Evaluation of a protocol for coronary artery disease investigation in asymptomatic elderly hemodialysis patients

Jose Jayme G De Lima,1 Luis Henrique W Gowdak,1 Flavio J de Paula,1 Henrique Cotchi S Muela,2 Elias David-Neto,1 Luiz A Bortolotto1 1Heart Institute (InCor) and Renal Transplant Unit, Division of Urology, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, SP, Brazil; 2Department of Medicine, Agostinho Neto University Medical School, Luanda, Angola Background: Coronary artery disease (CAD) is prevalent in older patients on dialysis, but the prognostic relevance of coronary assessment in asymptomatic subjects remains undefined. We tested the usefulness of a protocol, based on clinical, invasive, and noninvasive coronary assessment, by answering these questions: Could selecting asymptomatic patients for coronary invasive assessment identify those at higher risk of events? Is CAD associated with a worse prognosis?Methods: A retrospective study including 276 asymptomatic patients at least 65 years old on the waiting list, prospectively evaluated for CAD and followed up until death or renal transplantation, were classified into two groups: 1) low-risk patients who did not undergo coronary angiography (n=63) and 2) patients who did undergo angiography (n=213). The latter group was reclassified into patients with significant CAD or normal angiograms/nonsignificant CAD.Results: CAD (≥70% stenosis) occurred in 124 subjects (58%). The incidence of death by any cause, coronary death, and major cardiovascular (CV) events were similar in patients selected or not for angiography and in those with or without significant CAD. Myocardial revascularization (surgical/percutaneous) was performed in only 21/276 patients (7.6%) and did not result in a reduction in mortality.Conclusion: In older patients on renal replacement therapy, the prevalence of CAD was high, but coronary investigation was not useful as a risk stratification tool and also resulted in a rather small proportion of patients eligible for intervention. Therefore, in the elderly, coronary investigation should not be considered routine in asymptomatic patients. Keywords: elderly, hemodialysis, coronary artery disease, kidney transplantation, cardiovascular, chronic kidney disease