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Baudo M, Torregrossa G, Dokollari A, Bisleri G, Bacco LD, Benussi S, Muneretto C, Rosati F. Impact of coronary-subclavian steal after surgical myocardial revascularization with internal thoracic artery in chronic hemodialysis patients: A meta-analysis. Trends Cardiovasc Med 2024; 34:183-190. [PMID: 36632858 DOI: 10.1016/j.tcm.2022.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 11/30/2022] [Accepted: 12/31/2022] [Indexed: 01/09/2023]
Abstract
Patients in hemodialysis with an arm arteriovenous fistula undergoing coronary artery bypass grafting (CABG) with an internal thoracic artery have been reported to suffer from coronary-subclavian steal (CSS) during dialysis session. However, its occurrence is still debated. A systematic literature review was performed to identify all studies investigating the occurrence of a CSS event in this subset of patients. The primary endpoint was the analysis of CSS and the following early and late survival outcomes. Independent determinants of CSS and the impact of the distance between the arteriovenous fistula (upper arm vs forearm) and the ipsilateral internal thoracic artery graft on CSS events and mortality were studied. Early and late survival outcomes were analyzed by comparing ipsilateral versus contralateral arteriovenous fistula. Of the 1,383 retrieved articles, 10 were included (n = 643 patients). The pooled event rate of CSS was 6.46% [95%CI=2.10-18.15], while of symptomatic CSS incidence was 3.99% [95%CI=0.95-15.25]. No survival differences were noted when comparing ipsilateral to contralateral arteriovenous fistula-internal thoracic artery combinations. On meta-regression, the upper arm was associated with more CSS events, while the forearm to lower late mortality rates. Independently from arteriovenous fistula-internal thoracic artery combination, CSS was not associated to higher mortality rates. Particular attention is warranted when selecting the type of conduits for CABG in patients with an arteriovenous fistula or if highly expected to need one in the near future after surgery. A contralateral arteriovenous fistula-internal thoracic artery combination is preferable. If this is not possible, a forearm arteriovenous fistula position should be preferred.
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Affiliation(s)
- Massimo Baudo
- Division of Cardiac Surgery, Spedali Civili di Brescia, University of Brescia, Piazza Spedali Civili, 1, Brescia 25123, Italy.
| | - Gianluca Torregrossa
- Division of Cardiac Surgery, Main Line Health - Lankenau Heart Institute, Wynnewood, PA, United States
| | - Aleksander Dokollari
- Division of Cardiac Surgery, Main Line Health - Lankenau Heart Institute, Wynnewood, PA, United States
| | - Gianluigi Bisleri
- Division of Cardiac Surgery, St Michael's Hospital, University of Toronto, ON, Canada
| | - Lorenzo Di Bacco
- Division of Cardiac Surgery, Spedali Civili di Brescia, University of Brescia, Piazza Spedali Civili, 1, Brescia 25123, Italy
| | - Stefano Benussi
- Division of Cardiac Surgery, Spedali Civili di Brescia, University of Brescia, Piazza Spedali Civili, 1, Brescia 25123, Italy
| | - Claudio Muneretto
- Division of Cardiac Surgery, Spedali Civili di Brescia, University of Brescia, Piazza Spedali Civili, 1, Brescia 25123, Italy
| | - Fabrizio Rosati
- Division of Cardiac Surgery, Spedali Civili di Brescia, University of Brescia, Piazza Spedali Civili, 1, Brescia 25123, Italy
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Shell D. Coronary Artery Bypass Grafting in Dialysis-Dependent Patients - Key Peri-Operative Considerations. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2023; 54:73-80. [PMID: 37183155 DOI: 10.1016/j.carrev.2023.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 04/26/2023] [Accepted: 05/09/2023] [Indexed: 05/16/2023]
Abstract
Cardiovascular disease represents the leading cause of mortality in dialysis-dependent (DD) patients, with the great majority of these patients afflicted by severe coronary artery disease. As rates of end-stage renal disease increase worldwide, DD patients represent a growing proportion of the coronary artery bypass grafting (CABG) cohort. Yet, these patients are complex, with crucial changes in their haemodynamic and physiologic profiles that complicate revascularisation surgery. First, this comprehensive literature review explores the outcomes and prognostic factors for DD patients undergoing CABG. We then summarise the intricacies relating to important peri-operative decisions such as use of cardio-pulmonary bypass and choice of conduit.
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Affiliation(s)
- Daniel Shell
- Department of Cardiothoracic Surgery, St Vincent's Hospital - Melbourne, St Vincent's Health Australia, Melbourne, Australia.
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Tasoudis PT, Varvoglis DN, Tzoumas A, Doulamis IP, Tzani A, Sá MP, Kampaktsis PN, Gallo M. Percutaneous coronary intervention versus coronary artery bypass graft surgery in dialysis-dependent patients: A pooled meta-analysis of reconstructed time-to-event data. J Card Surg 2022; 37:3365-3373. [PMID: 35900307 DOI: 10.1111/jocs.16805] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 07/02/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Το perform a systematic review with meta-analysis of published data comparing outcomes between a percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in dialysis-dependent patients. METHODS We searched PubMed, Scopus, and Cochrane databases for studies including dialysis-dependent patients who underwent either CABG or PCI. This meta-analysis follows the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. We conducted one-stage and two-stage meta-analysis with Kaplan-Meier-derived individual patient data for overall survival and meta-analysis with the random-effects model for the in-hospital mortality and repeat revascularization. RESULTS Twelve studies met our eligibility criteria, including 13,651 and 28,493 patients were identified in the CABG and PCI arms, respectively. Patients who underwent CABG had overall improved survival compared with those who underwent PCI at the one-stage meta-analysis (hazard ratio [HR]: 1.12, 95% confidence interval [CI]: 1.09-1.16, p < .0001) and the two-stage meta-analysis (HR: 1.15, 95% CI: 1.08-1.23, p < .001, I2 = 30.0%). Landmark analysis suggested that PCI offers better survival before the 8.5 months of follow-up (HR: 0.96, 95% CI: 0.92-0.99, p = .043), while CABG offers an advantage after this timepoint (HR: 1.3, 95% CI: 1.22-1.32, p < .001). CABG was associated with increased odds for in-hospital mortality (odds ratio [OR]: 1.70, 95% CI: 1.50-1.92, p < .001, I2 = 0.0%) and decreased odds for repeat revascularization (OR: 0.22, 95% CI: 0.14-0.34, p < .001, I2 = 58.08%). CONCLUSIONS In dialysis-dependent patients, CABG was associated with long-term survival but a higher risk for early mortality. The risk for repeat revascularization was higher with PCI.
