fibrosis, NSF.
CMR spectroscopy, assess early cardiac dysfunction, in advance CKD.
CMR deputamine stress test , safe in pre-renal kidney transplantation.
In conclusion : ESE is recommended, to assess inducible myocardial ischemia, arrythmia, and to assess exercise capacity, and symptoms.
Resting ECHO. to exclude significant aortic stenosis, prior to exercise and to assess degree of LVH.
# In my facility :
$ inpatient general and routine investigation and imaging for detection of any abnormality that related to our CKD patient , and to apply cardioprotective measures according to the guidelines, and to refer to cardilogist for invasive and non-invasive techniques to diagnose and manage defects.
$ in our dialysis center we become more specific in categorization of the dialysis patients , to delay, prevent, and prevent as quick as possible patient at risk, includinf scanned ECG, and ECHO, with followup by cardiologist, as well as intervention cardilogy .
Thank You, well done
DIAGNOSTIC EVALUATION
1st step; bedside evaluation
A thorough clinical history and examination
and a baseline 12-lead ECG, exclusion of uncontrolled hypertension or significant aortic stenosis
2nd step; cardiac stress investigation
EXERCISE STRESS ECG
Deconditioning problems in the advanced CKD population render EST of limited use with a sensitivity of 36%
EXERCISE STRESS ECHOCARDIOGRAPHY
Because of the same physical reasons as EST limitations, its use in CKD population is still limited. nevertheless, it allows assessment of ventricular size and function, valvular calcification, left ventricular hypertrophy (LVH), and potentially CFR.
DOBUTAMINE STRESS ECHOCARDIOGRAPHY
DSE has a reduced accuracy in the advanced CKD population and of moderate sensitivity of 80% (confidence interval 64–90) in detecting inducible myocardial ischemia in renal transplant candidates however, It may be recommended as a screening test in advanced CKD patients.
MYOCARDIAL PERFUSION SCINTIGRAPHY
It can see more than 50% coronary artery stenosis in patients without advanced CKD with 87 % sensitivity and 89 % specificity. however, it has the same limitation as EST in the advanced CKD population.
CARDIOVASCULAR MAGNETIC RESONANCE( CONTRAST ENHANCED)
Its use in CKD population should be limited as the contrast media used may result in a severe condition (NSF).
So for this 60-year-old woman with stage 5CKD who presented with atypical chest discomfort at rest, and worried about (CAD). She
has hypertension .with no DM, no family history of premature CAD, and does not smoke.
I would recommend ESE to detect possible ischemia and to asses her ventricles regarding LVH after completing her bedside evaluation.
Please reflect on your practice explaining how you would manage this case in your hospital setting
history of exertional dyspnea
Clinical examination
Resting ECG
Cardiac enzymes
CXR- abdominal U/S
Cardiology consultation if further investigations are needed.
Thank You, I’m sure you can add more reflection on your practice. You work up potential recipients in your clinic. Please add more
In general: cardiac evaluation starts with history, clinical examination then investigation. Is Important for risk stratification of the patients and identifications of possible contraindication to stress studies such as significant aortic stenosis and uncontrolled hypertension.
Exercise stress ECG
In patients with normal renal function, exercise stress test (EST) with ECG has a low to moderate sensitivity 68 ± 16% and specificity 77 ± 17%.EST is further limited in the advanced CKD population, with poor sensitivity of 36%. In advanced CKD patients, the ST segment changes at stress were shown to be not significantly different between non-severe CAD and severe CAD group
Exercise stress echocardiography and dobutamine stress echocardiography
Exercise stress echocardiography (ESE) is better than the standard stress ECG in detecting and excluding CAD Its sensitivity has been reported ranging from 71 to 97% with specificity ranging from 64 to 90%. But they share the same limitation by physical activity and exercise intolerance in CKD population. The echocardiography allows assessment of ventricular size and function, aortic and mitral valvular calcification, left ventricular hypertrophy (LVH).
Dobutamine and dipyridamole stress echocardiography (DSE) technique detects inducible myocardial ischemia based on detection of wall motion abnormalities, so they detect significant epicardial CAD, not microvascular disease. It has relitaivly high sensitivity 80 (64–90) % and specificity 89 (79–94) % in CKD population so It is often recommended as a screening test in advanced CKD patients. Abnormal DSE results in CKD patients have been associated with poorer prognosis for cardiac events and overall mortality.
