Short- and long-term outcomes of coronary artery bypass grafting or drug-eluting stent implantation for multivessel coronary artery disease in patients with chronic kidney disease

Effect of Procedural Volume on In-Hospital Outcomes After Percutaneous Coronary Intervention in Patients With Chronic Kidney Disease (from the Japanese National Clinical Data [J-PCI Registry])

Chronic kidney disease (CKD) increases the risk of death and other poor outcomes in patients with cardiovascular diseases. This study investigated the relation between the institutional CKD percutaneous coronary intervention (PCI) volume and in-hospital clinical outcomes in patients with CKD. Among 1,199,901 patients who underwent PCI in 2014 to 2018 from the Japanese nationwide registry, we analyzed 220,509 patients with CKD. Patients were classified into quartiles (Q) according to the mean annual institutional CKD-PCI volume (Q1 <42 PCIs/year, Q2 <74 PCIs/year, Q3 <124 PCIs/year, Q4 ≥125 PCIs/year). The primary outcome was a composite of in-hospital death and periprocedural complications. The mean age of patients was 73 ± 10 years, and 36% (n = 78,332) were on dialysis. PCI was more likely to be performed with rotational atherectomy devices in high-volume institutions. Contrast volume was lower, the rate of radial access PCI was higher, and door-to-balloon time (for ST-elevation myocardial infarction) was shorter in the highest quartile institutions. Primary outcomes were observed in 6,539 patients (3.0%). The crude rate of the primary outcome was lowest in institutions with the highest PCI volume (Q1 3.4%, Q2 3.0%, Q3 3.0%, Q4 2.4%, p <0.001); higher PCI volume was associated with reduced frequency of the primary outcome (odds ratio [95% confidence interval] relative to Q1:Q2, 0.89 [0.83 to 0.96]; Q3 0.90 [0.84 to 0.97]; and Q4 0.76 [0.84 to 0.97]). In conclusion, the procedural characteristics and outcomes of PCI differed significantly by institutional volume in patients with CKD. When considering revascularization among these patients, institutional CKD-PCI volume needs to be incorporated in decision-making.

Coronary revascularisation in patients with chronic kidney disease and end-stage renal disease: A meta-analysis

OBJECTIVES

To compare coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) for revascularising coronary arteries in patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD). CKD is described as a continuous decrease in the glomerular filtration rate or abnormalities in kidney structure or function.

METHODS

PubMed, Cochrane Library and Embase databases were searched for studies on the revascularisation of coronary arteries in patients with CKD and ESRD.

RESULTS

Since no randomised controlled trials (RCTs) have addressed this issue so far, 31 observational studies involving 74 805 patients were included in this meta-analysis. Compared with PCI, patients undergoing CABG have significantly higher early mortality (CKD: RR = 1.62, 95% CI: 1.17-2.25, pheterogeneity = 0.476, I²  = 0; ESRD: RR = 1.99, 95% CI: 1.46-2.71, pheterogeneity = 0.001, I²  = 66.9%). Patients with ESRD undergoing CABG have significantly lower all-cause mortality (RR = 0.95, 95% CI: 0.93-0.96, pheterogeneity < 0.001, I²  = 82.9%) and cardiac mortality (RR = 0.73, 95% CI: 0.58-0.92, pheterogeneity = 0.908, I²  = 0). The long-term risk of repeat revascularisation (CKD: RR = 0.24, 95% CI: 0.19-0.30, pheterogeneity = 0.489, I²  = 0; ESRD: RR = 0.23, 95% CI: 0.15-0.34, pheterogeneity = 0.012, I²  = 54.4%) and myocardial infarction (CKD: RR = .57, 95% CI: 0.38-0.85, pheterogeneity = 0.025, I²  = 49.9%; ESRD: RR = 0.42, 95% CI: 0.40-0.44, pheterogeneity = 0.49, I²  = 0) remained significantly higher in the PCI group.

CONCLUSIONS

Patients with ESRD, but not CKD, who underwent CABG had significantly lower all-cause mortality and cardiac mortality. However, CABG was associated with an increased risk of early mortality in patients with CKD or ESRD. Adequately powered, contemporary, prospective RCTs are needed to define the optimal revascularisation strategy for patients with CKD and ESRD.

Comparative analysis of revascularization with percutaneous coronary intervention versus coronary artery bypass surgery for patients with end-stage renal disease: a nationwide inpatient sample database

BACKGROUND

The role of percutaneous coronary intervention (PCI) vs coronary artery bypass grafting (CABG) in patients with coronary artery disease (CAD) and concomitant end-stage renal disease (ESRD) remains unknown.

RESEARCH DESIGN & METHODS

The National Inpatient Sample (NIS) (2002-2017) was queried to identify all cases of CAD and ESRD. The relative merits of PCI vs CABG were determined using a propensity-matched multivariate logistic regression model. Adjusted odds ratios (aOR) for mortality and other in-hospital complications were calculated.

RESULTS

A total of 350,623 [CABG = 112,099 (32%) and PCI = 238,524 (68%)] hospitalizations were included in the analysis. The overall adjusted odds for major bleeding (aOR 1.28, 95% CI 1.25-1.31, P < 0.0001), post-procedure bleeding (aOR 5.19, 95% CI 4.93-5.47, P < 0.0001), sepsis (aOR 1.29, 95% CI 1.26-1.33, P < 0.0001), cardiogenic shock (aOR 1.23, 95% CI 1.20-1.26, P < 0.0001), and in-hospital mortality (aOR 1.65, 95% CI 1.61-1.69, P < 0.0001) were significantly higher for patients undergoing CABG compared with PCI. The need for intra-aortic balloon pump (IABP) placement (aOR 2.52, 95% CI 2.45-2.59, P < 0.001) was higher in the CABG group, while the adjusted odds of vascular complications were similar between the two groups (aOR 0.99, 95% CI 0.94-1.06, P = 0.82). As expected, patients undergoing CABG had a higher mean length of stay and mean cost of hospitalization.

CONCLUSION

CABG in ESRD may be associated with higher in-hospital complications, increased length of stay, and higher resource utilization.

