Page 25 - Cardiac testing for coronary artery disease in potential kidney transplant recipients

Summary of results (Continued)

Post test probability after positive screening 73% to 90% 55% to 81%
test result for a patient with intermediate
risk (30% to 59% pre test probability) dis-
ease

Post test probability after positive screening 91% to 98% 81% to 96%
test result for a patient with high risk (60%
to 90% pre test probability) disease

Post test probability after negative screen- 3% to 10% 5% to 15%
ing test result for a patient with low risk
(10% to 29% pre test probability) disease
Post test probability after negative screen- 10% to 27% 16% to 38%
ing test result for a patient with intermedi-
ate risk (30% to 59% pre test probability)
disease

Post test probability after negative screen- 28% to 70% 39% to 79%
ing test result for a patient with high risk
(60% to 90% pre test probability) disease

Conclusions and comments
Both tests, especially DSE, have a role as triage tests for intermediate risk transplant candidates, with negative results precluding
the need for further evaluation with coronary angiography, thereby avoiding unnecessary risk to patients and potentially reducing
healthcare costs
Given the wide heterogeneity in the estimates for both DSE and MPS, there is still considerable uncertainty in the true post-test
probabilities of each test
Current evidence suggests that, where feasible, DSE should be used as the screening investigation of choice over MPS

Applicability of tests in clinical practice

Both DSE and MPS have a role as triage tests for the intermediate risk transplant candidates, with negative results reducing the need
for further evaluation with coronary angiography. In high risk patients, a positive non-invasive DSE or MPS confirms the high risk
of severe CAD, but a negative result does not conclusively rule out severe CAD. In these patients, one may consider proceeding
immediately to coronary angiography and avoid using functional tests
The relatively low sensitivity and specificity of both DSE and MPS however means that they are not perfect triage tests and a significant
number of patients will either have their significant CAD missed (false negatives) or be referred in vain for coronary angiography
(false positive)
Despite the shortcomings of the non-invasive tests in their role as triage tests, the very select nature of the population and the unique
challenges facing cardiac investigation in this population (particularly, the need to avoid complications arising from an invasive gold
standard) and the lack of an alternate better performing test means that we are forced to accept an imperfect triage test
Functional testing may provide additional prognostic information, although an investigation into this was not included under the
scope of this review.

Costs

Cardiac testing for coronary artery disease in potential kidney transplant recipients (Review) 23
Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.