Skip Navigation

European Journal of Echocardiography 2005 6(5):327-335; doi:10.1016/j.euje.2005.04.011
This Article
Right arrow Abstract Freely available
Right arrow FREE Full Text (PDF) Freely available
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Related articles in Eur J Echocardiogr
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrowRequest Permissions
Right arrow Disclaimer
Google Scholar
Right arrow Articles by Sharma, R.
Right arrow Articles by Brecker, S.J.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Sharma, R.
Right arrow Articles by Brecker, S.J.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?

Copyright © 2005, The European Society of Cardiology

Dobutamine stress echocardiography and cardiac troponin T for the detection of significant coronary artery disease and predicting outcome in renal transplant candidates

R. Sharmaa,*, D. Pellerinb, D.C. Gazec, J.S. Shahb, C.P. Streatherd, P.O. Collinsonc and S.J. Breckera

aDepartment of Cardiology, St George's Hospital, London, UK
bThe Heart Hospital, London, UK
cDepartment of Chemical Pathology, St George's Hospital, London, UK
dDepartment of Renal Medicine, St George's Hospital, London, UK

Received 27 October 2004; received in revised form 20 April 2005; accepted after revision 27 April 2005.

rsharma{at}tinyworld.co.uk

* Corresponding author. Department of Cardiology, E Level East Wing, Mailpoint 46, Southampton General Hospital, Tremona Road, Southampton SO16 6YD, UK. Tel.: +44 781 448 2140.


   Abstract
Top
 Abstract
Background
 Methods
 Results
 Discussion
 References
 
Aims

Ischaemic heart disease is the leading cause of mortality and morbidity in patients with end-stage renal disease (ESRD) and after renal transplantation. However, the optimal non-invasive test for coronary artery disease (CAD) diagnosis in this population has yet to be established. The aim of this study was to assess the diagnostic accuracy of dobutamine stress echocardiography (DSE) and baseline plasma cardiac troponin T (cTnT) for detecting significant CAD and predicting adverse cardiac events in patients referred for renal transplantation.

Methods

Coronary angiography, DSE, and baseline cTnT measurements were performed in 118 consecutive patients (mean age 52±12 years, 75 male) with ESRD (mean creatinine 608±272µmol/L) referred for renal transplantation. The mean follow-up period was 1.32±0.48 years. Significant CAD was defined as a reduction in luminal diameter >70% by visual estimation in at least one major epicardial vessel. An abnormal DSE result defined as the development of a new regional wall motion abnormality in one or more normal resting segments or a deterioration of wall motion in one or more resting hypokinetic segments. A baseline cTnT>0.1µg/L was taken as positive.

Results

Significant CAD in at least one vessel was present in 35 patients (30%). The number of patients with significant 3 vessel and 2 vessel disease was 6 and 7, respectively. An abnormal DSE result was present in 36 (31%) patients. Thirty-one (26%) had cTnT>0.1µg/L. Sixty-four (54%) patients were on dialysis and 46 (39%) were diabetic. The sensitivity, specificity, positive and negative predictive values for DSE in detecting significant coronary artery disease were 88%, 94%, 86% and 95%, respectively. The same values for a raised cTnT were 54%, 62%, 40% and 74%, respectively. The combination of an abnormal DSE result and raised cTnT gave values of 61%, 91%, 76%, and 80%, respectively. Over the follow-up period, mortality was significantly higher in those with a raised baseline cTnT but not those with an abnormal DSE result or significant CAD.

Conclusion

DSE is an accurate technique for the detection of significant CAD in renal transplant candidates. An elevated cTnT does not predict significant CAD in this population and when used in conjunction with DSE, reduces the sensitivity of the combined tests. cTnT is an important marker of prognosis in renal transplant candidates.

Keywords: End stage renal disease; Dobutamine stress echocardiography; Cardiac troponin T; Coronary artery disease


   Background
Top
 Abstract
 Background
Methods
 Results
 Discussion
 References
 
Cardiovascular disease is the major cause of mortality in patients with end-stage renal disease (ESRD).1,2 After renal transplantation half of all deaths are cardiac, usually in the first 5 years in the presence of functional graft.3 Cardiac events are reduced by coronary revascularisation prior to renal transplantation.4 The detection and treatment of CAD is therefore advocated in all renal transplant candidates.5 This is especially important as their disease is often silent.