Optimal treatment strategies for coronary artery disease in patients with advanced kidney disease: a meta-analysis

Background:

Coronary artery disease (CAD) is the leading cause of death in advanced kidney disease. However, its best treatment has not been determined.

Methods:

We searched PubMed and Cochrane databases and scanned references to related articles. Studies comparing the different treatments for patients with CAD and advanced CKD (estimated glomerular filtration rate <30 ml/min/1.73 m² or dialysis) were selected. The primary result was all-cause death, classified according to the follow-up time: short-term (<1 month), medium-term (1 month-1 year), and long-term (>1 year).

Results:

A total of 32 studies were selected to enroll 84,498 patients with advanced kidney disease. Compared with medical therapy (MT) alone, percutaneous coronary intervention (PCI) was associated with low risk of short-, medium-term and long-term all-cause death (more than 3 years). For AMI patients, compared with MT, PCI was not associated with low risk of short- and medium-term all-cause death. For non-AMI patients, compared with MT, PCI was associated with low risk of long-term mortality (more than 3 years). Compared with MT, coronary artery bypass surgery (CABG) had no significant advantages in each follow-up period of all-cause death. Compared with PCI, CABG was associated with a high risk of short-term death, but low risk of long-term death: 1–3 years; more than 3 years. CABG could also reduce the risk of long-term risk of cardiac death, major adverse cardiovascular events (MACEs), myocardial infarction (MI), and repeat revascularization.

Conclusions:

In patients with advanced kidney disease and CAD, PCI reduced the risk of short-, medium- and long- term (more than 3 years) all-cause death compared with MT. Compared with PCI, CABG was associated with a high risk of short-term death and a low risk of long-term death and adverse events.

Coronary artery bypass grafting versus percutaneous coronary intervention in end-stage kidney disease: A systematic review and meta-analysis of clinical studies

The most significant complication of end-stage kidney disease (ESKD) is cardiovascular disease, mainly coronary artery disease (CAD). Although the effective treatment of CAD is an important prognostic factor, whether percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) is better for treating CAD in this group of patients is still controversial. We searched Pubmed/Medline, Web of Science, Embase, the Cochrane Central Register of Controlled Trials articles that compared the outcomes of CABG versus PCI in patients with ESKD requiring dialysis. A total of 10 observational studies with 39,666 patients were included. Our analysis showed that when compared to PCI, CABG had lower risk of need for repeat revascularization (relative risk [RR] = 2.25, 95% confidence interval [CI] 2.1-2.42, p < 0.00001) and cardiovascular death (RR = 1.19, 95% CI 1.14-1.23, p < 0.00001) and higher risk for short-term mortality (RR = 0.43, 95% CI 0.38-0.48, p < 0.00001). There was no statistically significant difference between the PCI and CABG groups in the risk for late mortality (RR = 1.05, 95% CI 0.97-1.14, p = 0.25), myocardial infarction (RR = 1.05, 95% CI 0.46-2.36, p = 0.91) or stroke (RR = 1.02, 95% CI 0.64-1.61, p = 0.95). This meta-analysis showed that in ESKD patients requiring dialysis, CABG was superior to PCI in regard to cardiovascular death and need for repeat revascularization and inferior to PCI in regard to short term mortality. However, this meta-analysis has limitations and needs confirmation with large randomized controlled trials.

The Better Option of Revascularization in Complex Coronary Artery Disease Patients Complicate With Chronic Kidney Disease: A Review and Meta-Analysis

The treatment of complex coronary artery disease (CAD) combined with chronic kidney disease (CKD) faces great challenges. We thus did a systematic review and meta-analysis to assess the effect of percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG). We systematically searched PubMed, Embase, Cochrane Library and other relevant articles refer to reference. Our main endpoints were main adverse cardiovascular and cerebrovascular events (MACCE), all cause death, myocardial infarction (MI), repeat revascularization and stoke. 24 studies were included in our analysis. Compared with PCI, CABG improved outcomes such as MACCE (Odds Ratio [OR] 1.75; 95%CI 1.26-2.42), all cause death (OR 1.13; 95%CI 1.00-1.28), repeat revascularization (OR 4.24; 95%CI 3.29-5.47) and MI (OR 2.16; 95%CI 1.59-2.91), but stoke (OR 0.84, 95%CI 0.61-1.17). CABG shows absolute advantage in complex CAD complicated with CKD and ESRD patients than stent implantation in the long-term following-up.

All-Cause Mortality and Progression to End-Stage Kidney Disease Following Percutaneous Revascularization or Surgical Coronary Revascularization in Patients with CKD

Introduction

Relative impacts of coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) on mortality and end-stage kidney disease (ESKD) in chronic kidney disease (CKD) are uncertain.

Methods

Data from Massachusetts residents with CKD undergoing CABG or PCI from 2003 to 2012 were linked to the United States Renal Data System. Associations with death, ESKD, and combined death and ESKD were analyzed in propensity score−matched multivariable survival models.

Results

We identified 6805 CABG and 17,494 PCI patients. Among 3775 matched-pairs, multi-vessel disease was present in 97%, and stage 4 CKD was present in 11.9% of CABG and 12.2% of PCI patients. One-year mortality (CABG 7.7%, PCI 11.0%) was more frequent than ESKD (CABG 1.4%, PCI 1.7%). Overall survival was improved and ESKD risk decreased with CABG compared to PCI, but effects differed in the presence of left main disease and prior myocardial infarction (MI). Survival was worse following PCI than following CABG among patients with left main disease and without MI (hazard ratio = 3.7, 95% confidence interval = 1.3−10.5). ESKD risk was higher with PCI for individuals with left main disease and prior infarction (hazard ratio = 8.1, 95% confidence interval = 1.7−39.2).

Conclusion

Risks following CABG and PCI were modified by left main disease and prior MI. In individuals with CKD, survival was greater after CABG than after PCI in patients with left main disease but without MI, whereas ESKD risk was lower with CABG in those with left main and MI. Absolute risks of ESKD were markedly lower than for mortality, suggesting prioritizing mortality over ESKD in clinical decision making.