Myocardial Perfusion Scintigraphy
Exercise and pharmacological myocardial perfusion scintigraphy (MPS) have sensitivity of 87 and 89%, and specificity of 73 and 75%, respectively, in detecting >50% coronary artery stenosis in patients without advanced CKD .Exercise MPS in the
advanced CKD population has the same limitation as EST and ESE. MPS has high false negative result in detecting ischemia in people with significant triple vessel CAD, as in the CKD population, because of homogeneous tracer uptake due to balanced ischemia. abnormal MPS results in CKD patients have been shown to be associated with a higher incidence of cardiac events and mortality. The presence of fixed defects was associated with a nearly fivefold increased risk of cardiac death
Cardiovascular Magnetic Resonance
Cardiovascular magnetic resonance (CMR) with gadolinium contrast not used in CKD population due risk of nephrogenic systemic fibrosis (NSF) Dobutamine stress CMR was shown to be safe in the pre-renal transplant population.
*The lady is having risk factors for CAD (traditional) Age, HTN, Hyperlipidaemia and most importantly atypical chest discomfort. she might have other risk factors when assessed by further investigation.
When screening for CAD They depend mainly on:
Exercise stress ECG: which is better than the standard stress ECG in ruling in CAD, but in CKD patients its limited by exercise tolerance and fatigability. When compared sensitivity its reduced from 68 % normal people to 36% in CKD.
Echocardiography: allows assessment of ventricular size and function, aortic and mitral valvular calcifications left ventricular hypertrophy (LVH).
Start assessment with: detailed history, clinical examination, investigate as possible all risk factors * traditional + non-traditional (including dialysis duration if on dialysis)
Standard 12 lead ECG, Echocardiography for ALL.
MDT with cardiologist for risk stratification and further steps individualized according to each patient’s condition.
Thank You, well done
– 60 y old male chronic kidney disease stage five with atypical chest pain and onARBS and B blockers with no family history of coronary artery disease.
– for diagnosis :-
* execise stress test:
studies shown poor sensitivity in advanced kidneys diseases especially those who under dialysis.
Chronic kidney disease patients have poor response to exercise inform of impaired heart rate with abnormal baseline ECG.
* exercise stress Ecchocardiography and dobutamine stress echocardiography:
helps in assessment of assessments of ventricular size and function s valve calcification (mitral and aortic) and measurement of Coronary flows reserve in left anterior descending artery , while dobatamine and dipyridamole stress has 85% sensitivity and 89% specificity and recommended as a screening test in patients with advanced coronary artery disease .
Abnormal DSE has poor prognosis with high mortality while negative one had low adverse cardiac events.
* myocardial perfusion scientigraphy :-
studies shown MPS has false negative result in detecting ischemia in patient with triple vessels diseases. While abnormal MPS has increased incidence of cardiac diseases with increased mortality.
* cardiovascular magnetic resonance :-
CMR with gadolinium contrast carried risk of nephrogenic systemic fibrosis while dobutamine stress CMR safe in pre-renal transplant recipients.
– full history regarding risk factors traditional and non-traditional).
– examination.
– Investigation.- cardiac enzymes- lipid profiles-lives enzymes – CBC – chest X-rays.
– ECG -ecchocardiography.
-Cardiology consultation.. For assessment and choice of different modalities of cardiac investigation and plan of management.
Thank you, please explain the cardiac investigations in more detail
DIAGNOSTIC EVALUATION according to the article
low to moderate sensitivity and specificity
the frequently abnormal baseline ECG in CKD patients (often secondary to hypertension) hampers the interpretation of standard stress testing.
the ST segment changes at stress were shown to be not significantly different between non-severe CAD and severe CAD group
5. Exercise stress ECHOCARDIOGRAPHY
low to moderate sensitivity and specificity
imited due to the same physical reasons as EST limitations above.
