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Chronic kidney disease (CKD) is now well-recognized as an important coronary risk factor and is considered in our preoperative guidelines as a clinical predictor of perioperative death, myocardial infarction (MI), or the development of congestive heart failure. It can be considered as a coronary disease equivalent, such as a history of prior MI, diabetes mellitus, compensated or prior heart failure, or class I or II angina. Moreover, there is extensive data indicating that cardiovascular disease (CVD) is the chief cause of morbidity and mortality in patients with end-stage kidney disease. This issue of the Journal has an interesting extension of knowledge in the field of CVD in CKD. Coceani et al. examined the relationship among coronary artery disease (CAD), myocardial ischemia, subsequent death and reduced glomerular filtration rate (GFR) in 650 patients undergoing SPECT perfusion imaging and coronary angiography. Not surprisingly, they documented that a reduced GFR was associated with a greater degree of inducible myocardial ischemia, a higher frequency of significant coronary stenoses on coronary angiography and higher mortality at 5 years. However, the fact that this risk extends to patients with even a mild reduction of GFR (mean of 72 mL/minute/ 1.73 m) is new and important information. While the authors are to be applauded for these observational insights, there are some concerns about the interpretation of their findings. The selection of patients for revascularization, which leads to alteration of cardiovascular outcomes and their definition of ‘‘coronary artery disease,’’ both may mislead those who do not absorb the methodological details. Moreover, selection of coronary angiographic evidence of a 70% stenosis as the definition of CAD or greater is problematic for many reasons.

Chronic kidney disease, SPECT, and coronary angiography: “head of gold and feet of clay?”