Medical Therapy Versus Revascularization in Patients with Stable Ischemic Heart Disease and Advanced Chronic Kidney Disease

PURPOSE OF REVIEW

This article reviews the evidence on optimal medical therapy (OMT) versus coronary revascularization in patients with stable ischemic heart disease (SIHD) and advanced chronic kidney disease (CKD).

RECENT FINDINGS

A post hoc analysis of the COURAGE trial in patients with SIHD and CKD showed no difference in freedom from angina, death, and nonfatal myocardial infarction (MI) between OMT and percutaneous intervention plus OMT compared with patients without CKD. The ISCHEMIA-CKD trial of 777 patients with advanced CKD revealed no difference in cumulative incidence of death or nonfatal MI at 3 years between OMT and revascularization but the composite of death or new dialysis was higher in the invasive arm. Additionally, there were no significant or sustained benefits in related to angina-related health status in invasive versus conservative strategy. An initial revascularization strategy does not reduce mortality or MI or relieve angina symptoms in patients with SIHD and advanced CKD.

Comparison of coronary artery bypass graft versus drug-eluting stents in dialysis patients: an updated systemic review and meta-analysis

INTRODUCTION

As percutaneous coronary intervention (PCI) technologies have been far improved, we hence conducted an updated systemic review and meta-analysis to determine the comparability between coronary artery bypass graft (CABG) and PCI with drug-eluting stent (DES) in ESRD patients.

METHODS

We comprehensively searched the databases of MEDLINE, EMBASE, PUBMED and the Cochrane from inception to January 2020. Included studies were published observational studies that compared the risk of cardiovascular outcomes among dialysis patients with CABG and DES. Data from each study were combined using the random-effects, generic inverse variance method of DerSimonian and Laird to calculate risk ratios and 95% confidence intervals. Subgroup analyses and meta-regression were performed to explore heterogeneity.

RESULTS

Thirteen studies were included in this analysis, involving total 56 422 (CABG 21 740 and PCI 34 682). Compared with DES, our study demonstrated CABG had higher 30-day mortality [odds ratio (OR) 3.85, P = 0.009] but lower cardiac mortality (OR 0.78, P < 0.001), myocardial infarction (OR 0.5, P < 0.001) and repeat revascularization (OR 0.35, P < 0.001). No statistical differences were found between CABG and DES for long-term mortality (OR 0.92, P = 0.055), composite outcomes (OR 0.88, P = 0.112) and stroke (OR 1.49, P = 0.457). Meta-regression suggested diabetes and the presence of left main coronary artery disease as an effect modifier of long-term mortality.

CONCLUSION

PCI with DES shared similar long-term mortality, composite outcomes and stroke outcomes to CABG among dialysis patients but still was associated with an improved 30-day survival. However, CABG had better rates of myocardial infarction, repeat revascularization and cardiac mortality.

Coronary artery bypass grafting vs. drug-eluting stent implantation in patients with end-stage renal disease requiring dialysis

Objectives

To evaluate the optimal revascularization strategy for patients with coronary artery disease (CAD) and end stage renal disease (ESRD) in the drug-eluting stent (DES) era.

Methods

One hundred and twelve patients with ESRD treated with coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) were enrolled from 2007 to 2017. All patients were dialysis-dependent, of which 26 received CABG and 86 underwent PCI. The primary endpoint was all-cause mortality. Secondary endpoints were major adverse cardiovascular events including myocardial infarction, stroke, repeat revascularization, and death.

Results

The CABG group had a higher prevalence of left main CAD (57.7% vs. 11.6%, p < .01) compared with PCI group. The short-term (within 30 days after the procedure) risk of death was higher in CABG group compared with PCI group (15.4% vs. 1.2%, p < .05). The two groups exhibited similar rate of primary endpoints (50.0% vs. 40.7%, p = .37) and secondary endpoints (65.4% vs. 60.5%, p = .97) in long-term observation. Multivariate Cox regression showed that patients older than 65 or underwent peritoneal dialysis (PD) had significant higher rate of mortality than those under 65 (HR 2.85; 95% CI 1.20–6.85; p < .05) or underwent hemodialysis (HD) (HR 6.69; 95% CI 2.35–19.05; p < .01).

Conclusions

Among patients with CAD and dialysis-dependent chronic kidney disease (CKD), treatment with CABG or PCI with DES exhibited similar long-term outcomes. However, CABG was associated with higher short-term risk of death. Higher mortality was revealed in patients over 65 years and underwent PD.

Impact of Preoperative Occult Renal Dysfunction on Early and Late Outcomes After Off-Pump Coronary Artery Bypass

BACKGROUND

Renal dysfunction is independently associated with increased early and late mortality after coronary artery bypass graft (CABG) surgery. Off-pump CABG (OPCABG) avoids postoperative complications from the cardiopulmonary bypass, but it is unclear how it is impacted by occult renal dysfunction (ORD). This study aimed to investigate the effects of ORD on early and late outcomes after OPCABG.

METHODS

This retrospective and observational cohort study reviewed data on 1,188 patients who underwent first isolated OPCABG with normal serum creatinine (SCr) levels. According to preoperative estimated creatinine clearance (eCrCl) by the Cockcroft-Gault formula, the patients were divided into an ORD group (n=260, eCrCl <60 mL/min/1.73 m²) and a control group (n=928, eCrCl ≥60 mL/min/1.73 m²).

RESULTS

The ORD patients presented with older age, higher incidence of small body surface area, hypertension, low preoperative eCrCl, cerebrovascular accident, peripheral vascular disease, New York Heart Association (NYHA) Ⅲ, and high risk score. The prevalence of hospital mortality, postoperative acute kidney injury (AKI), peak postoperative SCr, and prolonged hospital stay were greater in the ORD patients than the control patients. Multivariable logistic regression analysis showed that the ORD patients were at significantly higher risk of postoperative AKI (OR, 2.702; 95% CI, 1.994-3.662) and in-hospital mortality (OR, 2.884; 95% CI, 1.293-6.432). Multivariate Cox proportional hazard models confirmed that ORD was significantly associated with high later mortality (HR, 2.847; 95% CI, 1.262-6.425).

CONCLUSIONS

Occult renal dysfunction is an independent risk factor for postoperative AKI in-hospital and later mortality in patients undergoing OPCABG with normal SCr levels.