The optimal cardiovascular screening technique remains unclear. Stress echocardiography is a reliable technique for the estimation of significant CAD in ESRD.6–10 Most of these studies relied on clinical event rates and/or selected angiography for the validation of test accuracy. In only one study was coronary angiography performed on all patients8 but the total number studied was small and predominantly consisted of selected high risk cases.

Patients with ESRD and a persistently elevated plasma cardiac troponin T or I level have significantly increased mortality.11–13 The reasons for this remain unclear, but some studies suggest an association with underlying ischaemic heart disease.14

The aim of this study was to assess the diagnostic accuracy of DSE and plasma cardiac troponin T (cTnT) for the detection of significant CAD and predicting outcome in renal transplant candidates. The patients were not selected and the presence of CAD defined by coronary angiography.


   Methods
Top
 Abstract
 Background
 Methods
Results
 Discussion
 References
 
Population
One hundred and twenty one consecutive patients referred for renal transplantation evaluation at St George's Hospital were prospectively studied. Three patients refused coronary angiography so were not included in the analysis. Exclusion criteria were: age less than 18 years, severe aortic stenosis, unstable angina and inability to consent.

At study entry, all patients underwent full history, examination, resting electrocardiogram. Haematological and biochemical parameters were recorded on the day of the DSE. Medical care was directed by a single team of physicians with policies established by consensus. Advances in medical therapy were systematically implemented over the follow-up period.

Dobutamine stress echocardiography
DSE was performed using General Electric Vingmed System 7. A full cross sectional study was performed at baseline. For those on dialysis, the studies were performed 16–24h post dialysis, when the patients were most likely to be closest to their euvolaemic state.15,16 Beta blockers were stopped 72h prior to the test but all other anti-hypertensive and anti-ischaemic medication taken up to the day of the examination. If the baseline systolic blood pressure was greater than 190mmHg, DSE was rescheduled.

Images were acquired in standard parasternal long- and short-axis and apical 2-, 3-, 4-chamber views at baseline and during stepwise infusion of dobutamine infusion. This was given according to a protocol based on 3min stages of 5, 10, 20, 30, 40µg/kg/min. Atropine was administered up to a total of 1.0mg intravenously if the target heart rate was not achieved with dobutamine alone. Metoprolol was available as antagonist if required. Blood pressure and 12-lead ECG were recorded at each infusion stage. Baseline, low-dose (heart 10–15 beats above baseline), peak and recovery (10min after drug infusion terminated) stage images were stored and analysed in digital quad screen format. The test was stopped if: target heart rate was achieved ([220–age]0.85), ST depression>2mm, significant tacharrhythmia (sustained supraventricular tachycardia or >3 beat run of ventricular tachycardia), symptomatic severe hypotension, blood pressure>240mmHg systolic or 140mmHg diastolic.

All images were reported off-line by 2 experienced observers blinded to the rest of the study. Qualitative analysis was performed with the left ventricle divided into a 16 segment model. Regional motion described as hyperkinetic, normal, hypokinetic, akinetic and dyskinetic. Results were classified as a normal response with an overall increase in wall motion or abnormal response. Abnormal response was described as the occurrence under stress of hypokinesia, akinesia, or dyskinesia in one or more resting normal segments and/or worsening of wall motion in one or more resting hypokinetic segments. The level of agreement between the 2 sonographers was 92%, and a consensus obtained in discordant cases. Regional wall motion score index (RWMSI) at rest and at peak stress was calculated.

Cardiac troponin T (cTnT) assay
Whole blood samples were obtained at baseline before the DSE. Serum was obtained after clotting and centrifugation at 3000rpm for 10min. cTnT was measured using the third generation Elecsys 2010 STAT electrochemiluminescent immunoassay (Roche Diagnostics, Lewes).17 The assay detection limit was <0.01µg/L. The total assay coefficient of variation (CV) was 5.5% at 0.32µg/L and 5.4% at 6.0µg/L. The corresponding concentration with a 10% CV was 0.03µg/L. The receiver operator characteristic (ROC) curve medical decision cut off for myocardial infarction is 0.1µg/L.18 The 99.5 percentile of 350 healthy subjects was found to be 0.01µg/L.