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Affiliation(s)
- Panagiotis T Tasoudis
- Department of Cardiothoracic Surgery, School of Health Sciences, University of Thessaly, Larisa, Greece
| | - Dimitrios N Varvoglis
- Department of Cardiothoracic Surgery, School of Health Sciences, University of Thessaly, Larisa, Greece
| | - Andreas Tzoumas
- Department of Internal Medicine, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
| | - Ilias P Doulamis
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Aspasia Tzani
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michel P Sá
- Department of Cardiothoracic Surgery Research, Lankenau Institute for Medical Research, Wynnewood, Pennsylvania, USA
| | - Polydoros N Kampaktsis
- Department of Medicine, Division of Cardiology, New York University Langone Medical Center, New York, New York, USA
| | - Michele Gallo
- Department of Cardiac Surgery, Cardiocentro Ticino, Lugano, Switzerland
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Li X, Xiao F, Zhang S. Coronary revascularisation in patients with chronic kidney disease and end-stage renal disease: A meta-analysis. Int J Clin Pract 2021; 75:e14506. [PMID: 34117687 PMCID: PMC8596450 DOI: 10.1111/ijcp.14506] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 06/06/2021] [Indexed: 01/11/2023] Open
Abstract
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.
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Affiliation(s)
- Xihui Li
- Department of Cardiac SurgeryPeking University First HospitalBeijingChina
| | - Feng Xiao
- Department of Cardiac SurgeryPeking University First HospitalBeijingChina
| | - Siyu Zhang
- Department of Cardiac SurgeryPeking University First HospitalBeijingChina
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Ullah W, Ur Rahman M, Rauf A, Zahid S, Thalambedu N, Mir T, Khan MZ, Fischman DL, Virani S, Alam M. 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. Expert Rev Cardiovasc Ther 2021; 19:763-768. [PMID: 34275404 DOI: 10.1080/14779072.2021.1955350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
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.
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Affiliation(s)
- Waqas Ullah
- Department of Medicine, Section of Cardiology, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
| | | | - Abdul Rauf
- Department of Medicine, SSM health St. Mary's Hospital, Missouri, USA
| | - Salman Zahid
- Department of Medicine, Rochester General Hospital, New York, USA
| | - Nishanth Thalambedu
- Department of Medicine, Section of Cardiology, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
| | - Tanveer Mir
- Department of Medicine, Detroit Medical Center, Detroit, Michigan, USA
| | - Muhammad Zia Khan
- Department of Medicine, University of West Virginia Morgantown, West Virginia, USA
| | - David L Fischman
- Department of Medicine, Section of Cardiology, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
| | - Salim Virani
- Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, Texas, USA
| | - Mahboob Alam
- Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, Texas, USA
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Yong J, Tian J, Zhao X, Yang X, Xing H, He Y, Song X. Optimal treatment strategies for coronary artery disease in patients with advanced kidney disease: a meta-analysis. Ther Adv Chronic Dis 2021; 12:20406223211024367. [PMID: 34285788 PMCID: PMC8267045 DOI: 10.1177/20406223211024367] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 04/21/2021] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Jingwen Yong
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Jinfan Tian
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xin Zhao
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xueyao Yang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Haoran Xing
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yi He
- Department of Radiology, Beijing Friendship Hospital, Capital Medical University, Yongan Road 95, Beijing City, 100050, China
| | - Xiantao Song
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Chaoyang District, Anzhen Road No. 2, Beijing City, 100029, China
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Kanbay M, Tapoi L, Ureche C, Bulbul MC, Kapucu I, Afsar B, Basile C, Covic A. Coronary artery bypass grafting versus percutaneous coronary intervention in end-stage kidney disease: A systematic review and meta-analysis of clinical studies. Hemodial Int 2021; 25:288-299. [PMID: 34085386 DOI: 10.1111/hdi.12946] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 03/25/2021] [Accepted: 05/16/2021] [Indexed: 01/04/2023]
Abstract
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.
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Affiliation(s)
- Mehmet Kanbay
- Department of Medicine, Division of Nephrology, Koc University School of Medicine, Istanbul, Turkey
| | - Laura Tapoi
- Cardiovascular Diseases Institute, "Grigore T. Popa" University of Medicine and Pharmacy, Iasi, Romania
| | - Carina Ureche
- Cardiovascular Diseases Institute, "Grigore T. Popa" University of Medicine and Pharmacy, Iasi, Romania
| | - Mustafa C Bulbul
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Irem Kapucu
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Baris Afsar
- Department of Medicine, Division of Nephrology, Suleyman Demirel University School of Medicine, Isparta, Turkey
| | - Carlo Basile
- Division of Nephrology, Miulli General Hospital, Acquaviva delle Fonti, Italy
| | - Adrian Covic
- Department of Nephrology, "Grigore T. Popa" University of Medicine and Pharmacy, Iasi, Romania
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Hachiro K, Kinoshita T, Suzuki T, Asai T. Internal thoracic artery graft ipsilateral to the arteriovenous fistula in haemodialysis patients. Interact Cardiovasc Thorac Surg 2021; 32:864-872. [PMID: 33561216 DOI: 10.1093/icvts/ivab022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 11/30/2020] [Accepted: 01/01/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES The aim of this study was to investigate the impact of in situ internal thoracic artery (ITA) grafting ipsilateral to the arteriovenous fistula (AVF) on postoperative outcomes in haemodialysis patients undergoing isolated coronary artery bypass grafting (CABG). METHODS We reviewed 132 haemodialysis patients who underwent isolated CABG between January 2002 and December 2019. With a difference between the left and right upper arms blood pressure measurement of ≥20 mmHg, we did not use the ITA on the lower value side. We categorized patients into 55 patients (41.7%, ipsilateral group) whose left anterior descending artery was revascularized using the in situ ITA ipsilateral to the AVF, and 77 patients (58.3%, contralateral group) whose left anterior descending artery was revascularized using the ITA opposite the AVF. We compared patients' postoperative outcomes after adjusting for their backgrounds using weighted logistic regression analysis and inverse probability of treatment weighting. RESULTS No patients developed coronary steal postoperatively, and there was no significant difference in 30-day mortality between the groups (P = 0.353). The adjusted 5-year estimated rates of freedom from all-cause and cardiac death in the ipsilateral vs contralateral groups were 52.3% vs 54.0% and 78.2% vs 88.6%, respectively; survival curves were not statistically significantly different (P = 0.762 and P = 0.229, respectively). CONCLUSIONS In situ ITA grafting ipsilateral to the AVF was not associated with postoperative early and mid-term worse outcomes in haemodialysis patients undergoing isolated CABG.