Risk Stratification and Treatment of Coronary Disease in Chronic Kidney Disease and End-Stage Kidney Disease

Patients with advanced chronic kidney disease have an enormous burden of cardiovascular morbidity and mortality, but, paradoxically, their representation in randomized trials for the evaluation and management of coronary artery disease has been limited. Clinicians therefore are faced with the conundrum of synergizing evidence from observational studies, expert opinion, and extrapolation from the general population to provide care to this complex and clinically distinct patient population. In this review, we address clinical risk stratification of patients with chronic kidney disease and end-stage kidney disease using traditional cardiovascular risk factors, noninvasive functional and structural cardiac imaging, invasive coronary angiography, and cardiovascular biomarkers. We highlight the unique characteristics of this population, including the high competing risk of all-cause mortality relative to the risk of major adverse cardiac events, likely owing to important contributions from nonatherosclerotic mechanisms. We further discuss the management of coronary artery disease in patients with chronic kidney disease and end-stage kidney disease, including evidence pertaining to medical management, coronary revascularization with percutaneous coronary intervention, and coronary artery bypass grafting. Our discussion includes considerations of drug-eluting versus bare metal stents for percutaneous coronary intervention and off-pump versus on-pump coronary artery bypass graft surgery. Finally, we address currently ongoing randomized trials, from which clinicians are optimistic about receiving guidance regarding the best strategies to incorporate into their practice for the evaluation and management of coronary artery disease in this high-risk population.

Multivessel Coronary Revascularization Strategies in Patients with Chronic Kidney Disease: A Meta-Analysis

Background: Early revascularization can lead to better prognosis in multivessel coronary artery disease (CAD) patients with chronic kidney disease (CKD). However, whether coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) is better remains unknown. Methods: We searched PubMed and the Cochrane Library database from inception until December 9, 2017, for articles that compare outcomes of CABG and PCI in multivessel CAD patients with CKD. We pooled the odds ratios with a fixed-effects model when I2 < 50% or a random-effects model when I2 > 75% and conducted heterogeneity and quality assessments as well as publication bias analyses. Results: A total of 17 studies with 62,343 patients were included. Compared with CABG, the pooled analysis showed that PCI had a lower risk of short-term all-cause death (OR, 0.56; 95% CI, 0.37–0.84) and cerebrovascular accidents (OR, 0.65; 95% CI, 0.53–0.79) but a higher risk of cardiac death (OR, 1.29; 95% CI, 1.21–1.37), myocardial infarction (MI) (OR, 1.73; 95% CI, 1.35–2.21), and repeat revascularization (RR) (OR, 3.9; 95% CI, 2.99–5.09). There was no significant difference in the risk of long-term all-cause death (OR, 1.08; 95% CI, 0.95–1.23) and major adverse cardiac and cerebrovascular events (MACCE) (OR, 1.58; 95% CI, 0.99–2.52) between the PCI and CABG groups. A subgroup analysis restricted to patients treated with dialysis or with PCI-drug-eluting stent yielded similar results. Conclusions: PCI for patients with CKD and multivessel disease (multivessel CAD) had advantages over CABG with regard to short-term all-cause death and cerebrovascular accidents, but disadvantages regarding the risk of myocardial death, MI, and RR; there was no significant difference in the risk of long-term all-cause death and MACCE. Large randomized controlled trials are needed to confirm our findings.

Predialysis coronary revascularization and postdialysis mortality

Objectives

Coronary artery bypass grafting (CABG) is associated with better survival than percutaneous coronary intervention (PCI) in patients with mild-to-moderate chronic kidney disease (CKD) and End-Stage Renal Disease (ESRD). However, the optimal strategy for coronary artery revascularization in advanced CKD patients who transition to ESRD is unclear.

Methods

We examined a contemporary national cohort of 971 US veterans with incident ESRD, who underwent first CABG or PCI up to 5 years prior to dialysis initiation. We examined the association of a history of CABG versus PCI with all-cause mortality following transition to dialysis, using Cox proportional hazards models adjusted for time between procedure and dialysis initiation, socio-demographics, comorbidities and medications.

Results

582 patients underwent CABG and 389 patients underwent PCI. The mean age was 66±8 years, 99% of patients were male, 79% were white, 19% were African Americans, and 84% were diabetics. The all-cause post-dialysis mortality rates after CABG and PCI were 229/1000 patient-years (PY) [95% CI: 205-256] and 311/1000PY [95% CI: 272-356], respectively. Compared to PCI, patients who underwent CABG had 34% lower risk of death [multivariable adjusted Hazard Ratio (95% CI) 0.66 (0.51-0.86), p=0.002] after initiation of dialysis. Results were similar in all subgroups of patients stratified by age, race, type of intervention, presence/absence of myocardial infarction, congestive heart failure and diabetes.

Conclusion

CABG in advanced CKD patients was associated lower risk of death after initiation of dialysis compared to PCI.

CABG or PCI: which is better for revascularization of coronary artery disease in chronic kidney disease?

Chronic kidney disease (CKD) is a potent risk factor for coronary artery disease and premature death. However, the optimal strategies for revascularization versus medical management remain unclear. Charytan et al. address this knowledge gap with a well-structured individual patient meta-analysis. We discuss the implications of their findings for patients with moderate CKD and highlight the need for randomized, controlled trials on this issue in more severe CKD.

Comparison of coronary artery bypass grafting and drug-eluting stents in patients with chronic kidney disease and multivessel disease: A meta-analysis

BACKGROUND

The optimal revascularization strategy of coronary artery bypass grafting (CABG) versus percutaneous coronary intervention with drug-eluting stent (PCI-DES) in patients with chronic kidney disease (CKD) and multivessel disease (MVD) remains unclear.

METHODS

Pubmed, EMBASE and Cochrane Library electronic databases were searched from inception until June 2016. Studies that evaluate the comparative benefits of DES versus CABG in CKD patients with multi-vessel disease were considered for inclusion. We pooled the odds ratios from individual studies and conducted heterogeneity, quality assessment and publication bias analyses.