For this study a serum cTnT level>0.1µg/L was taken as positive. Previous studies have shown that ESRD patients with baseline cTnT values>0.1µg/L are at highest risk of cardiovascular mortality.11,13

Coronary angiography
The procedure was via femoral route by standard Judkins technique. All predialysis patients had intravenous fluid before and after the procedure. Contrast load kept to a minimum (mean contrast load 44±12ml). Angiograms were interpreted blindly by 2 experienced observers and consensus obtained for disagreement. The level of agreement was 94%. Luminal stenosis severity of each epicardial artery was assessed visually and graded as follows: normal, mild (<50%), moderate (50–70%), significant (>70%).

Statistical analysis
Continuous variables were expressed as mean±SD. Groups were compared by unpaired t-test or chi-square test. Sensitivity, specificity, positive and negative predictive values for the diagnosis of severe CAD were calculated in turn for: DSE, cTnT and the two tests in combination. Long-term survival related to angiographic findings, DSE and cTnT was analysed in a Kaplan–Meier model. The log-rank test was used to evaluate the difference between Kaplan–Meier curves. The SPSS statistics package (SPSS Inc, version 12, Chicago, IL, USA) was used.

Follow-up
This was obtained by review of inpatient and outpatient medical records and telephone calls to the transplant unit.


   Results
Top
 Abstract
 Background
 Methods
 Results
Discussion
 References
 
Baseline characteristics
Table 1 lists the demographic and clinical characteristics of the 118 subjects studied. The predominant cause of renal failure was diabetes (39 patients). Amongst diabetics, mean glycosylated haemoglobin concentration was 7.6±4.7%. The mean time for those receiving dialysis (54%) was only 2.73±2.19 months. Medication use included aspirin in 50 patients (43%), beta blockers in 40 patients (34%), angiotensin-converting enzyme inhibitors in 52 patients (44%), statins in 62 patients (53%), erythropoietin in 52 patients (44%), and diuretic in 54 patients (46%). Medication was not adjusted in relation to the DSE or coronary angiogram results.


View this table:
[in this window]
[in a new window]

  		Table 1 Baseline characteristics

 
Dobutamine stress echocardiography
Resting and peak stress echocardiographic results are shown in Table 2. Five patients had significant valve disease: moderate mitral regurgitation (2), severe mitral stenosis (1), moderate aortic stenosis (2).


View this table:
[in this window]
[in a new window]

  		Table 2 Echocardiographic results

 
Thirty-six patients (31%) had a positive DSE result. Only 5 patients did not achieve 85% of their predicted heart rate. Three patients developed atrial arrhythmias requiring treatment. None required hospitalisation. Three percent of segments could not be analysed due to poor image quality. Mean delay between DSE and coronary angiography was 61±15 days (range 1–114 days).

Cardiac troponin T
A significantly elevated plasma cTnT>0.1µg/L was seen in 31 (26%) patients. Seventy-three (62%) patients had baseline cTnT levels greater than the detection limit of the assay (>0.01µg/L).

Coronary angiography
There were no significant complications with angiography. Significant CAD was seen in 35 (30%) patients. Seven had significant 3 vessel disease, 8 two vessel and 20 single vessel disease. Fifteen (13%) patients had moderate coronary disease and 25 (21%) had mild disease. Forty-three (36%) patients had angiographically normal coronary arteries.

Four patients with significant 3 vessel disease had coronary artery bypass surgery. The remaining 4 were taken off the transplant list. Of those with 2 vessel disease, 2 had coronary artery bypass surgery, 1 had percutaneous angioplasty and the remaining 5 medical therapy. Seven of the 20 patients with single vessel disease had percutaneous angioplasty, with medical therapy for the rest.

Diagnostic accuracy of DSE and cTnT for the detection of significant CAD
Table 3 shows a comparison of echocardiography and cTnT parameters in patients with and without significant CAD. The proportion of patients with an elevated cTnT were not significantly different between the 2 groups. Those with significant CAD had larger baseline LV cavity size, lower baseline and peak LVEF. Baseline and new RWMA were significantly greater in those with CAD. The diagnostic accuracy of DSE and plasma cTnT is shown in Fig. 1. The sensitivity, specificity, positive and negative predictive values for DSE in detecting significant CAD were 88%, 94%, 86% and 95%, respectively. The same values for a raised cTnT were 54%, 62%, 40%, and 74%, respectively. The combination of an abnormal DSE result and raised cTnT gave values of 61%, 91%, 76% and 80%, respectively. The values for patients with a resting RWMA are also shown.