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Affiliation(s)
- Kohei Hachiro
- Division of Cardiovascular Surgery, Department of Surgery, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Takeshi Kinoshita
- Division of Cardiovascular Surgery, Department of Surgery, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Tomoaki Suzuki
- Division of Cardiovascular Surgery, Department of Surgery, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Tohru Asai
- Division of Cardiovascular Surgery, Department of Surgery, Shiga University of Medical Science, Otsu, Shiga, Japan
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Prasitlumkum N, Cheungpasitporn W, Sato R, Thangjui S, Thongprayoon C, Kewcharoen J, Bathini T, Vallabhajosyula S, Ratanapo S, Chokesuwattanaskul R. Comparison of coronary artery bypass graft versus drug-eluting stents in dialysis patients: an updated systemic review and meta-analysis. J Cardiovasc Med (Hagerstown) 2021; 22:285-296. [PMID: 33633044 DOI: 10.2459/jcm.0000000000001167] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
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.
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Affiliation(s)
- Narut Prasitlumkum
- Department of Cardiology, University of California Riverside, Riverside, California
| | - Wisit Cheungpasitporn
- Department of Internal Medicine, University of Mississippi Medical Center, Jackson, Mississippi
| | - Ryota Sato
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Ohio, USA
| | - Sittinun Thangjui
- Department of Internal Medicine, Basset Healthcare Network, Cooperstown, New York
| | | | | | - Tarun Bathini
- Department of Internal Medicine, University of Arizona, Tucson, Arizona
| | - Saraschandra Vallabhajosyula
- Section of Interventional Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
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Wang Z, Gong Y, Fan F, Yang F, Qiu L, Hong T, Huo Y. Coronary artery bypass grafting vs. drug-eluting stent implantation in patients with end-stage renal disease requiring dialysis. Ren Fail 2020; 42:107-112. [PMID: 31918608 PMCID: PMC6968570 DOI: 10.1080/0886022x.2019.1710187] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Zhi Wang
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Yanjun Gong
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Fangfang Fan
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Fan Yang
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Lin Qiu
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Tao Hong
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Yong Huo
- Department of Cardiology, Peking University First Hospital, Beijing, China
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Doulamis IP, Tzani A, Tzoumas A, Iliopoulos DC, Kampaktsis PN, Briasoulis A. Percutaneous Coronary Intervention With Drug Eluting Stents Versus Coronary Artery Bypass Graft Surgery in Patients With Advanced Chronic Kidney Disease: A Systematic Review and Meta-Analysis. Semin Thorac Cardiovasc Surg 2020; 33:958-969. [DOI: 10.1053/j.semtcvs.2020.11.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 11/05/2020] [Indexed: 12/22/2022]
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12
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Hu YN, Luo CY, Tsai MT, Lin TW, Kan CD, Roan JN. Post-Coronary Artery Bypass Medications in Dialysis Patients: Do We Need to Change Strategies? Thorac Cardiovasc Surg 2020; 68:706-713. [PMID: 31891949 DOI: 10.1055/s-0039-3400471] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Coronary artery bypass grafting (CABG) is frequently performed in patients with end-stage renal disease (ESRD) together with severe coronary artery disease, after which, patients with ESRD have higher surgical risk and poorer long-term outcomes. We report our experience in patients with ESRD who survived in CABG and identify predictors of long-term outcomes. METHODS We retrospectively investigated 93 consecutive patients with ESRD who survived to discharge after isolated CABG between January 2005 and December 2016 at our institution. Long-term outcomes, including all-cause mortality after discharge, readmission due to major adverse cardiac events, and reintervention, were evaluated. Predictors affecting long-term outcomes were also analyzed. RESULTS The rates of freedom from all-cause mortality after discharge in 1, 3, 5, and 10 years were 92.1, 81.3, 71.9, and 34.9%, respectively. The rates of freedom from readmission due to major adverse cardiac events in 1, 3, 5, and 10 years were 90.7, 79.1, 69.9, and 55.6%, respectively. The rates of freedom from reintervention in 1, 3, 5, and 10 years were 95.3, 86.5, 79.0, and 66.6%, respectively. Postoperative β-blocker and statin use significantly improved overall long-term survival (β-blocker, p = 0.013; statin, p = 0.009). After case-control matching, patients who received statins showed better long-term survival than those without statins. The comparison of long-term survival between patients with and without β-blockers showed no significant difference after matching. CONCLUSIONS After CABG, dialysis patients who survived to discharge had acceptable long-term overall survival. Post-CABG statin use in dialysis patients is a predictor of better long-term survival.
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Affiliation(s)
- Yu-Ning Hu
- Department of Surgery, Division of Cardiovascular Surgery, National Cheng Kung University College of Medicine, Tainan, Taiwan
| | - Chwan-Yau Luo
- Department of Surgery, Division of Cardiovascular Surgery, National Cheng Kung University College of Medicine, Tainan, Taiwan
| | - Meng-Ta Tsai
- Department of Surgery, Division of Cardiovascular Surgery, National Cheng Kung University College of Medicine, Tainan, Taiwan
| | - Ting-Wei Lin
- Department of Surgery, Division of Cardiovascular Surgery, National Cheng Kung University College of Medicine, Tainan, Taiwan
| | - Chung-Dann Kan
- Department of Surgery, Division of Cardiovascular Surgery, National Cheng Kung University College of Medicine, Tainan, Taiwan
| | - Jun-Neng Roan
- Department of Surgery, Division of Cardiovascular Surgery, National Cheng Kung University College of Medicine, Tainan, Taiwan.,Medical Device Innovation Center, National Cheng Kung University College of Medicine, Tainan, Taiwan.,Institute of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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Klein EC, Kapoor R, Lewandowski D, Mason PJ. Revascularization Strategies in Patients with Chronic Kidney Disease and Acute Coronary Syndromes. Curr Cardiol Rep 2019; 21:113. [PMID: 31471758 DOI: 10.1007/s11886-019-1213-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
PURPOSE OF REVIEW Chronic kidney disease (CKD) is a highly prevalent condition that increases the incidence and complexity of acute coronary syndrome (ACS). The purpose of this review is to summarize current evidence, uncertainties, and opportunities in the management of patients with CKD and ACS, with a focus on revascularization. RECENT FINDINGS Patients with CKD have been systematically under-represented or excluded from clinical trials in ACS. Available data, however, demonstrates that although patients with CKD and ACS benefit from revascularization, they are also less likely to receive recommended medical and revascularization therapies when compared to patients with normal kidney function. Despite the increased short-term risk of major morbidity and mortality, patients with CKD and ACS should be considered for an early invasive strategy while also trying to mitigate the risks of procedural related complications. Until evidence emerges from randomized clinical trials, the decision about revascularization strategy should involve multi-disciplinary collaboration, heart team consensus, and patient shared decision-making.