6. Dobutamin stress ECHOCARDIOGRAPHY
based on detection of wall motion abnormalities ,thus, would detect significant epicardial CAD, not microvascular disease
7.MPI SCINTIGRAPH
have sensitivity of 87and89%, and specificity of 73 and 75% ,respectively ,indetecting>50% coronary artery stenosis in patients without advanced CKD
False negative results in multi-vessel disease due to balance dischemia
8. Cardiovascular magnetic resonance
with gadolinium contrast has not been widely utilized clinically in the CKD population due to the concern of nephrogenicsy stemicfibrosis(NSF)(4
Dobutamine stress CMR was shown to be safe in the pre-renaltransplant population
In our practice
History and examination
Echo cardiogram
ECG
our Hospital is lacking of MPI
SO we perform cardiologist to make decision about ICA
echo doppler to rule out atherosclerotic vascular disease
Thank you
A 60-year-old woman with stage 5 chronic kidney disease (CKD) from glomerulonephritis presented with atypical chest discomfort at rest. She is worried about coronary artery disease (CAD). She has hypertension treated with an angiotensin converting enzyme inhibitor and a beta blocker. Her total cholesterol is 5 mmol/L with low-density lipoprotein of 3.2 mmol/L. She has no diabetes mel[1]litus, no family history of premature CAD, and does not smoke. How should she be evaluated?
Management of the case starts with a thorough clinical history about presenting symptoms, risk factors for CAD, traditional and non-traditional and symptoms of complications of CAD specifically heart failure and arrythmias and examination and a baseline 12-lead ECG.
Cardiovascular examination, especially to exclude uncontrolled hypertension, heart failure or significant aortic stenosis is important prior to cardiac stress investigation.
Then, if there is no contra indication, will go for cardiac stress investigations. These investigations have a lot of limitations in CKD patients as discussed below.
Exercise stress ECG
Has a low to moderate sensitivity and specificity of 68% and 77% respectively, even when adequate exercise capacity and 85% heart rate is achieved. EST is further limited in the advanced CKD population, with poor sensitivity of 36% specially those undergoing dialysis. This because of deconditioning which leads to reduced exercise capacity. Deconditioning can be due to vascular, neurological or musculoskeletal comorbidities, and the catabolic/cachexic metabolic state associated with CKD.
EXERCISE STRESS ECHOCARDIOGRAPHY AND DOBUTAMINE STRESS ECHOCARDIOGRAPHY
Exercise stress echocardiography (ESE) is better than the standard stress ECG in ruling in CAD (Positive likelihood ratio ESE 7.94 versus EST 3.57) and ruling out CAD (Negative likelihood ratio ESE 0.19 versus EST 0.38). Its sensitivity has been reported ranging from 71 to 97% with specificity ranging from 64 to 90%. However, the utility of ESE in CKD population remains limited due to the same physical reasons as EST limitations above. The addition of echocardiography allows assessment of Ventricular size and function, aortic and mitral valvular calcification, left ventricular hypertrophy (LVH), and potentially CFR.
MYOCARDIAL PERFUSION SCINTIGRAPHY
Exercise and pharmacological myocardial perfusion scintigraphy (MPS) have sensitivity of 87 and 89%, and specificity of 73 and 75%, respectively, in detecting >50% coronary artery stenosis in patients without advanced CKD. Exercise MPS in the advanced CKD population has the same limitation as EST and ESE, i.e related to the inadequate exercise performance and chronotropic incompetence.
CARDIOVASCULAR MAGNETIC RESONANCE
Cardiovascular magnetic resonance (CMR)with gadolinium contrast has not been widely utilized clinically in the CKD population due to the concern of nephrogenic systemic fibrosis (NSF). The use of Gadolinium chelates is prohibitive in CKD patients Due to the rare but serious side effect of NSF. NSF manifests as a Hardening of the skin and internal organs resembling scleroderma, which is irreversible and potentially fatal.
In this case we recommend ESE, to exclude inducible myocardial ischemia, inducible arrhythmia, and to assess exercise capacity and symptoms objectively. Resting echocardiography is useful to exclude significant aortic stenosis prior to exercise stress and to visually assess the degree of LVH.
In our hospital setting, this case needs full history, including presenting symptoms analysis, risk factors for CAD and initial targeted examination of her cardiovascular systems. Then initial 12 leads ECG, routine lab including cardiac enzymes and Chest x ray. Since presentation is with chest pain in patient with multiple risk factors for CAD, cardiologist involvement to decide further investigations and management of the case is needed. If acute coronary syndrome is diagnosed such case will be primarily under cardiology care with follow up from nephrology for kidney issues.
Excellent
DIAGNOSTIC EVALUATION
* clinical history
* Clinical examination
* Cardiovascular examination
* Assess fluid overload , Urea , hemoglobin vitamin D, calcium, phosphate, PTH ,Alb , Chol , TG, and proteinuria .