Figure 1
View larger version (24K):
[in this window]
[in a new window]
[Download PowerPoint slide]
  		Figure 1 Accuracy of resting RWMA, positive DSE result and elevated cTnT for the diagnosis of CAD (for abbreviations see text).

 


View this table:
[in this window]
[in a new window]

  		Table 3 Comparison of DSE and cTnT parameters in patients with and without significant CAD

 
Four patients with a positive DSE result did not have significant CAD. Only one of these had angiographically normal arteries. One had a moderate left anterior descending artery stenosis with an inducible RWMA seen at the apex. The other 2 had minor 1 and 3 vessel disease, respectively. There were 4 false negative results, none of whom have had cardiovascular events thus far.

The accuracy of DSE for the diagnosis of significant 1, 2 and 3 vessel disease is shown in Fig. 2. Importantly, there was 100% specificity and 100% negative predictive value for significant 2 and 3 vessel CAD. When the ischaemic burden during stress was taken into account by calculating peak RWMSI, assessing the number of ischaemic segments at peak stress and calculating the heart rate threshold for ischaemia, there were significant differences between patients with 2 and 3 vessel disease and those without. This is shown in Table 4.


Figure 2
View larger version (24K):
[in this window]
[in a new window]
[Download PowerPoint slide]
  		Figure 2 Accuracy of positive DSE result for the diagnosis of significant 1, 2 and 3 vessel CAD (for abbreviations see text).

 


View this table:
[in this window]
[in a new window]

  		Table 4 Assessment of the total ischaemic burden during DSE in patients with 0, 1, 2, 3 CAD

 
Follow-up and survival
Patients were followed up for 1.32±0.48 years (range 0.19–2.12 years). Thirty-three patients have received renal transplants. Fourteen patients have had coronary revascularisation, 6 coronary artery bypass surgery, and 8 percutaneous angioplasty. There were 9 deaths, 3 from myocardial infarction (MI), 1 sudden cardiac death, 2 cerebrovascular accidents, 1 sepsis and 2 unknown. One patient has had a non-fatal MI. The mean time to death was 0.77±0.66 years (range 0.19–2.0 years) and the mean age at death was 61.89±9.91 years (vs 51.24±12 years in alive patients, p=0.012).

As shown in Fig. 3, there were similar but non-significant trends towards worse survival in patients with significant CAD and a positive DSE result. Of those who died from cardiac causes, 3 had a positive DSE and significant CAD at angiography. The fourth had minor CAD and a normal DSE. The peak RWMSI (1.09 vs 1.23), number of ischaemic segments at peak stress (0.77 vs 2.78) and heart rate threshold for ischaemia (91% vs 84%) were not significantly different in survivors and non-survivors, respectively. Patients with an elevated plasma cTnT had significantly worse survival than those without (p=0.004) (Fig. 4). Figure 5 shows the ROC curve representing the capability of the cTnT value to predict mortality. The area under the curve (AUC) is 0.76 (p=0.02, 95% CI 0.617, 0.935). A cTnT cut off value of 0.08µg/L predicts mortality with sensitivity 75% and specificity 76%, respectively.


Figure 3
View larger version (10K):
[in this window]
[in a new window]
[Download PowerPoint slide]
  		Figure 3 Kaplan–Meier survival curves for patients according to DSE result and severity of CAD (for abbreviations see text).

 


Figure 4
View larger version (10K):
[in this window]
[in a new window]
[Download PowerPoint slide]
  		Figure 4 Kaplan–Meier curves for survival according to plasma cTnT result (for abbreviations see text).

 


Figure 5
View larger version (10K):
[in this window]
[in a new window]
[Download PowerPoint slide]
  		Figure 5 ROC curve for cTnT level to predict mortality (for abbreviations see text).