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Affiliation(s)
- Evan C Klein
- Medical College of Wisconsin, Milwaukee, WI, USA
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14
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Wu YS, Hsieh SR, Wei HJ, Hsu CY, Tsai CL. Long-Term Outcomes in Coronary Artery Bypass Graft Patients Using Internal Thoracic Artery with Ipsilateral Arteriovenous Shunt for Hemodialysis. ACTA CARDIOLOGICA SINICA 2019; 35:387-393. [PMID: 31371899 DOI: 10.6515/acs.201907_35(4).20181208a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background The goal of this study was to evaluate the long-term results of coronary artery bypass grafting (CABG) using internal thoracic artery (ITA) grafts in hemodialysis (HD) patients with arteriovenous (AV) fistulae or AV grafts involving the ipsilateral or contralateral brachial artery or radial artery. Methods From March 2007 to May 2017, 76 end-stage renal disease (ESRD) patients with an upper limb AV fistula or graft for HD underwent CABG at a single center. Group A included 23 patients who underwent CABG using an ITA graft ipsilateral to the AV vascular access (AVVA); Group B included 22 patients who underwent CABG using a contralateral ITA with AVVA; and Group C included 29 patients who underwent CABG with AVVA without the use of an ITA graft. The primary end-point was death from any cause. Results The average follow-up period was 34.4 ± 26.9 months. Death from any cause occurred in 6 (26.09%) patients in Group A, 8 (36.36%) patients in Group B, and 17 (58.62%) patients in Group C (log-rank p = 0.04). There was no significant difference in death rate between Groups A and B. The risk of death was lower in the patients with CABG using an ITA graft (ITA CABG) compared to the patients without ITA CABG [HR 0.41 (95% CI, 0.20-0.84), p = 0.015]. Conclusions The HD patients who underwent CABG with an ipsilateral location of the ITA and AVVA did not have an increased risk of death compared to the patients who underwent CABG with a contralateral location of the ITA and AVVA. In addition, the use of ITA in CABG resulted in better outcomes in the HD patients.
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Affiliation(s)
- Yung-Szu Wu
- Department of Cardiovascular Surgery, Cardiovascular Center, Taichung Veterans General Hospital, Taichung
| | - Shih-Rong Hsieh
- Department of Cardiovascular Surgery, Cardiovascular Center, Taichung Veterans General Hospital, Taichung.,National Yang-Ming University School of Medicine, Taipei
| | - Hao-Ji Wei
- Department of Cardiovascular Surgery, Cardiovascular Center, Taichung Veterans General Hospital, Taichung.,National Yang-Ming University School of Medicine, Taipei
| | - Chiann-Yi Hsu
- Biostatistics Task Force of Taichung Veterans General Hospital, Taichung, Taiwan
| | - Chung-Lin Tsai
- Department of Cardiovascular Surgery, Cardiovascular Center, Taichung Veterans General Hospital, Taichung
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15
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Wu P, Luo F, Fang Z. Multivessel Coronary Revascularization Strategies in Patients with Chronic Kidney Disease: A Meta-Analysis. Cardiorenal Med 2019; 9:145-159. [PMID: 30844786 DOI: 10.1159/000494116] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 09/27/2018] [Indexed: 11/19/2022] Open
Abstract
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.
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Affiliation(s)
- Panyun Wu
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Fei Luo
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Zhenfei Fang
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, China,
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Shim H, Jeong DS, Kim WS, Park PW, Sung K, Jeon CS, Lee YT. Impact of Arteriovenous Fistula for Hemodialysis on Clinical Outcomes of Coronary Artery Bypass. Ann Thorac Surg 2018; 106:1820-1826. [DOI: 10.1016/j.athoracsur.2018.06.071] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 05/31/2018] [Accepted: 06/21/2018] [Indexed: 10/28/2022]
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Formica F, D'Alessandro S. Coronary patients on dialysis: Coronary artery bypass grafting or percutaneous coronary intervention? A complex question for a complex scenario. J Thorac Cardiovasc Surg 2018; 157:984-985. [PMID: 30396730 DOI: 10.1016/j.jtcvs.2018.09.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 09/17/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Francesco Formica
- Mechanical Circulatory Support Program Coordinator, Cardiac Surgery Unit, San Gerardo Hospital, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.
| | - Stefano D'Alessandro
- Cardiac Surgery Unit, Cardio-thoracic-vascular Department, San Gerardo Hospital, Monza, Italy
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18
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Cormican D, Jayaraman AL, Sheu R, Peterson C, Narasimhan S, Shaefi S, Núñez-Gil IJ, Ramakrishna H. Coronary Artery Bypass Grafting Versus Percutaneous Transcatheter Coronary Interventions: Analysis of Outcomes in Myocardial Revascularization. J Cardiothorac Vasc Anesth 2018; 33:2569-2588. [PMID: 30340948 DOI: 10.1053/j.jvca.2018.09.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Indexed: 01/13/2023]
Affiliation(s)
- Daniel Cormican
- Division of Cardiothoracic Anesthesiology & Critical Care Medicine, Department of Anesthesiology, Allegheny Health Network, Pittsburgh, PA
| | | | - Richard Sheu
- Department of Anesthesiology and Pain Medicine, University of Washington Medical Center, Seattle, WA
| | - Carly Peterson
- Department of Anesthesiology and Pain Medicine, University of Washington Medical Center, Seattle, WA
| | - Seshasayee Narasimhan
- Department of Cardiology, Manning Base Hospital, Taree, New South Wales, Australia University of Newcastle, Callaghan, New South Wales, Australia; University of New England, Armidale, New South Wales, Australia
| | - Shahzad Shaefi
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Iván J Núñez-Gil
- Interventional Cardiology, Cardiovascular Institute, Hospital Clinico Universitario San Carlos, Madrid, Spain; Cardiovascular Unit, Centro Medico Paris, Pozuelo, Madrid, Spain
| | - Harish Ramakrishna
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, AZ.
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19
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Perioperative Assessment and Intraoperative Core Concepts in the Complex Kidney Patient. CURRENT TRANSPLANTATION REPORTS 2018. [DOI: 10.1007/s40472-018-0204-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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20
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Wang Y, Zhu S, Gao P, Zhang Q. Comparison of coronary artery bypass grafting and drug-eluting stents in patients with chronic kidney disease and multivessel disease: A meta-analysis. Eur J Intern Med 2017; 43:28-35. [PMID: 28400078 DOI: 10.1016/j.ejim.2017.04.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2016] [Revised: 03/30/2017] [Accepted: 04/05/2017] [Indexed: 12/01/2022]
Abstract
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.
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Affiliation(s)
- Yushu Wang
- Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu 610041, Sichuan, China
| | - Sui Zhu
- Department of Epidemiology and Biostatistics, School of Public Health, Sichuan University, Chengdu, Sichuan, China
| | - Peijuan Gao
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Qing Zhang
- Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu 610041, Sichuan, China.