* Assess Inflammatory state
* Resting ECG
* Resting echocardiography
** Exercise stress ECG ( poor sensitivity , Deconditioning due to vascular, neurological or musculoskeletal comorbidities, catabolic/cachexic metabolic state that leads to reduced exercise capacity )
** Exercise stress echocardiography ( high Sensitivity and Specificity , limitations due to the same physical reasons )
Dobutamine stress echocardiography
( recommended in advanced CKD patients)
** Myocardial perfusion scintigraphy
( high false negative result in triple vessel CAD, and CKD )
** Cardiovascular magnetic resonance ( risk of Nnephrogenic systemic fibrosis , assess early cardiac dysfunction in pediatric population with advanced CKD
# In our practice for assessment this patient we do cardiovascular examination , Chest X ray , resting ECG , resting echocardiography , assest PAD , MPI and Consult cardiologist .
Thank you Dr Huda
· Summarise the management of the case presented in this article
This patient has many risk factors for CVD: her age, hypertension, advanced chronic kidney disease, dyslipidaemia, and maybe proteinuria due to GN.
But she the good thing that she is not smoker, not diabetic, and has no family history of CVD.
1) We need more detailed history of type of pain, exacerbating and relieving factors, distribution and localization.
2) Good clinical examination for chest, abdomen, to role out extracardiac cause of pain, and cardiac examination for JVP and murmurs to role out valve lesion, and exclude uncontrolled hypertension.
3) Chest XR, ultrasound abdomen, baseline 12 -lead ECG and rest Echocardiography.
4) I will not go for Exercise stress ECG because of : Reduced exercise capacity, Impaired chronotropic response, and abnormal base line ECG.
5) Exercise Stress Echocardiography and Dobutamine Stress Echocardiography also the same as ESE in advanced kidney disease.
6) Exercise Myocardial perfusion scintigraphy in the advanced chronic kidney disease patient has the sane limitation as EST and ESE.
7) Cardiovascular magnetic resonance with gadolinium is contraindicated due to risk of rare but fatal nephrogenic systemic fibrosis.
· Please reflect on your practice explaining how you would manage this case in your hospital setting
After excluding extracardiac causes, I would consult the cardiologist to evaluate ECG and Echo and possible to do Exercise Stress Echo, if it is strongly suggestive of CVD and needs Angiography, I will discuss with the patient the risk and benefit of coronary angiography.
Thank you, but this is a short reflection on your practice
CVD is the main cause of mortality in CKD patients even in young patients. Assessment of patient with suspected coronary disease may include:
In conclusion for this CKD patient ESE recommended to exclude inducible ischemia, inducible arrhythmia, in addition to assessing exercise capacity.
In my hospital we can assess CKD patients with resting ECG, resting ECHO and pharmacological stress ECHO in addition to clinical history & examination.
Thank you Ban
Chronic kidney disease is associated with increase cardiovascular risk and cardiovascular mortality.
Renal transplant candidate awaiting for kidney transplantation should be stratified for cardiovascular risk and evaluated carefully before proceeding into transplantation surgery. Cardiovascular evaluation of renal transplant candidate passes through a multidisciplinary approach including endocrinologist, pulmonologist, nephrologist and cardiologist.
Standard evaluation begins with a detailed clinical history and examination, a baseline 12-lead ECG and transthoracic echocardiography in patient with suspected underlying LVH, valvular, pericardial disease or pulmonary hypertension.
Diagnostic approaches:
– Exercise stress testing is the initial testing in exercise tolerating patients however it is limited in the advanced CKD population, with poor sensitivity of 36% as deconditioning leads to reduced exercise capacity.The stress induced ST segment changes in patients with advanced CKD, were shown to be not indicative of the severity of CAD, non-severe CAD a VS severe CAD group.
– Exercise stress echocardiography is an alternative or complementary option to the standard stress ECG in ruling in CAD and ruling out CAD). Its sensitivity has been reported ranging from 71 to 97% with specificity ranging from 64 to 90%.However, deconditioning of CKD population and exercise intolerance limits its use.