RESULTS

A total of 11 studies with 29,246 patients were included (17,928 DES patients; 11,318 CABG). Compared with CABG, pooled analysis of studies showed DES had higher long-term all-cause mortality (OR, 1.22; p<0.00001), cardiac mortality (OR, 1.29; p<0.00001), myocardial infarction (OR, 1.89; p=0.02), repeat revascularization (OR, 3.47; p<0.00001) and major adverse cardiac and cerebrovascular events (MACCE) (OR, 2.00; p=0.002), but lower short-term all-cause mortality (OR, 0.33; p<0.00001) and cerebrovascular accident (OR, 0.64; p=0.0001). Subgroup analysis restricted to patients with end-stage renal disease (ESRD) yielded similar results, but no significant differences were found regarding CVA and MACCE.

CONCLUSIONS

CABG for patients with CKD and MVD had advantages over PCI-DES in long-term all-cause mortality, MI, repeat revascularization and MACCE, but the substantial disadvantage in short-term mortality and CVA. Future large randomized controlled trials are certainly needed to confirm these findings.

Coronary Artery Bypass Grafting vs. Drug-Eluting Stent Implantation for Multivessel Disease in Patients with Chronic Kidney Disease

BACKGROUND AND OBJECTIVES

There is currently a limited amount of data that demonstrate the optimal revascularization strategy for chronic kidney disease (CKD) patients with multivessel coronary artery disease (CAD). We compared the long-term outcomes of percutaneous coronary intervention (PCI) with drug-eluting stents (DES) versus coronary artery bypass graft surgery (CABG) for multivessel CAD in patients with CKD.

SUBJECTS AND METHODS

We analyzed 2108 CKD patients (estimated glomerular filtration rate <60 mL/min/1.73 m²) with multivessel CAD that were treated with PCI with DES (n=1165) or CABG (n=943). The primary outcome was a composite of all causes of mortality, myocardial infarction, or stroke. The mean age was 66.9±9.1 years.

RESULTS

Median follow-up duration was 41.4 (interquartile range 12.1-75.5) months. The primary outcome occurred in 307 (26.4%) patients in the PCI group compared with 304 (32.2%) patients in the CABG group (adjusted hazard ratio [HR], 0.941; 95% confidence interval [CI], 0.79-1.12; p=0.493). The two groups exhibited similar rates of all-cause mortality (adjusted HR, 0.91; 95% CI, 0.77-1.09; p=0.295), myocardial infarction (adjusted HR, 1.86; 95% CI, 0.85-4.07; p=0.120) and stroke (3.2% vs. 4.8%; HR, 0.93; 95% CI, 0.57-1.61; p=0.758). However, PCI was associated with significantly increased rates of repeat revascularization (adjusted HR, 4.72; 95% CI, 3.20-6.96; p<0.001).

CONCLUSION

Among patients with CKD and multivessel CAD, PCI with DES when compared with CABG resulted in similar rates of composite outcome of mortality from any cause, MI, or stroke; however, a higher risk of repeat revascularization was observed.

ANMCO/GICR-IACPR/SICI-GISE Consensus Document: the clinical management of chronic ischaemic cardiomyopathy

Stable coronary artery disease (CAD) is a clinical entity of great epidemiological importance. It is becoming increasingly common due to the longer life expectancy, being strictly related to age and to advances in diagnostic techniques and pharmacological and non-pharmacological interventions. Stable CAD encompasses a variety of clinical and anatomic presentations, making the identification of its clinical and anatomical features challenging. Therapeutic interventions should be defined on an individual basis according to the patient's risk profile. To this aim, management flow charts have been reviewed based on sustainability and appropriateness derived from recent evidence. Special emphasis has been placed on non-pharmacological interventions, stressing the importance of lifestyle changes, including smoking cessation, regular physical activity, and diet. Adherence to therapy as an emerging risk factor is also discussed.

Recent Trends in Management and Inhospital Outcomes of Acute Myocardial Infarction in Renal Transplant Recipients

Renal transplant recipients (RTR) are at high risk of cardiovascular events including acute myocardial infarction (AMI). We evaluated recent trends in AMI admissions in 9,243 RTR with functioning grafts using data from the 2003 to 2011 Nationwide Inpatient Sample database. Findings were compared with those of patients with end-stage renal disease without transplantation (ESRD-NRT, n = 160,932) and those without advanced kidney disease (non-ESRD/RT, n = 5,640,851) admitted with AMI. RTR comprised 0.2% of AMI admissions with increasing numbers during the study period (adjusted odds ratio [aOR] 1.04; 95% confidence interval [CI] 1.04 to 1.05; p_trend <0.001). Overall, 29.3% of admissions in RTR were for acute ST-segment elevation myocardial infarction (STEMI). Compared with non-ESRD/RT, history of renal transplantation was independently associated with a decreased likelihood of STEMI at presentation (aOR 0.73; 95% CI 0.65 to 0.80; p <0.001). Inhospital mortality among RTR admitted for NSTEMI decreased from 3.8% in 2003 to 2.1% in 2011 (aOR 0.85; 95% CI 0.78 to 0.93; p <0.001), whereas that for STEMI remained unchanged (7.6% in 2003; 9.3% in 2011, aOR 0.97; 95% CI 0.90 to 1.03; p = 0.36). Rates of percutaneous coronary interventions were higher, and inhospital mortality was lower among RTR compared with ESRD-NRT (p <0.001 for both). Treatment strategies appeared largely unchanged during the course of this study with the exception of an increase in primary percutaneous coronary intervention among RTR admitted with STEMI. In conclusion, RTR were frequently admitted with AMI, particularly NSTEMI, and were found to have multiple coronary artery disease risk factors despite their younger age. Compared with other forms of renal replacement therapy, renal transplant was associated with lower inhospital mortality.

Diagnosis and management of atherosclerotic cardiovascular disease in chronic kidney disease: a review

Patients with chronic kidney disease (CKD) have a high prevalence of atherosclerotic cardiovascular disease, likely reflecting the presence of traditional risk factors. A greater distinguishing feature of atherosclerotic cardiovascular disease in CKD is the severity of the disease, which is reflective of an increase in inflammatory mediators and vascular calcification secondary to hyperparathyroidism of renal origin that are unique to patients with CKD. Additional components of atherosclerotic cardiovascular disease that are prominent in patients with CKD include microvascular disease and myocardial fibrosis. Therapeutic interventions that minimize cardiovascular events related to atherosclerotic cardiovascular disease in patients with CKD, as determined by well-designed clinical trials, are limited to statins. Data are lacking regarding other available therapeutic measures primarily due to exclusion of patients with CKD from major trials studying cardiovascular disease. Data from well-designed randomized controlled trials are needed to guide clinicians who care for this high-risk population in the management of atherosclerotic cardiovascular disease to improve clinical outcomes.