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21
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Volodarskiy A, Kumar S, Amin S, Bangalore S. Optimal Treatment Strategies in Patients with Chronic Kidney Disease and Coronary Artery Disease. Am J Med 2016; 129:1288-1298. [PMID: 27476086 DOI: 10.1016/j.amjmed.2016.06.046] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 06/24/2016] [Accepted: 06/25/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND Chronic kidney disease is an independent risk factor for coronary artery disease and is associated with an increase in adverse outcomes. However, the optimal treatment strategies for patients with chronic kidney disease and coronary artery disease are yet to be defined. METHODS MEDLINE, EMBASE, and CENTRAL were searched for studies including at least 100 patients with chronic kidney disease (defined as estimated glomerular filtration rate ≤60 mL/min/1.73 m2 or on dialysis) and coronary artery disease treated with medical therapy, percutaneous coronary intervention, or coronary artery bypass surgery and followed for at least 1 month and reporting outcomes. The outcome evaluated was all-cause mortality. Meta-analysis was performed to evaluate the outcomes with revascularization (percutaneous coronary intervention or coronary artery bypass surgery) when compared with medical therapy alone. In addition, outcomes with percutaneous coronary intervention vs coronary artery bypass surgery were evaluated. RESULTS The search yielded 38 nonrandomized studies that enrolled 85,731 patients. Revascularization (percutaneous coronary intervention or coronary artery bypass surgery) was associated with lower long-term mortality (mean 4.0 years) when compared with medical therapy alone (relative risk [RR] 0.73; 95% confidence interval [CI], 0.62-0.87), driven by lower mortality with percutaneous coronary intervention vs medical therapy and coronary artery bypass surgery vs medical therapy. Coronary artery bypass surgery was associated with a higher upfront risk of death (RR 1.81; 95% CI, 1.47-2.24) but a lower long-term risk of death (RR 0.94; 95% CI, 0.89-0.98) when compared with percutaneous coronary intervention. CONCLUSIONS In chronic kidney disease patients with coronary artery disease, the current data from nonrandomized studies indicate lower mortality with revascularization, via either coronary artery bypass surgery or percutaneous coronary intervention, when compared with medical therapy. These associations should be tested in future randomized trials.
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22
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Möckel M, Searle J, Baberg HT, Dirschedl P, Levenson B, Malzahn J, Mansky T, Günster C, Jeschke E. Revascularisation of patients with end-stage renal disease on chronic haemodialysis: bypass surgery versus PCI-analysis of routine statutory health insurance data. Open Heart 2016; 3:e000464. [PMID: 27752331 PMCID: PMC5051505 DOI: 10.1136/openhrt-2016-000464] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 07/28/2016] [Accepted: 08/08/2016] [Indexed: 11/23/2022] Open
Abstract
Objectives We aimed to analyse the short-term and long-term outcome of patients with end-stage renal disease (ESRD) undergoing percutaneous intervention (PCI) as compared to coronary artery bypass surgery (CABG) to evaluate the optimal coronary revascularisation strategy. Design Retrospective analysis of routine statutory health insurance data between 2010 and 2012. Main outcome measures Primary outcome was adjusted all-cause mortality after 30 days and major adverse cardiovascular and cerebrovascular events at 1 year. Secondary outcomes were repeat revascularisation at 30 days and 1 year and bleeding events within 7 days. Results The total number of cases was n=4123 (PCI; n=3417), median age was 71 (IQR 62–77), 30.4% were women. The adjusted OR for death within 30 days was 0.59 (95% CI 0.43 to 0.81) for patients undergoing PCI versus CABG. At 1 year, the adjusted OR for major adverse cardiac and cerebrovascular events (MACCE) was 1.58 (1.32 to 1.89) for PCI versus CABG and 1.47 (1.23 to 1.75) for all-cause death. In the subgroup of patients with acute myocardial infarction (AMI), adjusted all-cause mortality at 30 days did not differ significantly between both groups (OR 0.75 (0.47 to 1.20)), whereas in patients without AMI the OR for 30-day mortality was 0.44 (0.28 to 0.68) for PCI versus CABG. At 1 year, the adjusted OR for MACCE in patients with AMI was 1.40 (1.06 to 1.85) for PCI versus CABG and 1.47 (1.08 to 1.99) for mortality. Conclusions In this cohort of unselected patients with ESRD undergoing revascularisation, the 1-year outcome was better for CABG in patients with and without AMI. The 30-day mortality was higher in non-AMI patients with CABG reflecting an early hazard with surgery. In cases where the patient's characteristics and risk profile make it difficult to decide on a revascularisation strategy, CABG could be the preferred option.
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Affiliation(s)
- Martin Möckel
- Division of Emergency Medicine and Chest Pain Units, Department of Cardiology , Campus Virchow Klinikum and Campus Charité Mitte, Charité-Universitätsmedizin Berlin , Berlin , Germany
| | - Julia Searle
- Division of Emergency Medicine and Chest Pain Units, Department of Cardiology , Campus Virchow Klinikum and Campus Charité Mitte, Charité-Universitätsmedizin Berlin , Berlin , Germany
| | - Henning Thomas Baberg
- Department of Cardiology and Nephrology , Helios Klinikum, Berlin-Buch , Berlin , Germany
| | - Peter Dirschedl
- Medical Service of the Health Funds (MDK) Baden-Württemberg , Lahr , Germany
| | - Benny Levenson
- German Society of Cardiologists in Private Practise (BNK-Bundesverband niedergelassener Kardiologen) , München , Germany
| | - Jürgen Malzahn
- Federal Association of the Local Health Care Funds (AOK) , Berlin , Germany
| | - Thomas Mansky
- Faculty of Economics and Management, Division of Structural Development and Quality Management in Healthcare , Technische Universität Berlin , Berlin , Germany
| | - Christian Günster
- Research Institute of the Local Health Care Funds (WIdO) , Berlin , Germany
| | - Elke Jeschke
- Research Institute of the Local Health Care Funds (WIdO) , Berlin , Germany
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Lee MS, Lee AC, Shlofmitz RA, Martinsen BJ, Hargus NJ, Elder MD, Généreux P, Chambers JW. ORBIT II sub-analysis: Impact of impaired renal function following treatment of severely calcified coronary lesions with the Orbital Atherectomy System. Catheter Cardiovasc Interv 2016; 89:841-848. [DOI: 10.1002/ccd.26778] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2016] [Revised: 05/17/2016] [Accepted: 08/10/2016] [Indexed: 11/09/2022]
Affiliation(s)
| | - Arthur C. Lee
- The Cardiac and Vascular Institute; Gainesville Florida
| | | | | | | | - Mahir D. Elder
- Detroit Medical Center - Heart Hospital Detroit; Michigan
| | - Philippe Généreux
- New York-Presbyterian Hospital and Columbia University Medical & Cardiovascular Research Foundation; New York New York
| | - Jeffrey W. Chambers
- Metropolitan Heart and Vascular Institute, Mercy Hospital; Minneapolis Minnesota
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Bundhun PK, Bhurtu A, Chen MH. 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. Medicine (Baltimore) 2016; 95:e4129. [PMID: 27399124 PMCID: PMC5058853 DOI: 10.1097/md.0000000000004129] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
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.