– Dobutamine and dipyridamole stress echocardiography technique detects inducible myocardial ischemia based on detection of wall motion abnormalities.Dipyridamole and dobutamine stress echocardiography had a sensitivity of 85and 86%, respectively, and a specificity of 89% and 86% , respectively, in detecting myocardial ischemia in the non-renal population. In renal population, a systematic review of 11 DSE studies with 690 potential renal transplant recipients reported that DSE had moderate sensitivity of 80% in detecting inducible myocardial ischemia. Abnormal DSE results in CKD patients have been associated with poorer prognosis for cardiac events and overall mortality.
– Exercise and pharmacological myocardial perfusion scintigraphy have sensitivity of 87 and 89%, and specificity of 73 and 75%, respectively, in detecting >50% coronary artery stenosis in patients without advanced CKD. Exercise MPS is limited for the same reasons of exercise intolerance in CKD population. A systematic review in 2011 showed that MPS has sensitivity of 69% and specificity of 77% in diagnosing inducible myocardial ischemia in the pre-renal transplant population. A meta analysis of 12 studies of prerenal transplant patients showed that the presence of reversible defects of inducible myocardial ischemia was associated with sixfold increased risk of myocardial infarction and almost fourfold risk of cardiac death. The presence of fixed defects was associated with a nearly fivefold increased risk of cardiac death.
In my practice, kidney transplant candidates with traditional risk factors of cardiovascular complications (smokers, diabetic, obese, hypertensive, dyslipidemic) are evaluated initially with ECG and Echocardiography followed by stress exercise testing and in cases with findings suggestive of underlying ischemia, patients are sent to cardiac catheterization.
Excellent as usual Dr Mohamed
Cardiovascular disease accounts for almost half the deaths of patient with esrd (20% to coronary artery disease )
Screening is indicated is symptomatic patient
Symptoms mabay typical and may atypical(silent -arrythmias _exertional dyspnea_weakness _ syncope)
Our patient is 60 year old female with hypertension and without family
history of cad
She asked to be investigated for cad
First thing to do is Ecg(cad changes as general population)
Second to do echocardiography for the patient to exclude valvular heart disease(especially aortic stenosis )
Then a non invasive test should be done
There are multiple tests with deffirence in sensitivity and specificity summarised as follow :
1_excesice stress test :
It is of moderate sensitivity and specificity
Many patients couldn’t reach the wanted heart rate due to exercise intolerance
Other probleme is basic ecg changes due to hypertension which could affect the interpretation of standard stress testing .
2_ Exercise echocardiography:
It is of better sensitivity and specificity compare to exercise test alone
The echocardiography could give us information about valvular lesions and cardiac wall movment with stress, however similar problems like exercise test are present (exercise intoleranc and other interpretation).
3_dobutamin stress echocardiography:
May solves the problemes with exercise sterss test with better sensitivity and specificity compare to stress test ,however cause it depends on cardiac wall abnormality ,it is ability to detect microvascular lesions is limited.
Cariac waa thickness due to LVH may reduce it’s sensitivity.
4_myocardial perfusion scintigraphy :
Althoug have tow methods to do
Throughout excersie or pharmacological
It is of good sensitivity with less specificity percentage.
Same problems in exercise test
The test has ahigh prevelance of false negative results.
5_cardiovascular magnitic resonance :
Of no clinical use cause due to concern of nephrogenic systemic fibrosis .
First thing i will do ecg and echocardiography
Correct anemia if present
Add aspirin with monitoring of bleeding .
Correct mbd especially if the patient takes unneeded calcium containing drug.
Blood control to goal of 130/80
A cardiologist must be consulted
We don’t have mps
So the best choice in my center will be stress echocardiography cause it is available and cheap as primary noninvasive test.
The cardiologist opinion is also important
Thank you Dr Hindawy
PLAN OF MANAGEMENTS:
How to mangment in hospital:
Thank you
Clinical history, cardiovascular examination and baseline ECG to exclude severe aortic stenosis and uncontrolled HTN before proceeding to cardiac stress investigations.
Exercise stress ECG:
Has several limitations in CKD patients due to:
Exercise stress echocardiography (ESE) and dobutamine stress echocardiography (DSE):
ESE is more sensitive than exercise stress ECG but its use in CKD patients is limited due to the limited exercise capacity.
Echocardiography provide information about ventricular size and function, valvular calcifications, left ventricular hypertrophy (LVH) and potential coronary flow reserve.
DSE detects significant epicardial CAD but not microvascular disease as it detects wall motion abnormalities resulting from inducible ischemia.
