CAD: coronary artery disease; CCTA: coronary computed tomographic angiography; DSE: dobutamine stress echocardiography; LAD: left anterior descending.
* This algorithm is appropriate for patients with new or worsening symptoms of CAD (eg, chest discomfort, dyspnea, intra- and interdialytic hypotension) whose presentation is not suspicious for an acute coronary syndrome.
¶ The diagnostic evaluation should be performed in collaboration with a cardiologist, whose role is to assist with the selection and interpretation of tests and to formulate a plan for antianginal therapy.
Δ For most patients, we prefer initial testing for CAD with a dobutamine stress echocardiogram. Myocardial perfusion scintigraphy or CCTA are reasonable alternatives to echocardiography in select patients. Refer to UpToDate topics on the diagnosis of CAD in patients on dialysis for further details on the approach to initial testing.
◊ Signs of extensive CAD on stress testing include hypotension, left ventricular dilation, and reduced left ventricular ejection fraction at rest or with stress.
§ Refer to UpToDate topics on the secondary prevention of CAD and medical management of chronic coronary syndrome.
¥ If preservation of residual kidney function is a goal of ongoing management, and iodinated contrast exposure is required for further testing (eg, invasive coronary angiography, CCTA), we typically use methods to prevent contrast-induced nephropathy prior to the administration of contrast. Refer to UpToDate topics on the risk factors and management of contrast-induced acute kidney injury for further details.