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Affiliation(s)
| | | | - Meng-Hua Chen
- Institute of Cardiovascular Diseases, the First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, P.R. China
- Correspondence: Meng-Hua Chen, Institute of Cardiovascular Diseases, the First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi 530027, P.R. China (e-mail: )
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Krishnaswami A, Goh AC, Go AS, Lundstrom RJ, Zaroff J, Jang JJ, Allen E. Effectiveness of Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting in Patients With End-Stage Renal Disease. Am J Cardiol 2016; 117:1596-1603. [PMID: 27013385 DOI: 10.1016/j.amjcard.2016.02.035] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2015] [Revised: 02/19/2016] [Accepted: 02/19/2016] [Indexed: 01/24/2023]
Abstract
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.
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Ferguson TB, Buch AN. Improving quality and outcomes of coronary artery bypass grafting procedures. Expert Rev Cardiovasc Ther 2016; 14:617-31. [PMID: 26818448 DOI: 10.1586/14779072.2016.1147347] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
The evolution in the approach, clinical care and outcomes of ischemic heart disease, has been dramatic over the past decade. Optimizing medical therapy initially and throughout the care delivery process has been transformative. The addition of new physiologic data to the traditional anatomic framework for diagnosis and therapy of more extensive stable ischemic heart disease (SIHD) enables quality and outcomes improvements in this patient population overall and in the patient subsets of acute coronary syndrome and SIHD. In patients undergoing coronary artery bypass grafting (CABG), these developments have changed the objective goal of surgical revascularization over this time interval. This review discusses the opportunities for quality and outcomes improvement in CABG, in the context of SIHD overall.
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Affiliation(s)
- T Bruce Ferguson
- a Department of Cardiovascular Sciences , East Carolina Heart Institute, East Carolina Diabetes and Obesity Institute, The Brody School of Medicine at ECU , Greenville , NC , USA
| | - Ashesh N Buch
- b Department of CV Sciences , East Carolina Heart Institute, The Brody School of Medicine at ECU , Greenville , NC , USA
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Bangalore S, Guo Y, Samadashvili Z, Blecker S, Xu J, Hannan EL. Revascularization in Patients With Multivessel Coronary Artery Disease and Chronic Kidney Disease: Everolimus-Eluting Stents Versus Coronary Artery Bypass Graft Surgery. J Am Coll Cardiol 2015; 66:1209-1220. [PMID: 26361150 DOI: 10.1016/j.jacc.2015.06.1334] [Citation(s) in RCA: 101] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Revised: 06/26/2015] [Accepted: 06/30/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND Randomized trials of percutaneous coronary intervention (PCI) versus coronary artery bypass graft (CABG) routinely exclude patients with chronic kidney disease (CKD). OBJECTIVES This study evaluated outcomes of PCI versus CABG in patients with CKD. METHODS Patients with CKD who underwent PCI using everolimus-eluting stents were propensity-score matched to patients who underwent isolated CABG for multivessel coronary disease in New York. The primary outcome was all-cause mortality. Secondary outcomes were myocardial infarction (MI), stroke, and repeat revascularization. RESULTS Of 11,305 patients with CKD, 5,920 patients were propensity-score matched. In the short term, PCI was associated with a lower risk of death (hazard ratio [HR]: 0.55; 95% confidence interval [CI]: 0.35 to 0.87), stroke (HR: 0.22; 95% CI: 0.12 to 0.42), and repeat revascularization (HR: 0.48; 95% CI: 0.23 to 0.98) compared with CABG. In the longer term, PCI was associated with a similar risk of death (HR: 1.07; 95% CI: 0.92 to 1.24), higher risk of MI (HR: 1.76; 95% CI: 1.40 to 2.23), a lower risk of stroke (HR: 0.56; 95% CI: 0.41 to 0.76), and a higher risk of repeat revascularization (HR: 2.42; 95% CI: 2.05 to 2.85). In the subgroup with complete revascularization with PCI, the increased risk of MI was no longer statistically significant (HR: 1.18; 95% CI: 0.67 to 2.09). In the 243 matched pairs of patients with end-stage renal disease on hemodialysis, PCI was associated with significantly higher risk of death (HR: 2.02; 95% CI: 1.40 to 2.93) and repeat revascularization (HR: 2.44; 95% CI: 1.50 to 3.96) compared with CABG. CONCLUSIONS In patients with CKD, CABG is associated with higher short-term risk of death, stroke, and repeat revascularization, whereas PCI with everolimus-eluting stents is associated with a higher long-term risk of repeat revascularization and perhaps MI, with no long-term mortality difference. In the subgroup on dialysis, the results favored CABG over PCI.
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Affiliation(s)
| | - Yu Guo
- New York University School of Medicine, New York, New York
| | - Zaza Samadashvili
- School of Public Health, State University of New York at Albany, Albany, New York
| | - Saul Blecker
- New York University School of Medicine, New York, New York
| | - Jinfeng Xu
- New York University School of Medicine, New York, New York
| | - Edward L Hannan
- School of Public Health, State University of New York at Albany, Albany, New York
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Agrawal H, Aggarwal K, Littrell R, Velagapudi P, Turagam MK, Mittal M, Alpert MA. Pharmacological and non pharmacological strategies in the management of coronary artery disease and chronic kidney disease. Curr Cardiol Rev 2015; 11:261-9. [PMID: 25981315 PMCID: PMC4558358 DOI: 10.2174/1573403x1103150514155757] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Revised: 12/18/2014] [Accepted: 01/08/2015] [Indexed: 02/06/2023] Open
Abstract
Patients with advanced chronic kidney disease (CKD), including those treated with dialysis, are at high risk for the development of cardiovascular disease (CVD). CVD accounts for 45-50% of deaths among dialysis patients. Therapy of acute and chronic coronary heart disease (CHD) that is effective in the general population is frequently less effective in patients with advanced CKD. Drug therapy in such patients may require dose modification in some cases. Oral anti-platelet drugs are less effective in those with advanced CKD than in persons with normal or near normal renal function. The intravenous antiplatelet drugs eptifibatide and tirofiban both require dose reductions in patients with advanced CKD. Enoxaparin requires dose reduction in early stage CKD and is contraindicated in hemodialysis patients. Unfractionated heparin and warfarin maybe used without dose adjustment in CKD patients. Atenolol, acetbutolol and nadolol may require dose adjustments in CKD. Metoprolol and carvedilol do not. Calcium channel blockers and nitrates do not require dose adjustment, whereas ranolazine does. Angiotensin converting enzyme inhibitors and angiotensin receptor blockers may safely be used in CKD patients with close observation for hyperkalemia. The safety of spironolactone in such patients is questionable. Statins are less effective in reducing cardiovascular complication in CKD patients and their initiation is not recommended in dialysis patients. Coronary artery bypass grafting is associated with higher short-term mortality, but better long-term morbidity and mortality than percutaneous coronary interventions in patients with advanced CKD with non-ST segment ACS and chronic CHD.