DSE has lower accuracy in CKD patients due to
Abnormal DSE in CKD patients is associated with poor prognosis for cardiac events and mortality.
However, DSE is recommended as screening test in advanced CKD population.
Myocardial perfusion scintigraphy (MPS):
Exercise MPS is limited in CKD patients due to the decreased exercise capacity and poor chronotropic response
Has sensitivity of 69% and specificity of 77% in diagnosing inducible myocardial ischemia in pre-transplant patients.
Associated with high false negative results in triple vessel CAD in CKD patients due to “balanced ischemia” that cause homogenous uptake of tracer.
A study showed that CKD patients with normal MPS have three times higher rate of cardiac death than non-CKD patients with normal MPS, this may be due to reduced coronary flow reserve, LVH with increased baseline myocardial blood flow and peripheral endothelial dysfunction in CKD patients.
Abnormal MPS results in CKD patients are associated with higher incidence of cardiac events and mortality.
Blunted heart rate response in CKD patients during stress MPI is associated with increased mortality.
Cardiovascular magnetic resonance (CMR):
Its use is limited in CKD patients due to the associated risk of nephrogenic systemic fibrosis which is irreversible and potentially fatal.
New non-contrast blood oxygen level dependent CMR technique and non-contrast whole heart MR coronary angiography are potential for assessing myocardial ischemia in CKD patients and need further studies.
In our practice:
This patient is considered at high risk for CAD and presenting with atypical chest pain, we will do serial resting ECG and cardiac enzymes to exclude active cardiac condition.
Resting echocardiography to assess ventricular size and function
She will be referred to cardiologist who will ask for Dobutamine stress echocardiography, if positive or non-conclusive (predicted heart rate wasn’t reached), she will have coronary angiography after informing her about the risk of contrast induced nephropathy.
Thank you Heba
Given data:
Age 60 years, female, stage 5 ckd, presented with atypial chest dyscomfort.
Evaluation:
History – examination (BP, cardiovascular system) to exclude accelerated hypertension and aortic stenosis) – ECG- exercise stress echo.
In my hospital, I wll assess the same way as described here. one other thing, I will do s. Troponin I level to exclude acute MI during initial presentation
Thank you for your reply; please explain more. You need also to structure your summary
• Summarise the management of the case presented in this article.
EXERCISE STRESS ECG
In patient with normal renal function, EST has a low to moderate sensitivity and specificity, even when adequate exercise capacity and 85% heart rate is achieved. EST limited further in advanced kidney disease, with poor sensitivity (36%). Because deconditioning leads further to decrease exercise capacity. Deconditioning occurs as a result to vascular, neurological or musculoskeletal comorbidities,
and the catabolic/cachexic metabolic state associated with CKD. CKD patients have also been shown to have impaired heart rate response to exercise, and abnormal baseline ECG which interfere with EST interpretation. In advanced CKD patients, the ST segment changes at stress were shown to be not significantly different between non-severe CAD and severe CAD group, despite a longer treadmill exercise time in the non-severe group.
EXERCISE STRESS ECHOCARDIOGRAPHY AND DOBUTAMINE STRESS ECHOCARDIOGRAPHY
Exercise stress echocardiography (ESE) is better than the standard stress ECG in ruling in CAD and ruling out CAD. However, the utility of ESE in CKD population remains limited due to the same physical reasons as EST limitations above.
The addition of echocardiography allows assessment of ventricular size and function, aortic and mitral valvular calcification, left ventricular hypertrophy (LVH), and potentially CFR. CFR measurement by Doppler echocardiography in the left anterior descending artery has been shown to be a determinant of cardiac events in CKD patients in the absence of obstructive epicardial CAD, but, it is not performed routinely by many echocardiography laboratories due to technical difficulties.
Dobutamine and dipyridamole stress echocardiography (DSE)technique detects inducible myocardial ischemia based on detection of wall motion abnormalities, thus, would detect significant epicardial CAD, not microvascular disease.
It is often recommended as a screening test in advanced CKD patients.
The majority of advanced CKD patients had a blunted chronotropic response, and even with the use of atropine they do not reach 85% maximal predicted heart rate, which further reduce the DSE sensitivity in detecting myocardial ischemia. Additionally, LVH with small intracavitary volume, obscures the detection of wall motion abnormalities at stress, thus, reduce the sensitivity of stress echocardiography.
