From the Guidelines
The workup for pre-syncope in an elderly man with kidney transplant and coronary artery disease (CAD) should prioritize a thorough history, physical examination, and orthostatic vital signs, followed by initial testing including a 12-lead ECG, complete blood count, comprehensive metabolic panel, and medication review, as these are crucial in identifying potential causes and guiding further management 1. Given the patient's history of kidney transplant and CAD, it is essential to consider the potential for cardiovascular causes of pre-syncope, such as arrhythmias or cardiac ischemia.
- Initial evaluation should include:
- A 12-lead ECG to assess for arrhythmias or ischemic changes
- Echocardiography to evaluate cardiac function and possible valvular disease
- Holter monitoring or event recorder to capture arrhythmias
- Carotid ultrasound to evaluate for carotid stenosis
- Medication review is critical, as certain medications such as antihypertensives, diuretics, and vasodilators can exacerbate orthostatic hypotension, a common cause of pre-syncope in this population.
- Coordination between nephrology, cardiology, and primary care is vital to manage this complex patient with multiple comorbidities and prevent adverse outcomes like falls or syncope.
- The approach to coronary heart disease screening in kidney transplant candidates, as outlined in the American Heart Association scientific statement, should be considered in the management of this patient, with a focus on risk stratification and tailored management strategies 1.
- Additionally, the use of physical counterpressure maneuvers (PCMs) may be beneficial in preventing syncope in patients with vasovagal or orthostatic presyncope, as suggested by the 2019 American Heart Association and American Red Cross focused update for first aid 1.
From the Research
Workup for Pre-Syncope in Old Man with Kidney Transplant and CAD
- The patient's history of kidney transplant and coronary artery disease (CAD) increases the risk of cardiovascular events, including pre-syncope 2, 3.
- Cardiovascular disease is the leading cause of death in dialysis patients and kidney transplant recipients, and CAD is a common comorbidity in this population 2, 4.
- The workup for pre-syncope in this patient should include a thorough cardiovascular assessment, including:
- Echocardiography to evaluate left ventricular function and valvular disease 2, 4.
- Exercise stress testing or dobutamine stress echocardiography to evaluate for inducible ischemia 4, 5.
- Coronary angiography may be considered in high-risk patients, such as those with a history of myocardial infarction, stroke, or peripheral vascular disease 6.
- The choice of cardiac testing should be individualized based on the patient's risk factors and clinical presentation 4, 5.
- The patient's kidney transplant status and CAD should be taken into account when interpreting the results of cardiac testing and developing a management plan 2, 3.