Evolving practices in pre-transplant cardiovascular screening: moving toward personalized assessments

Cardiovascular (CV) disease remains the leading cause of morbidity and mortality in patients with end-stage kidney disease (ESKD), including those evaluated for kidney transplantation (KT). Pre-transplant CV screening has traditionally focused on detecting occult coronary artery disease and guiding revascularization to reduce perioperative risk. However, emerging evidence, most notably from the ISCHEMIA-CKD trial, has challenged this paradigm, demonstrating no clear benefit of routine invasive strategies or prophylactic revascularization in stable, asymptomatic patients over optimal medical therapy. Risk assessment in kidney transplant candidates should rely on an integrated clinical evaluation that incorporates symptoms, functional capacity, baseline electrocardiography and echocardiographic findings, and the presence of major CV risk factors. When further evaluation is indicated, stress echocardiography is generally preferred as the non-invasive modality. Invasive coronary angiography should be reserved for patients with cardiac symptoms or findings suggestive of significant ischemia, including reduced left ventricular ejection fraction, regional wall motion abnormalities (RWMAs), or moderate-to-large ischemia on stress testing. Pre-emptive revascularization should be limited to established guideline-based indications, such as left main disease, multivessel disease with reduced ejection fraction, or refractory angina despite optimal medical therapy. Non-coronary CV disorders, including heart failure, valvular disease, and pulmonary hypertension, require systematic assessment and cardiology referral. In conclusion, pre-transplant CV assessment is shifting from protocol-driven screening toward individualized, clinical suspicion-based evaluation, prioritizing optimal medical therapy, avoidance of unnecessary testing, and timely access to transplantation.