Abnormal DSE results in CKD patients have been associated with poorer prognosis for cardiac events and overall mortality. Negative stress echocardiography results, on the other hand, have been shown to be associated with low incidence of major adverse cardiac events. Blunted chronotropic response with exercise in CKD population may relate to poorer overall cardiac prognosis.
MYOCARDIAL PERFUSION SCINTIGRAPHY
Exercise and pharmacological myocardial perfusion scintigraphy (MPS) have sensitivity of 87 and 89%, and specificity of 73 and 75%, respectively, in detecting >50% coronary artery stenosis in patients without advanced CKD. MPS has high false negative result in detecting ischemia in people with significant triple vessel CAD, as in the CKD population, because of homogeneous tracer uptake due to “balanced ischemia. abnormal MPS results in CKD patients have been shown to be associated with a higher incidence of cardiac events and mortality.
CARDIOVASCULAR MAGNETIC RESONANCE
Cardiovascular magnetic resonance (CMR) with gadolinium contrast has not been widely utilized clinically in the CKD population due to the concern of nephrogenic systemic fibrosis (NSF).
my work up to this patient will include ECG, Echo, SET
IT is cardiologist decision according to the patient’s risk
Excellent
A 60-year-old woman with stage 5 CKD from glomerulonephritis presented with atypical
chest discomfort at rest.
She is worried about CAD.
She has hypertension treated with an angiotensin converting enzyme inhibitor and a beta
blocker.
Her total cholesterol is 5 mmol/L with low-density lipoprotein of 3.2 mmol/L.
DIAGNOSTIC EVALUATION:
Diagnostic evaluation starts with a thorough clinical history and examination.
. Cardiovascular examination, especially to exclude uncontrolled hypertension or
significant aortic stenosis.
Baseline 12-lead ECG.
Cardiac stress investigation.
EXERCISE STRESS ECG:
Has a low to moderate sensitivity and specificity, 68 ± 16% and 77 ± 17% in normal
renal function persons.
Low sensitivity in CKD patient (36%) due to:
Deconditioning
Impaired heart rate response to exercise
The frequently abnormal baseline ECG in CKD patient the interpretation of standard
stress testing.
The ST segment changes at stress were shown to be not significantly different
between non-severe CAD and severe CAD group.
EXERCISE STRESS ECHOCARDIOGRAPHY AND DOBUTAMINE STRESS
ECHOCARDIOGRAPHY:
Its sensitivity has been reported ranging from 71 to 97% with specificity ranging from
64 to 90%. However, the utility of ESE in CKD population remains limited due to the
same physical reasons as EST limitations above.
Dipyridamole and dobutamine stress echocardiography had a sensitivity of 85%
(confidence interval 80–89) and 86% (confidence interval 78–91), respectively, and a
specificity of 89% (confidence interval 82–94) and 86% (confidence interval 75–89),
respectively, in detecting myocardial ischemia in the non-renal population.
It is often recommended as a screening test in advanced CKD patients.
Several mechanisms explain the reduced accuracy of DSE in the advanced CKD
population:
The majority of advanced CKD patients had a blunted chronotropic response, thus,did
not achieve 85% maximal predicted heart rate.
Thick myocardium due to LVH with small intracavitary volume, commonly found in
CKD patients, obscures the detection of wall motion abnormality.
MYOCARDIAL PERFUSION SCINTIGRAPHY:
Exercise and pharmacological myocardial perfusion scintigraphy (MPS) have sensitivity
of 87 and 89%, and specificity of 73 and 75%, respectively, in detecting >50% coronary
artery stenosis in patients without advanced CKD.
Exercise MPS in the advanced CKD population has the same limitation as EST and ESE
i.e. related to the inadequate exercise performance and chronotropic incompetence.
High-false negative result from balanced ischemia.
Abnormal MPS results in CKD patients have been shown to be associated with a higher
incidence of cardiac events and mortality.
Presence of reversible defects of inducible myocardial ischemia was associated with six
fold increased risk of myocardial infarction and almost fourfold risk of cardiac death .
The presence of fixed defects was associated with a nearly fivefold increased risk of
cardiac death.
In our practice for patient with CAD we do Dobutamine echo and proceed to Cardiac
catheterization in patient with positive.
Thank you for your reply; excellent summary as always