Effect of dialysis dependence and duration on post-coronary artery bypass grafting outcomes in patients with chronic kidney disease: A nationwide cohort study in Asia

BACKGROUND

Chronic kidney disease (CKD) is associated with adverse outcomes in patients who undergo coronary artery bypass grafting (CABG). However, the impact of preoperative dialysis dependence and duration in CKD patients on outcomes after CABG has limited research.

OBJECTIVES

To evaluate the effect of preoperative dialysis dependence and duration on CABG outcomes in patients with CKD.

METHODS

A total of 33,920 patients without CKD and 2573 patients with CKD, all of whom underwent isolated CABG between 1998 and 2009, were identified using the Taiwan National Health Insurance Research Database. The patients with CKD were divided into non-dialysis (N=1167), dialysis<3years (N=749), and dialysis≥3years (N=657) groups. The primary outcomes were cumulative incidence of all-cause mortality, cardiovascular (CV) death, and myocardial infarction (MI) or repeat revascularization.

RESULTS

After adjustment of all covariates, a higher all-cause mortality was associated with dialysis≥3years than with dialysis<3years (hazard ratio [HR], 1.56; 95% confidence interval [CI], 1.35-1.80; P<0.001) and with non-dialysis (HR, 1.41; 95% CI, 1.20-1.66; P<0.001) after 2years of follow-up. Similar results were observed for CV death. In addition, both the dialysis groups had a higher risk of MI or revascularization than the non-dialysis group. Furthermore, subgroup analysis revealed that longer duration was associated with a higher risk of 30-day mortality (P for linear trend <0.001).

CONCLUSIONS

Among the CABG recipients, dialysis dependence is associated with a higher incidence of MI or repeat revascularization, and longer dialysis duration is associated with a higher risk of mortality.

Impact of coronary artery bypass surgery and percutaneous coronary intervention on mortality in patients with chronic kidney disease and on dialysis: A systematic review and meta-analysis

Controversies have been observed among previously published and recently published studies comparing coronary artery bypass surgery (CABG) and percutaneous coronary intervention (PCI) in patients with chronic kidney disease (CKD) and patients on chronic dialysis. This study aimed to show the impact of CABG and PCI on mortality in these patients.Electronic databases were searched for studies comparing CABG and PCI in patients with CKD. The primary outcome was all-cause death whereas the secondary endpoints included other adverse cardiovascular outcomes reported. Causes of death were also analyzed. Odds ratios (ORs) with 95% confidence intervals (CIs) were used to express the pooled effect on discontinuous variables and the pooled analyses were performed with RevMan 5.3.Eighteen studies involving a total number of 69,456 patients (29,239 patients in the CABG group and 40,217 patients in the PCI group) were included in this meta-analysis. Short-term mortality insignificantly favored PCI with OR: 1.24, 95% CI: 0.93-1.65; P = 0.15. Mortality at 1 year was similar in both groups with OR: 0.99, 95% CI: 0.91-1.08; P = 0.86, whereas the long-term mortality significantly favored CABG in patients with CKD and in patients on chronic dialysis with OR: 0.81, 95% CI: 0.70-0.94; P = 0.007 and OR: 0.81, 95% CI: 0.69-0.96; P = 0.01, respectively.In patients with CKD, the impact of CABG on the short-term mortality was insignificantly higher compared to PCI whereas at 1 year, a similar impact was observed. However, the impact of PCI on mortality was significantly higher during a long-term follow-up period in patients with CKD and in patients on chronic dialysis. Nevertheless, due to a high level of heterogeneity observed among several subgroups analyzed, randomized trials are required to completely solve this issue.

Reduced risk of myocardial infarct and revascularization following coronary artery bypass grafting compared with percutaneous coronary intervention in patients with chronic kidney disease

Coronary atherosclerotic disease is highly prevalent in chronic kidney disease (CKD). Although revascularization improves outcomes, procedural risks are increased in CKD, and unbiased data comparing coronary artery bypass grafting (CABG) and percutaneous intervention (PCI) in CKD are sparse. To compare outcomes of CABG and PCI in stage 3 to 5 CKD, we identified randomized trials comparing these procedures. Investigators were contacted to obtain individual, patient-level data. Ten of 27 trials meeting inclusion criteria provided data. These trials enrolled 3993 patients encompassing 526 patients with stage 3 to 5 CKD of whom 137 were stage 3b-5 CKD. Among individuals with stage 3 to 5 CKD, mortality through 5 years was not different after CABG compared with PCI (hazard ratio [HR] 0.99, 95% confidence interval [CI] 0.67-1.46) or stage 3b-5 CKD (HR 1.29, CI 0.68-2.46). However, CKD modified the impact on survival free of myocardial infarction: it was not different between CABG and PCI for individuals with preserved kidney function (HR 0.97, CI 0.80-1.17), but was significantly lower after CABG in stage 3-5 CKD (HR 0.49, CI 0.29-0.82) and stage 3b-5 CKD (HR 0.23, CI 0.09-0.58). Repeat revascularization was reduced after CABG compared with PCI regardless, of baseline kidney function. Results were limited by unavailability of data from several trials and paucity of enrolled patients with stage 4-5 CKD. Thus, our patient-level meta-analysis of individuals with CKD randomized to CABG versus PCI suggests that CABG significantly reduces the risk of subsequent myocardial infarction and revascularization without affecting survival in these patients.