 

   Discussion
Top
 Abstract
 Background
 Methods
 Results
 Discussion
References
 
This is the first prospective study to determine the diagnostic accuracy of DSE for significant CAD detection in an unselected renal transplant population. One hundred and eighteen patients had coronary angiography and DSE, making this the largest study of its kind in ESRD. We combined the DSE results with baseline cTnT levels to see if the accuracy was improved. A third of our population had significant CAD in keeping with previous studies on renal transplant candidates.4,19 Forty-six percent of patients were not on dialysis, a group of renal transplant candidates were not studied previously with DSE. Thirty-nine percent had diabetes, the commonest cause for ESRD. Glycosylated haemoglobin levels suggested short-term glucose control was satisfactory in the diabetic population. We found that DSE was well tolerated and had high accuracy in detecting significant CAD. A persistently elevated cTnT did not predict severe CAD in this population. The presence of significant CAD is dependant on the angiographic definition of severity. We used a qualitative visual assessment of angiographic severity as this was the study criterion used by Manske et al.4 for prophylactic revascularisation of diabetics with ESRD. Quantitative stenosis measurement can be problematic in the presence of diffuse disease as the reference segment may be inappropriately narrowed.

The optimal cardiovascular screening test for renal transplant candidates remains unclear. Coronary angiography carries small risks, especially contrast-induced nephropathy in predialysis patients.20,21 It is probably not cost effective as two thirds of renal transplant candidates will not have significant CAD.4,19 Exercise testing is unreliable as a significant proportion of patients will not achieve 85% predicted heart rate.22,23 The results of myocardial perfusion imaging are variable with some suggesting high negative predictive value24–26 and others low sensitivity.27,28 Stress echocardiography has widespread use in the general population with diagnostic accuracy comparable to other imaging techniques.29–31 The theoretical advantages of this technique in ESRD include maintained sensitivity and specificity in hypertension32 and bundle branch block.33 Studies have been published on the diagnostic efficacy in ESRD. The first two6,8 had conflicting results with sensitivities varying between 52% and 92% and specificities between 74% and 86%, respectively. The reasons for this discrepancy include the achievement of submaximal heart rate in a large number of patients in both studies and only one study involved angiography in all patients.8 Both studies involved high risk diabetic patients on dialysis with a >50% prevalence of CAD. This is not representative of a renal transplant population. Another study9 suggested much better sensitivity (86%) and specificity (94%) but the population selected was lower risk than a renal transplant population. Only 10% were diabetic and the prevalence of CAD was only 20%. It is unclear whether these results can be extrapolated to the renal transplant population where many of the patients are not on dialysis and the pretext probability of CAD different. Ours was the first study to assess DSE in this group of ESRD patients.

The results of our study compare favourably to the best estimates of accuracy for DSE in the diagnosis of CAD in the general population.30 and to the results of Dahan et al.9 in ESRD patients. They are markedly improved on other studies of DSE in this group of patients.6–8 Reasons include our much larger sample size and the fact that beta blockers were stopped 72h prior to the test, resulting in 95% patients achieving 85% predicted heart rate. Our use of second harmonic imaging is known to improve endocardial border definition which in turn results in better accuracy of DSE.34 This is reflected in the fact that there was 92% agreement of DSE interpretation between observers and only 3% of segments could not be analysed due to poor image quality.

There was a clear relationship between the number of affected coronary arteries and the total ischaemic burden during stress. Importantly, the accuracy of DSE was highest in patients with multivessel disease with 100% specificity in those with 2 and 3 vessel disease. This has important implications for screening renal transplant candidates. The presence of a baseline RWMA has high specificity but low sensitivity for CAD diagnosis. This compares with the results of Herzog et al.8

Significant baseline cTnT levels were found in 26% of renal transplant candidates but did not predict CAD. When all cause mortality was analysed with respect to the DSE result and angiographic severity, there was a non-significant trend toward worse survival in those with positive studies. The total ischaemic burden during DSE was also not significantly different in survivors and non-survivors. Reasons for this include the short follow-up period and the likely protective effect of revascularisation in 14 of the 35 patients with significant CAD. Medication was not adjusted based on the DSE or coronary angiogram results. All cause mortality was significantly higher in those with an elevated cTnT. This is in keeping with previous studies.11–13 The reasons for this remain unclear but our results suggest cTnT is not simply an indicator of underlying ischaemic heart disease. It is probably a marker of additional mechanisms of cardiac damage in this group of patients. Possible reasons include low-grade myocarditis or micro-infarction but further studies are required. In this study, a cTnT value≥0.08µg/L predicted adverse outcome with sensitivity 75% and specificity 76%, respectively.

