Coronary angiography is the best predictor of events in renal transplant candidates compared with noninvasive testing

Guidelines for the detection of coronary artery disease ( CAD) and assess of risk in renal transplant candidates are based on the results of noninvasive testing, according to data originated in the nonuremic population. We evaluated prospectively the accuracy of 2 noninvasive tests and risk stratification in detecting CAD ( greater than or equal to 70% obstruction) and assessing cardiac risk by using coronary angiography ( CA). One hundred twenty-six renal transplant candidates who were classified as at moderate ( greater than or equal to 50 years) or high ( diabetes, extracardiac atherosclerosis, or clinical coronary artery disease) coronary risk underwent myocardial scintigraphy ( SPECT), dobutamine stress echocardiography, and CA and were followed for 6 to 48 months. The prevalence of CAD was 42%. The sensitivities and negative predictive values for the 2 noninvasive tests and risk stratification were < 75%. After 6 to 48 months, there were 18 cardiac events, 9 fatal. Risk stratification ( P = 0.007) and CA ( P = 0.0002) predicted the crude probability of surviving free of cardiac events. The probability of event-free survival at 6, 12, 24, 36, and 48 months were 98%, 98%, 94%, 94%, and 94% in patients with < 70% stenosis on CA and 97%, 87%, 61%, 56%, and 54% in patients with greater than or equal to 70% stenosis. Multivariate analysis showed that the sole predictor of cardiac events was critical coronary lesions ( P = 0.003). Coronary angiography may still be necessary for detecting CAD and determining cardiac risk in renal transplant candidates. The data suggest that current algorithms based on noninvasive testing in this population should be revised.