title: A call to action: variability in guidelines for cardiac evaluation before renal transplantation.
abstract: OBJECTIVE
  Candidates for renal transplantation are at increased risk for complications related to cardiovascular disease; however, the optimal strategy to reduce this risk is not clear. The aim of this study was to evaluate the variability among existing guidelines for preoperative cardiac evaluation of renal transplant candidates.
  
  
  METHODS
  A consecutive series of renal transplant candidates (n=204) were identified, and four prominent preoperative cardiac evaluation guidelines, pertaining to this population, were retrospectively applied to determine the rate at which each guideline recommended cardiac stress testing.
  
  
  RESULTS
  The rate of pretransplant cardiac stress testing would have ranged from 20 to 100% depending on which guideline was applied. The American Heart Association/American College of Cardiology (ACC/AHA) guideline resulted in the lowest rate of testing (20%). In our population, 178 study subjects underwent stress testing: 17 were found to have ischemia and 10 underwent revascularization. The ACC/AHA approach would have decreased the number of noninvasive tests from 178 to 39; it would have identified only 4 of the 10 patients who underwent revascularization. The three other guidelines (renal transplant-specific guidelines) recommended widespread pretransplant cardiac testing and thus identified nearly all patients who had ischemia on stress testing.
  
  
  CONCLUSIONS
  The ACC/AHA perioperative guideline may be inadequate for identifying renal transplant candidates with coronary disease; however, renal transplant-specific guidelines may provoke significant overtesting. An intermediate approach based on risk factors specific to the ESRD population may optimize detection of coronary disease and limit testing.
authors.affiliation: Section of Cardiology, Dartmouth Medical School/ Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire 03756-0001, USA.
authors.forename: Scott E
authors.initials: SE
authors.lastname: Friedman
authors.forename: Robert T
authors.initials: RT
authors.lastname: Palac
authors.forename: David M
authors.initials: DM
authors.lastname: Zlotnick
authors.forename: Michael C
authors.initials: MC
authors.lastname: Chobanian
authors.forename: Salvatore P
authors.initials: SP
authors.lastname: Costa
mesh_terms: D000328:Adult; D000368:Aged; D016208:Databases, Factual / Q000706:statistics & numerical data; D005080:Exercise Test / Q000592:standards* / Q000706:statistics & numerical data; D019983:Guideline Adherence / Q000706:statistics & numerical data; D006801:Humans; D007676:Kidney Failure, Chronic / Q000453:epidemiology / Q000601:surgery*; D016030:Kidney Transplantation / Q000592:standards* / Q000706:statistics & numerical data; D008875:Middle Aged; D017202:Myocardial Ischemia / Q000175:diagnosis* / Q000453:epidemiology / Q000628:therapy; D009204:Myocardial Revascularization / Q000706:statistics & numerical data; D017410:Practice Guidelines as Topic; D011300:Preoperative Care / Q000592:standards* / Q000706:statistics & numerical data; D012189:Retrospective Studies; D012307:Risk Factors