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Affiliation(s)
| | | | | | | | - Mohit K Turagam
- Rm CE-306, University of Missouri Health Sciences Center, 5 Hospital Drive, Columbia, MO, USA 65212.
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Cohn WE, Frazier OH, Mallidi HR, Cooley DA. Surgical Treatment of Coronary Artery Disease. Coron Artery Dis 2015. [DOI: 10.1007/978-1-4471-2828-1_25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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30
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Komiya T, Ueno G, Kadota K, Mitsudo K, Okabayashi H, Nishiwaki N, Hanyu M, Kimura T, Tanaka S, Marui A, Sakata R. An optimal strategy for coronary revascularization in patients with severe renal dysfunction. Eur J Cardiothorac Surg 2014; 48:293-300. [DOI: 10.1093/ejcts/ezu426] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Accepted: 10/06/2014] [Indexed: 11/12/2022] Open
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Percutaneous coronary intervention versus coronary artery bypass grafting in patients with end-stage renal disease requiring dialysis (5-year outcomes of the CREDO-Kyoto PCI/CABG Registry Cohort-2). Am J Cardiol 2014; 114:555-61. [PMID: 24996550 DOI: 10.1016/j.amjcard.2014.05.034] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Revised: 05/13/2014] [Accepted: 05/13/2014] [Indexed: 11/23/2022]
Abstract
Ischemic heart disease is a major risk factor for morbidity and mortality in patients with end-stage renal disease. However, long-term benefits of percutaneous coronary intervention (PCI) relative to coronary artery bypass grafting (CABG) in those patients is still unclear in the drug-eluting stent era. We identified 388 patients with multivessel and/or left main disease with end-stage renal disease requiring dialysis among 15,939 patients undergoing first coronary revascularization enrolled in the Coronary REvascularization Demonstrating Outcome Study in Kyoto PCI/CABG Registry Cohort-2 (PCI: 258 patients and CABG: 130 patients). The CABG group included more patients with 3-vessel (38% vs 57%, p <0.001) and left main disease (10% vs 34%, p <0.001). Preprocedural Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery score in the CABG group was significantly higher than that in the PCI group (23.5 ± 8.7 vs 29.4 ± 11.0, p <0.001). Unadjusted 30-day mortality was 2.7% for PCI and 5.4% for CABG. Cumulative 5-year all-cause mortality was 52.3% for PCI and 49.9% for CABG. Propensity score-adjusted all-cause mortality was not different between PCI and CABG (hazard ratio [HR] 1.33, 95% confidence interval [CI] 0.85 to 2.09, p = 0.219). However, the excess risk of PCI relative to CABG for cardiac death was significant (HR 2.10, 95% CI 1.11 to 3.96, p = 0.02). The risk of sudden death was also higher after PCI (HR 4.83, 95% CI 1.01 to 23.08, p = 0.049). The risk of myocardial infarction after PCI tended to be higher than after CABG (HR 3.30, 95% CI 0.72 to 15.09, p = 0.12). The risk of any coronary revascularization after PCI was markedly higher after CABG (HR 3.78, 95% CI 1.91 to 7.50, p <0.001). Among the 201 patients who died during the follow-up, 94 patients (47%) died from noncardiac morbidities such as stroke, respiratory failure, and renal failure. In patients with multivessel and/or left main disease undergoing dialysis, 5-year outcomes revealed that CABG relative to PCI reduced the risk of cardiac death, sudden death, myocardial infarction, and any revascularization. However, the risk of all-cause death was not different between PCI and CABG.
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Ren X, Liu W, Peng Y, Li Q, Chai H, Zhao ZG, Meng QT, Chen C, Zhang C, Luo XL, Chen M, Huang DJ. Percutaneous coronary intervention compared with coronary artery bypass graft in coronary artery disease patients with chronic kidney disease: a systematic review and meta-analysis. Ren Fail 2014; 36:1177-86. [PMID: 24986458 DOI: 10.3109/0886022x.2014.934178] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Affiliation(s)
- Xin Ren
- Department of Cardiology, West China Hospital, Sichuan University , Chengdu , China
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Chou CL, Hsieh TC, Wang CH, Hung TH, Lai YH, Chen YY, Lin YL, Kuo CH, Wu YJ, Fang TC. Long-term Outcomes of Dialysis Patients After Coronary Revascularization: A Population-based Cohort Study in Taiwan. Arch Med Res 2014; 45:188-94. [DOI: 10.1016/j.arcmed.2014.01.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2013] [Accepted: 01/27/2014] [Indexed: 11/27/2022]
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34
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Effects of the side of arteriovenous fistula on outcomes after coronary artery bypass surgery in hemodialysis-dependent patients. J Thorac Cardiovasc Surg 2014; 147:619-24. [DOI: 10.1016/j.jtcvs.2013.01.031] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2012] [Revised: 12/11/2012] [Accepted: 01/14/2013] [Indexed: 11/17/2022]
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Sugumar H, Lancefield TF, Andrianopoulos N, Duffy SJ, Ajani AE, Freeman M, Buxton B, Brennan AL, Yan BP, Dinh DT, Smith JA, Charter K, Farouque O, Reid CM, Clark DJ. 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. Int J Cardiol 2014; 172:442-9. [PMID: 24521692 DOI: 10.1016/j.ijcard.2014.01.096] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Revised: 01/11/2014] [Accepted: 01/19/2014] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- Hariharan Sugumar
- Department of Cardiology, Austin Hospital, Melbourne, Victoria, Australia
| | | | - Nick Andrianopoulos
- Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Stephen J Duffy
- Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Cardiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Andrew E Ajani
- Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia; University of Melbourne, Melbourne, Victoria, Australia
| | - Melanie Freeman
- Department of Cardiology, Austin Hospital, Melbourne, Victoria, Australia
| | - Brian Buxton
- Department of Cardiac Surgery, Austin Hospital, Melbourne, Victoria, Australia; Department of Surgery, University of Melbourne, Melbourne, Victoria, Australia
| | - Angela L Brennan
- Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Bryan P Yan
- Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong; Department of Cardiology, Prince of Wales Hospital, Hong Kong, China
| | - Diem T Dinh
- Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Julian A Smith
- Department of Surgery, Monash University, Melbourne, Victoria, Australia; Department of Cardiothoracic Surgery, Monash Medical Centre, Melbourne, Victoria, Australia
| | - Kerrie Charter
- Department of Cardiology, Austin Hospital, Melbourne, Victoria, Australia
| | - Omar Farouque
- Department of Cardiology, Austin Hospital, Melbourne, Victoria, Australia; University of Melbourne, Melbourne, Victoria, Australia
| | - Christopher M Reid
- Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - David J Clark
- Department of Cardiology, Austin Hospital, Melbourne, Victoria, Australia; University of Melbourne, Melbourne, Victoria, Australia.