Effectiveness of Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting in Patients With End-Stage Renal Disease

The optimal coronary revascularization strategy (coronary artery bypass grafting [CABG] or percutaneous coronary intervention [PCI]) in patients with end-stage renal disease (ESRD) remains uncertain. We performed an updated systematic review and meta-analysis of observational studies comparing CABG and PCI in patients with ESRD using a random-effects model for the primary outcome of long-term all-cause mortality. Our review registered through PROSPERO included observational studies published after 2011 to ensure overlap with previous studies and identified 7 new studies for a total of 23. We found that the median sample size in the selected studies was 125 patients (25 to 15,784) with a large variation in the covariate risk adjustment and only 3 studies reporting the indications for the revascularization strategy. CABG was associated with a small reduction in mortality (relative risk 0.92, 95% CI 0.89 to 0.96) with significant heterogeneity demonstrated (p = 0.005, I(2) = 48.6%). Subgroup analysis by categorized "year of study initiation" (<1990, 1991 to 2003, >2004) further confirmed the summary estimate trending toward survival benefit of CABG along with a substantial decrease in heterogeneity after 2004 (p = 0.64, I(2) = 0%). In conclusion, our updated systematic review and meta-analysis demonstrated that in patients with ESRD referred for coronary revascularization, CABG was associated with a small decrease in the relative risk of long-term mortality compared with PCI. The generalizability of the finding to all patients with ESRD referred for coronary revascularization is limited because of a lack of known indications for coronary revascularization, substantial variation in covariate risk adjustment, and lack of randomized clinical trial data.

Is kidney function affecting the management of myocardial infarction? A retrospective cohort study in patients with normal kidney function, chronic kidney disease stage III-V, and ESRD

Patients with chronic kidney disease (CKD) are three times more likely to have myocardial infarction (MI) and suffer from increased morbidity and higher mortality. Traditional and unique risk factors are prevalent and constitute challenges for the standard of care. However, CKD patients have been largely excluded from clinical trials and little evidence is available to guide evidence-based treatment of coronary artery disease in patients with CKD. Our objective was to assess whether a difference exists in the management of MI (ST-segment elevation myocardial infarction and non-ST-segment elevation myocardial infarction) among patients with normal kidney function, CKD stage III–V, and end-stage renal disease (ESRD) patients. We conducted a retrospective cohort study on patients admitted to Staten Island University Hospital for the diagnosis of MI between January 2005 and December 2012. Patients were assigned to one of three groups according to their kidney function: Data collected on the medical management and the use of statins, platelet inhibitors, beta-blockers, and angiotensin converting enzyme inhibitors/angiotensin receptor blockers were compared among the three cohorts, as well as medical interventions including: catheterization and coronary artery bypass graft (CABG) when indicated. Chi-square test was used to compare the proportions between nominal variables. Binary logistic analysis was used in order to determine associations between treatment modalities and comorbidities, and to account for possible confounding factors. Three hundred and thirty-four patients (mean age 67.2±13.9 years) were included. In terms of management, medical treatment was not different among the three groups. However, cardiac catheterization was performed less in ESRD when compared with no CKD and CKD stage III–V (45.6% vs 74% and 93.9%) (P<0.001). CABG was performed in comparable proportions in the three groups and CABG was not associated with the degree of CKD (P=0.078) in binary logistics regression. Cardiac catheterization on the other hand carried the strongest association among all studied variables (P<0.001). This association was maintained after adjusting for other comorbidities. The length of stay for the three cohorts (non-CKD, CKD stage III–V, and ESRD on hemodialysis) was 16, 17, and 15 days, respectively and was not statistically different. Many observations have reported discrimination of care for patients with CKD considered suboptimal candidates for aggressive management of their cardiac disease. In our study, medical therapy was achieved at high percentage and was comparable among groups of different kidney function. However, kidney disease seems to affect the management of patients with acute MI; percutaneous coronary angiography is not uniformly performed in patients with CKD and ESRD when compared with patients with normal kidney function.

Coronary revascularization in the elderly with stable angina

A proportion of elderly with coronary artery disease is rapidly growing. They have more severe coronary artery disease, therefore, derive more benefit from revascularization and have a greater need for it. The elderly is a heterogeneous group, but compared to the younger cohort, the choice of the optimal revascularization method is much more complicated among them. In recent decades, results has improved dramatically both in surgery and percutaneous coronary intervention (PCI), even in very old persons. Despite the lack of evidence in elderly, it is obvious, that coronary artery bypass surgery (CABG) has a more pronounced effect on long-term survival in price of more strokes, while PCI is certainly less invasive. Age itself is not a criterion for the selection of treatment strategy, but the elderly are often more interested in quality of life and personal independence instead of longevity. This article discusses the factors that influence the choice of the revascularization method in the elderly with stable angina and presents a complex algorithm for making an individual risk-benefit profile. As a consequence the features of CABG and PCI in elderly patients are exposed. Emphasis is centered on the frailty and non-medical factors, including psychosocial, as essential components in making the decision of what strategy to choose. Good communication with the patients and giving them unbiased information is encouraged.

Clinical outcomes of treatment by percutaneous coronary intervention versus coronary artery bypass graft surgery in patients with chronic kidney disease undergoing index revascularization in Ontario

BACKGROUND

There is a paucity of data on the comparative effectiveness of percutaneous coronary intervention using contemporary drug-eluting stent (DES) compared with coronary artery bypass graft (CABG) surgery in patients with chronic kidney disease.

METHODS AND RESULTS

A population-based study was performed using the Cardiac Care Network, a provincial registry of all patients undergoing cardiac catheterization in Ontario, to evaluate patients treated with either percutaneous coronary intervention using DES or CABG between October 1, 2008, and September 30, 2011. Chronic kidney disease was defined as creatinine clearance <60 mL/min. A total of 1786 propensity-matched patients from 4006 patients with chronic kidney disease undergoing index revascularization for multivessel disease with either DES or isolated CABG (n=893 each group) were analyzed. Baseline and procedural characteristics between percutaneous coronary intervention and CABG groups were well-balanced, including urgent revascularization priority, diabetes mellitus, left ventricular function, and 3-vessel disease. The 1-, 2-, and 3-year Kaplan-Meier survival analyses in propensity-matched patients favored CABG (93.2% versus 89.3%; 86.6% versus 80.3%; 80.8% versus 71.5%, respectively; P<0.001). The CABG cohort had greater 1-, 2-, and 3-year freedom from major adverse cardiac and cerebrovascular events (89.4% versus 71.2%; 81.9% versus 60.5%; 75.2% versus 51.8%, respectively; P<0.001). Cox regression analysis identified DES use to be associated with greater hazard for late mortality (hazard ratio, 1.58; 95% confidence interval, 1.32-1.90) and major adverse cardiac and cerebrovascular events (2.62; 2.28-3.01; all P<0.001).

