Impact of chronic kidney disease and stress myocardial perfusion imaging as a predictor of cardiovascular events

Prognostic value of myocardial perfusion imaging in patients with chronic kidney disease: A systematic review and meta-analysis

BACKGROUND

We performed a systematic review and meta-analysis to investigate the prognostic value of stress myocardial perfusion single-photon emission computed tomography (MPS) in predicting adverse cardiovascular events in patients with chronic kidney disease (CKD).

METHODS

Studies published from inception until July 2020 were identified by PubMed and Embase databases search. Studies were included if they evaluated CKD patients referred for stress MPS, providing data on adjusted hazard ratio (HR) for the occurrence of adverse events. For studies providing only non-adjusted HR, the univariable risk estimate was included in the analysis. Pooled HR and 95% confidence interval (CI) were estimated using a random effects model to compare patients with abnormal and normal MPS. Whenever possible, incidence rate ratio (IRR) was also calculated and pooled.

RESULTS

Sixteen eligible studies were identified including 7834 patients with a follow-up range from 1 to 4.4 years. Eleven articles included patients with end-stage renal disease (IV-V CKD stage), 3 articles with III-V CKD stage and 2 articles with I-V CKD stage. The pooled HR for the occurrence of adverse events was 2.02 (95% CI 1.68-2.42) and heterogeneity was 34%. Among the included studies, 5 reported the HR for the occurrence of hard events, with a pooled HR of 2.36 (95% CI 1.77-3.13). A total of 8 studies reported data useful to calculate the IRR in patients with normal and abnormal perfusion. The pooled IRR was 2.37 (95% CI 1.63-3.47) and heterogeneity was 60%. At meta-regression analysis, we found an association between HR for adverse events and age, hypertension and smoking, while no significant association was found between HR for hard events and demographic and clinical variables.

CONCLUSIONS

In patients with CKD an abnormal myocardial perfusion at stress MPS is associated with adverse cardiovascular events.

Incremental prognostic value of SPECT-MPI in chronic kidney disease: A reclassification analysis

BACKGROUND

Traditional cardiovascular (CV) risk factors have limited predictive value of CV mortality in patients with chronic kidney disease (CKD, creatinine clearance less than 60 mL/minute per 1.73 m2). The aim of this study was to evaluate incremental and independent prognostic value of single-photon emission computerized tomography-myocardial perfusion imaging (SPECT-MPI) across continuum of renal function.

METHODS

We retrospectively studied 11,518 (mean age, 65 ± 12 years; 52% were men) patients referred for a clinical indication of SPECT-MPI between April 2004 and May 2009. Primary end point was composite of cardiac death and non-fatal myocardial infarction (CD/MI). We examined the relationship of total perfusion defect (TPD) and CD/MI in multiple Cox regression models for CV risk factors and GFR. The incremental predictive value of TPD was examined using Harrell's c-index, net reclassification index (NRI), and integrated discrimination index (IDI).

RESULTS

Over a median follow-up of 5 years (25th to 75th percentiles, 3.0-6.5 years), 1,692 (14.5%) patients experienced CD/MI (740 MI and 1,182 CD). In a multivariable model adjusted for traditional CV risk factors and GFR, the presence of a perfusion defect was independently associated with increased risk of CD/MI (HR = 2.10; 95% CI 1.81, 2.43, p < .001). Using Cox regression, TPD improved the discriminatory ability beyond traditional CV risk factors and GFR [from AUC = 0.725, (95% CI 0.712-0.738) to 0.784, (95% CI 0.772-0.796), p < .0001]. Furthermore, TPD improves risk stratification of CKD patients over and above traditional CV risk factors and GFR [NRI = 14%, 95% CI (12%-16%, p < .001) and relative IDI = 60%, 95% CI (51%, 66%, p < .001)].

CONCLUSIONS

Across the spectrum of renal function, SPECT-MPI perfusion defects independently and incrementally reclassified patients for their risk of CD/MI, beyond traditional CV risk factors.

The predictive value of chronic kidney disease for assessing cardiovascular events under consideration of pretest probability for coronary artery disease in patients who underwent stress myocardial perfusion imaging

Pretest probability of coronary artery disease (CAD) facilitates diagnosis and risk stratification of CAD. Stress myocardial perfusion imaging (MPI) and chronic kidney disease (CKD) are established major predictors of cardiovascular events. However, the role of CKD to assess pretest probability of CAD has been unclear. This study evaluates the role of CKD to assess the predictive value of cardiovascular events under consideration of pretest probability in patients who underwent stress MPI. Patients with no history of CAD underwent stress MPI (n = 310; male = 166; age = 70; CKD = 111; low/intermediate/high pretest probability = 17/194/99) and were followed for 24 months. Cardiovascular events included cardiac death and nonfatal acute coronary syndrome. Cardiovascular events occurred in 15 of the 310 patients (4.8 %), but not in those with low pretest probability which included 2 CKD patients. In patients with intermediate to high pretest probability (n = 293), multivariate Cox regression analysis identified only CKD [hazard ratio (HR) = 4.88; P = 0.022) and summed stress score of stress MPI (HR = 1.50; P < 0.001) as independent and significant predictors of cardiovascular events. Cardiovascular events were not observed in patients with low pretest probability. In patients with intermediate to high pretest probability, CKD and stress MPI are independent predictors of cardiovascular events considering the pretest probability of CAD in patients with no history of CAD. In assessing pretest probability of CAD, CKD might be an important factor for assessing future cardiovascular prognosis.