1Royal Hobart Hospital, Hobart, Australia, 2Launceston General Hospital, Launceston, Australia

Background: Cardiovascular disease is the leading cause of death amongst the end stage kidney disease (ESKD) population in Australia. Despite this high prevalence, it remains a diagnostic challenge to identify significant coronary artery disease (CAD). This population group establish CAD more rapidly, progress faster than the normal population and are more likely to present with atypical symptoms.
Case Report: To review two cases of symptomatic CAD  emphasising the diagnostic challenges to clinicians and importance for high clinical suspicion of CAD in ESKD patients.
First case: 74 year old female with ESKD presented with atypical central chest pain. This was on the background of shortness of breath on exertion and a normal echocardiogram 10 days prior. Serial troponins were mildly elevated. A clinical diagnosis of  costochondritis was made. Subsequent coronary angiogram showed a 90% lesion in the mid left anterior descending artery (LAD). Angioplasty and stenting of this lesion relieved her symptoms.
Second case: 85 year old female with ESKD presented with one week of intermittent shortness of breath on exertion. She never had typical chest pain. A coronary angiogram 9 months earlier showed 30-40% disease in major vessels. She was discharged home and booked for an urgent outpatient echocardiogram. She presented within 48 hours with severe shortness of breath. Echocardiogram revealed new inferolateral regional wall motion abnormality. Angiogram showed 80% culprit lesions in the mid LAD and ostial branch of the LAD.
Conclusion: These two cases expose the complexity of CAD in the ESKD population. Our cases demonstrate how much faster CAD can progress in ESKD patients, the tendency to present atypically and the need to investigate and treat with urgency to avoid adverse outcomes.

I am a second year basic physician trainee from Tasmania. My previous research projects have included the successful implementation of a Rapid Access Chest Pain Assessment Clinic at the Royal Hobart Hospital. My research passions include improving clinical service as well as well as improving diagnostic recognition. As well as medicine, I love getting out and about in beautiful Tasmania


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