CONCLUSIONS

In this large provincial registry, CABG was associated with improved early and late clinical outcomes when compared with percutaneous coronary intervention using DES in patients with chronic kidney disease undergoing index revascularization.

Outcome after coronary artery bypass grafting and percutaneous coronary intervention in patients with stage 3b-5 chronic kidney disease

OBJECTIVES

Patients with chronic kidney disease (CKD) are generally considered to be at an increased risk for cardiovascular events and cardiac mortality. The prognostic significance of severe renal impairment in patients undergoing coronary revascularization remains mainly unknown because these patients have been excluded from randomized clinical trials. The aim of the present study was to compare the outcome after percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in patients with an estimated glomerular filtration rate (eGFR) of <45 ml/min/m(2).

METHODS

This retrospective study includes 110 patients who underwent PCI and 148 patients who underwent isolated CABG between 2007 and 2010. All patients had stage 3b-5 CKD (eGFR <45 ml/min/m(2)).

RESULTS

The median follow-up time was 25 (interquartile range 30) months. At 30 days and 3 years, postoperative de novo dialysis was required in 3.4 and 16.2% of CABG patients and in 0 and 6.6% (P = 0.10) of PCI patients. PCI was associated with similar mortality at 30 days (PCI 10.0% and CABG 12.2%, P = 0.068). At 3 years, PCI was associated with a significantly higher risk of mortality (50.4 vs 32.9, adjusted analysis: HR 1.77, 95% CI 1.13-2.77), repeat revascularization (20.3 vs 0.8%, too few for adjusted analysis) and major adverse cardiac and cerebrovascular events (57.8 vs 34.3%, HR 2.19, 95% CI 1.41-3.40). These findings were supported by propensity score-matched analysis.

CONCLUSION

Patients with moderate to severe CKD have a high rate of mortality and morbidity after either PCI or CABG. The fear of postoperative dialysis rates after CABG appears overemphasized since less than 5% of patients needed dialysis in the early postoperative period. This study provides evidence that this high-risk subset of patients should also be revascularized according to general recommendations. When feasible, CABG could be associated with better survival and freedom from cardiovascular events than PCI.

Coronary artery disease in patients with chronic kidney disease: a clinical update

Chronic kidney disease (CKD) is an independent risk factor for coronary artery disease (CAD). Coronary artery disease is the leading cause of morbidity and mortality in patients with CKD. The outcomes of CAD are poorer in patients with CKD. In addition to traditional risk factors, several uremia-related risk factors such as inflammation, oxidative stress, endothelial dysfunction, coronary artery calcification, hyperhomocysteinemia, and immunosuppressants have been associated with accelerated atherosclerosis. A number of uremia-related biomarkers are identified as predictors of cardiac outcomes in CKD patients. The symptoms of CAD may not be typical in patients with CKD. Both dobutamine stress echocardiography and radionuclide myocardial perfusion imaging have moderate sensitivity and specificity in detecting obstructive CAD in CKD patients. Invasive coronary angiography carries a risk of contrast nephropathy in patients with advanced CKD. It should be reserved for those patients with a high risk for CAD and those who would benefit from revascularization. Guideline-recommended therapies are, in general, underutilized in renal patients. Medical therapy should be considered the initial strategy for clinically stable CAD. The effects of statins in patients with advanced CKD have been neutral despite a lipid-lowering effect. Compared to non-CKD population, percutaneous coronary intervention (PCI) is associated with higher procedure complications, restenosis, and future cardiac events even in the drug-eluting stent era in patients with CKD. Compared with PCI, coronary artery bypass grafting (CABG) reduces repeat revascularizations but is associated with significant perioperative morbidity and mortality. Screening for CAD is an important part of preoperative evaluation for kidney transplant candidates.

Impact of renal function in patients with multi-vessel coronary disease on long-term mortality following coronary artery bypass grafting compared with percutaneous coronary intervention

BACKGROUND

Comorbidities, such as diabetes, affect revascularization strategy for coronary disease. We sought to determine if the degree of renal impairment affected long-term mortality after percutaneous coronary intervention (PCI) compared to coronary artery bypass grafting (CABG) in patients with multi-vessel coronary disease (MVD).

METHODS AND RESULTS

8970 patients with MVD undergoing revascularization between 2004 and 2008, in two multi-center parallel PCI and CABG Australian registries were assigned to three groups based on their estimated glomerular filtration rate (eGFR)≥60 mL/min/1.73 m2 (n=1678:839), 30-59 mL/min/1.73 m2 (n=452:226) and <30 mL/min/1.73 m2 (n=74:37). We used 2:1 propensity matching to compare 3306 patients undergoing primary CABG versus PCI. Shock, myocardial infarction (MI)<24 h, previous CABG, valve surgery or PCI were exclusions. Long-term mortality (mean 3.1 years) was compared with Cox-proportional hazard-adjusted modeling. Observed long-term mortality rates (CABG vs. PCI) were 4.5% vs. 4.3% p=0.84, 12.8% vs. 17.3% p=0.12, and 23.0% vs. 40.5% p=0.05 in the three strata, respectively. In patients with eGFR≥60 mL/min/1.73 m2, long-term mortality between PCI and CABG (HR 0.99, 95% CI 0.65-1.49, p=0.95) was similar. However, amongst patients with eGFR 30-59 mL/min/1.73 m2, there was a significant mortality hazard with PCI (HR 2.00, 95% CI 1.32-3.04, p=0.001). In patients with eGFR<30 mL/min/1.73 m2, there was a trend for hazard with PCI (HR 1.66, 95% CI 0.80-3.46, p=0.17).

CONCLUSION

Long-term mortality in MVD patients with preserved renal function was very low and similar between PCI and CABG. However there was a long-term mortality hazard associated with PCI amongst patients with moderate renal impairment.