In conclusion, DSE is a safe and accurate technique for the diagnosis of CAD in renal transplant candidates. A negative result confidently excludes significant 2 and 3 vessel disease. Baseline plasma cTnT levels are raised in a proportion of these patients and are associated with poor outcome but do not predict significant CAD. Given its safety and low cost, DSE would be an ideal screening tool for cardiovascular disease in ESRD. Further studies are required to define the role of cTnT levels in the screening of renal transplant candidates.


   References
Top
 Abstract
 Background
 Methods
 Results
 Discussion
 References
 

  1. Raine A.E., Margreiter R., Brunner F.P., Ehrich J.H., Geerlings W., Landais P., et al. Report on management of renal failure in Europe, XXII, 1991. Nephrol Dial Transplant (1992) 7:7–35.[Web of Science][Medline]
  2. USRDS 2000 ANNUAL DATA REPORT. 2000:583–689.
  3. Ojo A.O., Hanson J.A., Wolfe R.A., Leichtman A.B., Agodoa L.Y., Port F.K. Long-term survival in renal transplant recipients with graft function. Kidney Int (2000) 57:307–313.[CrossRef][Web of Science][Medline]
  4. Manske C.L., Wang Y., Rector T., Wilson R.F., White C.W. Coronary revascularisation in insulin-dependent diabetic patients with chronic renal failure. Lancet (1992) 340:998–1002.[CrossRef][Web of Science][Medline]
  5. European Best Practice Guidelines for Renal Transplantation (part 1). Nephrol Dial Transplant (2000) 15(Suppl_7):1–85.[Free Full Text]
  6. Reis G., Marcovitz P.A., Leichtman A.B., Merion R.M., Fay W.P., Werns S.W., et al. Usefulness of dobutamine stress echocardiography in detecting coronary artery disease in end-stage renal disease. Am J Cardiol (1995) 75:707–710.[CrossRef][Web of Science][Medline]
  7. Bates J.R., Sawada S.G., Segar D.S., Spaedy A.J., Petrovic O., Fineberg N.S., et al. Evaluation using dobutamine stress echocardiography in patients with insulin-dependent diabetes mellitus before kidney and/or pancreas transplantation. Am J Cardiol (1996) 77:175–179.[CrossRef][Web of Science][Medline]
  8. Herzog C.A., Marwick T.H., Pheley A.M., White C.W., Rao V.K., Dick C.D. Dobutamine stress echocardiography for the detection of significant coronary artery disease in renal transplant candidates. Am J Kidney Dis (1993) 33:1080–1090.
  9. Dahan M., Viron B.M., Poiseau E., Kolta A.M., Aubry N., Paillole C., et al. Combined dipyridamole-exercise stress echocardiography for detection of myocardial ischemia in hemodialysis patients: an alternative to stress nuclear imaging. Am J Kidney Dis (2002) 40:737–744.[CrossRef][Web of Science][Medline]
  10. Brennan D.C., Vedala G., Miller S.B., Anstey M.E., Singer G.G., Kovacs A., et al. Pretransplant dobutamine stress echocardiography is useful and cost-effective in renal transplant candidates. Transplant Proc (1997) 29:233–234.[CrossRef][Web of Science][Medline]
  11. Dierkes J., Domrose U., Westphal S., Ambrosch A., Bosselmann H.P., Neumann K.H., et al. Cardiac troponin T predicts mortality in patients with end-stage renal disease. Circulation (2000) 102:1964–1969.[Abstract/Free Full Text]
  12. Ooi D.S., Zimmerman D., Graham J., Wells G.A. Cardiac troponin T predicts long-term outcomes in hemodialysis patients. Clin Chem (2001) 47:412–417.[Abstract/Free Full Text]
  13. Apple F.S., Murakami M.M., Pearce L.A., Herzog C.A. Predictive value of cardiac troponin I and T for subsequent death in end-stage renal disease. Circulation (2002) 106:2941–2945.[Abstract/Free Full Text]
  14. Porter G.A., Norten T.L., Lindsley J., Stevens J.S., Phillips D.S., Bennett W.M. Relationship between elevated serum troponin values in end-stage renal disease patients and abnormal isotopic cardiac scans following stress. Ren Fail (2003) 25:55–65.[CrossRef][Web of Science][Medline]
  15. London G.M., Fabiani F., Marchais, de Vernejoul M.C., Guerin A.P., Safer M.E., et al. Uremic cardiomyopathy: an inadequate left ventricular hypertrophy. Kidney Int (1987) 31:973–980.[Web of Science][Medline]
  16. Harnett J.D., Murphy B., Collingwood P., Purchase L., Kent G., Parfrey P.S. The reliability and validity of echocardiographic measurement of left ventricular mass index in hemodialysis patients. Nephron (1993) 65:212–214.[Web of Science][Medline]
  17. Hallermayer K., Klenner D., Vogel R. Use of recombinant human cardiac Troponin T for standardization of third generation Troponin T methods. Scand J Clin Lab Invest Suppl. (1999) 230:128–131.[Medline]
