Author + information
- Simon Winther, MD, PhD∗ (, )
- My Svensson, MD, PhD,
- Hanne Skou Jørgensen, MD,
- Kirsten Bouchelouche, MD, DMSc,
- Lars Christian Gormsen, MD, PhD,
- Birgitte Bang Pedersen, MD, PhD,
- Niels Ramsing Holm, MD,
- Hans Erik Bøtker, MD, DMSc,
- Per Ivarsen, MD, PhD and
- Morten Bøttcher, MD, PhD
- ↵∗Department of Cardiology, Aarhus University Hospital, Brendstrupgaardsvej 100, DK-8200 Aarhus, Denmark
We thank Drs. Nerlekar and Nasis for their interest in our paper. We compared the diagnostic accuracy of coronary computed tomographic angiography (CTA) and single-photon emission computed tomography (SPECT) against invasively verified obstructive coronary artery disease (CAD) in kidney transplantation candidates (1).
We agree that our study explores the utility of coronary CTA beyond the conventional area of indications. Currently, coronary CTA is used in the general population to rule out CAD in patients with a pre-test risk of obstructive CAD between 15% and 50%, which is comparable to the prevalence of CAD in kidney transplantation candidates (2). Furthermore, CTA is a rapidly developing technique and recent developments enable combined evaluation of coronary arteries and aorta/pelvic vessels using a single contrast dose. The fact that many hospitals are already using CTA for pre-transplantation evaluation of pelvic vessel facilitates primary coronary evaluation without use of supplementary noninvasive test and with only little extra contrast media and radiation dose.
Despite the fact that coronary CTA was performed in all patients without pre-test selections, we demonstrated that coronary CTA is a reliable test with high sensitivity, high negative predictive value, and similar positive predictive value to diagnose obstructive CAD compared to SPECT. A strategy with pre-test exclusion of patients with a high irregular heart rate or a high calcium score would also have increased the specificity in our study.
We agree with Drs. Nerlekar and Nasis that the evidence of an association between asymptomatic CAD and prognosis in this cohort is lacking. It might be due to bias in retrospective study designs, low sensitivity of noninvasive stress tests, and the inability of invasive coronary angiography to detect nonobstructive CAD. Nonetheless, De Lima et al. (3) demonstrated a prognostic value by invasive coronary angiography in an almost similar population and interestingly also by risk factors but not by SPECT or stress echocardiography. Even so, noninvasive stress tests are currently recommended as diagnostic tools in all guidelines. In general, coronary CTA has an excellent prognostic value for future coronary events, but we agree that specific data for patients with chronic kidney disease are needed (2).
Coronary evaluation of transplantation candidates will remain controversial as long as no studies have firmly demonstrated that the potential benefit outweighs the risk. In the meantime, we believe that CTA can substitute for the stress test and have a pivotal role as an initial evaluation tool in kidney transplantation candidates.
Please note: The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- American College of Cardiology Foundation
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