*Purpose: Despite cardiovascular (CV) assessment recommended all kidney transplant recipients to minimize perioperative risk, the utility and reliability of various assessments are not well established. In this study we investigated the CV evaluation and outcome of standardized CV assessment protocols.

*Methods: Data were analyzed for 266 end-stage renal disease patients (mean age 45.4 ± 13 years, F/M: 126/140) accepted for kidney transplantation (KT) wait-listing between January 2011-December 2017. Patients were classified as low and high cardiac risk according to their first cardiac evaluation. Major cardiovascular events (acute coronary syndrome, percutaneous coronary intervention, coronary artery by-pass grafting, congestive heart failure, cerebrovascular event and sudden death) and cardiac deaths observed through the follow-up period were recorded. The reliability of current stratification was tested using different CV assessments [Lisbon and American Society of Transplantation (AST)].

*Results: At the end of follow-up (median 639 days), 72 (27.1%) patients underwent KT. A total of 49 patients (18.4%) had CVE and 42 (15.8%) patients died. Among patients with CVE, 46 patients were in the non-transplant group and 3 patients were in the transplant group. Five of the 72 patients who had kidney transplant (6.9%) died. There were 37 (19.1%) deaths in the non-transplant group. Compared with patients with and without CVE older age, presence of hypertension, Left Ventricular Hypertrophy, diabetes, hemodialysis vintage > 1 year, and coronary artery disease history were significantly associated with CVE. In multivariate analysis, being over 45 years of age and more than 1 year of dialysis were found to independent risk factors for CVE. A total of 60 high-risk patients were evaluated with non-invasive tests [exercise electrocardiography (ECG) and myocardial perfusion scintigraphy (MPS)], however 12 of the 48 had CVE even though they had negative test results. Coronary angiography was performed in only 10 patients. Of these 10 patients, 1 patient had CVE and 1 patient died. When compared cardiac evaluation methods (AST, Lisbon, AHA), the sensitivity and specificity of the AST guideline (AUC = 0.647, P = 0.005, Sensitivity 83%, Specificity 54%) were higher than Lisbon and AHA guidelines.

*Conclusions: According to our study results, the most important risk factors for CVE in waitlisted patients were found age over 45 years and had dialysis vintage longer than a year. Our results also suggest exercise ECG and MPS for cardiac evaluation are less sensitive for CVE prediction. AHA guideline may be inadequate for identifying cardiac high-risk KT candidates. Therefore, we recommend that clinicians can apply AST guideline and prioritize CAG in pre-transplant CV assessment.

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