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Stress testing varies greatly among ESRD patients with CVD

The use of stress testing in patients waiting for renal transplants was inconsistent across transplant centers despite the frequent occurrence of ischemic heart disease in patients with end stage renal disease, according to a study published in JAMA Internal Medicine.

“Approximately 40% of patients with end stage renal disease (ESRD) have ischemic heart disease. Given this high prevalence, many renal transplant centers assess patients for ischemic heart disease in the pretransplant evaluation,” Adam A. Shpigel, MD, of the cardiovascular division at Washington University in St. Louis, and colleagues wrote. “Once accepted as a transplant candidate and placed on the waiting list, there is little guidance regarding subsequent stress testing in asymptomatic individuals.”

Researchers used the United States Renal Data System to identify patients with ESRD who underwent a first renal transplant from July 1, 2006, to Nov. 30, 2013. Patients included in the study were at least 40 years old and had primary Medicare insurance for at least 18 months prior to the transplant. Researchers compared patient-level and facility-level characteristics in patients who did and did not undergo stress testing.

The median OR described the likelihood a patient would undergo a stress test if the patient were to move from a center with a lower probability of conducting a stress test to a center with a higher probability of conducting a stress test.

The study included 26,694 patients from 217 renal transplant centers. The percentage of patients who underwent stress testing in the 18 months prior to renal transplant ranged from 11.1% to 96.2% across transplant centers.

Researchers found that white race (OR = 1.13; 95% CI, 1.05-1.21), diabetes (OR = 1.14; 95% CI, 1.05-1.24), hypertension (OR = 1.7; 95% CI, 1.55-1.86), coronary artery disease (OR = 2.66; 95% CI, 2.47-2.88), valvular disease (OR = 1.85; 95% CI, 1.66-2.07), peripheral vascular disease (OR = 1.11; 95% CI, 1.03-1.2), and cardiomyopathy (OR = 1.25; 95% CI, 1.09-1.43) were independent predictors of stress testing.

The median OR was 2.28 (95% CI, 2.04-2.48), which made the transplant center second only to the presence of coronary artery disease as factors in determining the likelihood of the use of stress testing in patients with ESRD.

Variation in stress testing was not attributed to differences in disease prevalence or access to care in the study population.

“The lack of consensus may reflect the cognitive dissonance created by the strong association of ischemia on stress testing with adverse outcomes, the absence of data regarding the benefit of stress testing in patients with ESRD awaiting renal transplantation, and the presence of high-quality data that revascularization does not improve outcomes in other high-risk surgical populations,” Shpigel and colleagues wrote. – by Erin Michael

Disclosures: The authors report no relevant financial disclosures.