  18. Wu A.H., Valdes R. Jr., Apple F.S., Gornet T., Stone M.A., Mayfield-Stokes S., et al. Cardiac troponin-T immunoassay for diagnosis of acute myocardial infarction. Clin Chem. (1994) 40:900–907.[Abstract/Free Full Text]
  19. Braun W.E., Marwick T.H. Coronary artery disease in renal transplant recipients. Cleve Clin J Med (1994) 61:370–385.[Web of Science][Medline]
  20. Parfrey P.S., Griffiths S.M., Barrett B.J., Paul M.D., Genge M., Withers J., et al. Contrast material-induced renal failure in patients with diabetes mellitus, renal insufficiency, or both. A prospective controlled study. N Engl J Med (1989) 320:143–149.[Abstract]
  21. McCullough P.A., Wolyn R., Rocher L.L., Levin R.N., O'Neil W.W. Acute renal failure after coronary intervention: incidence, risk factors, and relationship to mortality. Am J Med (1997) 103:368–375.[CrossRef][Web of Science][Medline]
  22. Morrow C.E., Schwartz J.S., Sutherland D.E., Simmons R.L., Ferguson R.M., Kjellstrand C.M., et al. Predictive value of thallium stress testing for coronary and cardiovascular events in uremic diabetic patients before renal transplantation. Am J Surg (1983) 146:331–335.[CrossRef][Web of Science][Medline]
  23. Philipson J.D., Carpenter B.J., Itzkoff J., Hakala T.R., Rosenthal J.T., Taylor R.J., et al. Evaluation of cardiovascular risk for renal transplantation in diabetic patients. Am J Med (1986) 81:630–634.[CrossRef][Web of Science][Medline]
  24. Boudreau R.J., Strony J.T., duCret R.P., Kuni C.C., Wang Y., Wilson R.F., et al. Perfusion thallium imaging of type I diabetes patients with end stage renal disease: comparison of oral and intravenous dipyridamole administration. Radiology (1990) 175:103–105.[Abstract/Free Full Text]
  25. Dahan M., Viron B.M., Faraggi M., Himbert D.L., Lagallicier B.J., Kolta A.M., et al. Diagnostic accuracy and prognostic value of combined dipyridamole-exercise thallium imaging in hemodialysis patients. Kidney Int (1998) 54:255–262.[CrossRef][Web of Science][Medline]
  26. Patel A.D., Abo Auda W.S., Davis J.M., Zoghbi G.J., Deierhoi M.H., Heo J., et al. Prognostic value of myocardial perfusion imaging in predicting outcome after renal transplantation. Am J Cardiol (2003) 92:146–151.[Web of Science][Medline]
  27. Holley J.L., Fenton R.A., Arthur R.S. Thallium stress testing does not predict cardiovascular risk in diabetic patients with end-stage renal disease undergoing cadaveric renal transplantation. Am J Med (1991) 90:563–570.[Web of Science][Medline]
  28. Marwick T.H., Steinmuller D.R., Underwood D.A., Hobbs R.E., Go R.T., Swift C., Braun W.E. Ineffectiveness of dipyridamole SPECT thallium imaging as a screening technique for coronary artery disease in patients with end-stage renal failure. Transplantation (1990) 49:100–103.[Web of Science][Medline]
  29. Sawada S.G., Segar D.S., Ryan T., Brown S.E., Dohan A.M., Williams R., et al. Echocardiographic detection of coronary artery disease during dobutamine infusion. Circulation (1991) 83:1605–1614.[Abstract/Free Full Text]
  30. Picano E., Bedetti G., Varga A., Cseh E. The comparable diagnostic accuracies of dobutamine-stress and dipyridamole-stress echocardiographies: a meta-analysis. Coron Artery Dis (2000) 11:151–159.[CrossRef][Web of Science][Medline]
  31. Marwick T.H., D'Hondt A.M., Mairesse G.H., Baudhuin T., Wijns W., Detry J.M., et al. Comparative ability of dobutamine and exercise stress in inducing myocardial ischaemia in active patients. Br Heart J (1994) 72:31–38.[Abstract/Free Full Text]
  32. Fragasso G., Lu C., Dabrowski P., Pangnotta P., Sheiban I., Chierchia S.L. Comparison of stress/rest myocardial perfusion tomography, dipyridamole and dobutamine stress echocardiography for the detection of coronary disease in hypertensive patients with chest pain and positive exercise test. J Am Coll Cardiol (1999) 34:441–447.[Abstract/Free Full Text]
  33. Geleijnse M.L., Vigna C., Kasprzak J.D., Rambaldi R., Salvatori M.P., et al. Usefulness and limitations of dobutamine-atropine stress echocardiography for the diagnosis of coronary artery disease in patients with left bundle branch block. A multicentre study. Eur Heart J (2000) 21:1666–1673.[Abstract/Free Full Text]
  34. Hoffmann R., Marwick T.H., Poldermans D., Lethen H., Ciani R., van der Meer P., et al. Refinements in stress echocardiographic techniques improve inter-institutional agreement in interpretation of dobutamine stress echocardiograms. Eur Heart J (2002) 23:821–829.[Abstract/Free Full Text]

