Presentation focused on pre-operative evaluation of Major Adverse Cardiac Events prior to renal transplantation. Modified from a presentation I gave in 2007; compared to the original there is a less enthusiastic endorsement of a peri-operative fixed dose beta blockade administration strategy given the discrepant results of the POISE and DECREASE-II studies

1. Cardiovascular Risk Evaluation and Management B efore Kidney Transplantation Christos Argyropoulos MD, PhD April 9 th 2007

7. Frequency of MACE in pts at cardiac risk (non-transplant Sx) CMAJ • September 13, 2005; 173 (6)

8. Frequency of MACE in pts at cardiac risk (non-transplant Sx) 3.9 % for ALL MACEs CI (3.3% - 4.6%) 3.1% for AMIs CMAJ • September 13, 2005; 173 (6)

12. Is “high CAD risk” = “high – perioperative” risk?

18. A Clinical Scoring System for MACEs in Noncardiac Surgery III Circulation. 1999;100:1043-1049.

23. Clinical Risk Factors for post-transplantation MACEs : Other

28. Risk Factors for MACEs in High – Risk Vascular Procedures IIa JAMA. 2001;285:1865-1873

29. Risk Factors for MACEs in High – Risk Vascular Procedures IIb JAMA. 2001;285:1865-1873

30. Risk Factors for MACEs in High – Risk Vascular Procedures IIc JAMA. 2001;285:1865-1873

31. Risk Factors for MACEs in High – Risk Vascular Procedures IIIa JAMA. 2001;285:1865-1873

32. Risk Factors for MACEs in High – Risk Vascular Procedures IIIb JAMA. 2001;285:1865-1873

34. Prognostic Value of Myocardial Perfusion Studies in Patients with End-Stage Renal Disease Assessed for Kidney or Kidney-Pancreas Transplantation: A Meta-Analysis

35. Prognostic Value of Myocardial Perfusion Studies in Patients with End-Stage Renal Disease Assessed for Kidney or Kidney-Pancreas Transplantation: A Meta-Analysis

36. Prognostic Value of Myocardial Perfusion Studies in Patients with End-Stage Renal Disease Assessed for Kidney or Kidney-Pancreas Transplantation: A Meta-Analysis Did these events occur before, immediately after, a long time after the transplant, or on dialysis, the cath table or a CTICU ? Toss a dice – they never told us

38. Prognostic Value of Myocardial Perfusion Imaging in Predicting Outcome After Renal Transplantation DM, known CAD, multiple clinical RFs

40. Prognostic Value of Myocardial Perfusion Imaging in Predicting Outcome After Renal Transplantation Similar to previous studies, no conclusion could be drawn apropos early perioperative MACEs

46. Coronary Angiography Is the Best Predictor of Events in Renal T ransplant Candidates Compared With Noninvasive Testing

47. Is Coronary Angiography a much better p redictor of Events in Renal T ransplant Candidates when c ompared to Clinical Risk Stratification ?

50. Routine Coronary Angiography in Diabetic N ephropathy Patients Before Transplantation 6% of predialytic patients required dialysis after they had their coronary angiogram !! SAFETY WARNING !

56. Derivation and validation of a disease-specific risk score for cardiac r isk stratification in chronic kidney disease (“Brisbane Score”) Derivation Population Validation Population

57. Derivation and validation of a disease-specific risk score for cardiac r isk stratification in chronic kidney disease (“Brisbane Score”) Validation Population Derivation Population AUC 0.61 0.80 0.58 0.67 AUC 0.60 0.77 0.64 0.67

67. Results: After Vascular Surgery

73. Devereaux, P.J. et al. CMAJ 2005;173:627-634 Potential triggers of states associated with perioperative elevations in troponin levels, arterial thrombosis and fatal myocardial infarction

76. Perioperative Ischemia

78. Effect of Bisoprolol on Perioperative Mortality and Myocardial Infarction in High-Risk Patients Undergoing Vascular Surgery. Poldermans D, Boersma E, et al, “Effect of Bisoprolol on Perioperative Mortality and Myocardial Infarction in High-Risk Patients Undergoing Vascular Surgery,” NEJM, Vol. 341, No. 24 (1999), pp. 1789-1794.

79. Let’s call a path consult (for an autopsy)

80. Let’s call a path consult (for an autopsy)

81. Let’s call a path consult (for an autopsy)

82. Let’s call a path consult (for an autopsy)

83. Autopsy Report Question: has revascularization been shown to prevent acute coronary events in stable CAD? Answer: The lesions that rupture are different from the ones that get stented i.e. a full metal jacket strategy is unlikely to work

89. EPILOGUE Cardiovascular Risk Evaluation and Management B efore Kidney Transplantation

93. Is Renal Transplantation a Surgical Therapy for CAD?

96. Time for a new conceptual framework? Think not what a stress test can’t do preoperatively, think what you can do for the patient perioperatively.

100. ECG evidence of “high troponin” syndrome or normal variant?