Add to CiteULike CiteULike   Add to Connotea Connotea   Add to Del.icio.us Del.icio.us    What's this?

Related articles in Eur J Echocardiogr:

Ischemic heart disease in renal transplant candidates: Towards non-invasive approaches for preoperative risk stratification
H.H.H. Feringa, J.J. Bax, O. Schouten, and D. Poldermans
Eur J Echocardiogr 2005 6: 313-316. [Abstract] [FREE Full Text]  



This article has been cited by other articles:


Home page
 Nephrol Dial TransplantHome page
C. A. Herzog
Kidney disease in cardiology
Nephrol. Dial. Transplant., January 1, 2008; 23(1): 42 - 46.
[Abstract] [Full Text] [PDF]

Home page
 Nephrol Dial TransplantHome page
C. A. Herzog
Kidney disease in cardiology
Nephrol. Dial. Transplant., January 1, 2007; 22(1): 43 - 46.
[Abstract] [Full Text] [PDF]

Home page
 HeartHome page
R Sharma, D C Gaze, D Pellerin, R L Mehta, H Gregson, C P Streather, P O Collinson, and S J D Brecker
Raised plasma N-terminal pro-B-type natriuretic peptide concentrations predict mortality and cardiac disease in end-stage renal disease.
Heart, October 1, 2006; 92(10): 1518 - 1519.
[Full Text] [PDF]

Home page
 Clin. Chem.Home page
M. N. Fahie-Wilson, D. J. Carmichael, M. P. Delaney, P. E. Stevens, E. M. Hall, and E. J. Lamb
Cardiac Troponin T Circulates in the Free, Intact Form in Patients with Kidney Failure
Clin. Chem., March 1, 2006; 52(3): 414 - 420.
[Abstract] [Full Text] [PDF]

Home page
 Clin. Chem.Home page
N. A. Abbas, R. I. John, M. C. Webb, M. E. Kempson, A. N. Potter, C. P. Price, S. Vickery, and E. J. Lamb
Cardiac Troponins and Renal Function in Nondialysis Patients with Chronic Kidney Disease
Clin. Chem., November 1, 2005; 51(11): 2059 - 2066.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow FREE Full Text (PDF) Freely available
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Related articles in Eur J Echocardiogr
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrowRequest Permissions
Right arrow Disclaimer
Google Scholar
Right arrow Articles by Sharma, R.
Right arrow Articles by Brecker, S.J.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Sharma, R.
Right arrow Articles by Brecker, S.J.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?