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Deo SV, Shah IK, Dunlay SM, Lim JY, Erwin PJ, Dillon JJ, Park SJ. Coronary Artery Bypass Grafting Versus Drug-Eluting Stents in Patients with End-Stage Renal Disease. J Card Surg 2014; 29:163-9. [DOI: 10.1111/jocs.12296] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Salil V. Deo
- Department of Cardiovascular Surgery; Adventist Wockhardt Heart Institute; Surat, Gujarat India
| | - Ishan K. Shah
- Department of Surgery; University of Minnesota; Minneapolis Minnesota
| | - Shannon M. Dunlay
- Division of Cardiovascular Diseases; Mayo Clinic; Rochester Minnesota
| | - Ju Yong Lim
- Division of Cardiovascular Surgery; Mayo Clinic; Rochester Minnesota
| | | | - John J. Dillon
- Division of Nephrology and Hypertension; Mayo Clinic; Rochester Minnesota
| | - Soon J. Park
- Division of Cardiovascular Surgery; University Hospitals; Case Western Reserve University; Cleveland Ohio
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Kumada Y, Ishii H, Aoyama T, Kamoi D, Kawamura Y, Sakakibara T, Nogaki H, Takahashi H, Murohara T. Long-Term Clinical Outcome After Surgical or Percutaneous Coronary Revascularization in Hemodialysis Patients. Circ J 2014; 78:986-92. [DOI: 10.1253/circj.cj-13-1357] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Yoshitaka Kumada
- Department of Cardiovascular Surgery, Matsunami General Hospital
- Cardiovascular Center, Nagoya Kyoritsu Hospital
| | - Hideki Ishii
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Toru Aoyama
- Cardiovascular Center, Nagoya Kyoritsu Hospital
| | | | | | | | - Haruhiko Nogaki
- Department of Cardiovascular Surgery, Matsunami General Hospital
| | | | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine
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Propensity-matched comparison of drug-eluting stent implantation and coronary artery bypass graft surgery in chronic hemodialysis patients. J Nephrol 2013; 27:87-93. [DOI: 10.1007/s40620-013-0023-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Accepted: 10/19/2013] [Indexed: 12/30/2022]
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Crouse SB, Kitko LA. Outcomes of coronary artery interventions: comparing coronary artery bypass surgery and percutaneous coronary intervention in patients with unprotected left main stenosis. J Am Assoc Nurse Pract 2013; 26:91-101. [PMID: 24170643 DOI: 10.1002/2327-6924.12078] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2012] [Accepted: 01/29/2013] [Indexed: 11/09/2022]
Abstract
PURPOSE The purpose of this integrative review is to examine the existing literature comparing short- and long-term outcomes of both coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) in patients with unprotected left main coronary artery (ULMCA) stenosis. CABG has long been considered the standard of treatment for ULMCA stenosis; however, advancements in the use of PCI have made it a viable alternative treatment option. DATA SOURCES Sixteen articles were selected from a literature search using the PubMed database, with at least 1 year of follow-up and adjustment for established risk factors. CONCLUSIONS The majority of studies found CABG and PCI with stenting to be comparable and equally safe treatment strategies for patients with ULMCA stenosis. Some studies found that PCI had a significantly lower risk for adverse events and mortality compared to CABG. However, a large number of studies found that PCI had a higher rate of target vessel restenosis. IMPLICATIONS FOR PRACTICE Advanced practice nurses have become a prominent and influential part of the healthcare delivery system. As such, advanced practice nurses should be educated on the current research about coronary artery interventions so that they may better screen, treat, and manage this patient population.
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Affiliation(s)
- Sarah B Crouse
- School of Nursing, Pennsylvania State University, University Park, Pennsylvania
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40
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Myocardial Revascularisation in Renal Dysfunction: A Systematic Review and Meta-Analysis. Heart Lung Circ 2013; 22:827-35. [DOI: 10.1016/j.hlc.2013.03.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2013] [Revised: 02/27/2013] [Accepted: 03/01/2013] [Indexed: 11/20/2022]
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Blicher TM, Hommel K, Olesen JB, Torp-Pedersen C, Madsen M, Kamper AL. Less use of standard guideline-based treatment of myocardial infarction in patients with chronic kidney disease: a Danish nation-wide cohort study. Eur Heart J 2013; 34:2916-23. [DOI: 10.1093/eurheartj/eht220] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Chen YY, Wang JF, Zhang YJ, Xie SL, Nie RQ. Optimal strategy of coronary revascularization in chronic kidney disease patients: a meta-analysis. Eur J Intern Med 2013; 24:354-61. [PMID: 23602222 DOI: 10.1016/j.ejim.2013.03.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2012] [Revised: 02/15/2013] [Accepted: 03/18/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND Patients with chronic kidney disease (CKD) have high risks of coronary artery disease (CAD). Coronary revascularization is beneficial for long-term survival, but the optimal strategy remains still controversial. METHODS We searched studies that have compared percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) for revascularization of the coronary arteries in CKD patients. Short-term (30 days or in-hospital) mortality, long-term (at least 12 months) all-cause mortality, cardiac mortality and the incidence of late myocardial infarction and recurrence of revascularization were estimated. RESULTS 28 studies with 38,740 patients were included. All were retrospective studies from 1977 to 2012. Meta-analysis showed that PCI group had lower short-term mortality (OR 0.55, 95% CI 0.41 to 0.73, P<0.01), but had higher long-term all-cause mortality (OR 1.29, 95% CI 1.23 to 1.35, P<0.01). Higher cardiac mortality (OR 1.08, 95% CI 1.01 to 1.15, P<0.05), higher incidence of late myocardial infarction (OR 1.78, 95% CI 1.65 to 1.91, P<0.01) and recurring revascularization rate (OR 2.94, 95%CI 2.15 to 4.01, P<0.01) is found amongst PCI treated patients compared to CABG group. CONCLUSIONS CKD patients with CAD received CABG had higher risk of short-term mortality but lower risks of long-term all-cause mortality, cardiac mortality and late myocardial infarction compared to PCI. This could be due to less probable repeated revascularization.
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Affiliation(s)
- Yu-Yang Chen
- Department of Cardiology, The Second Affiliated Hospital of Sun Yat-sen University, West Yanjiang Road 107, Guangzhou, Guangdong, 510120, China
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Coronary artery disease in dialysis patients: What is the optimal therapy? Tzu Chi Med J 2013. [DOI: 10.1016/j.tcmj.2013.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Shroff GR, Solid CA, Herzog CA. Long-term survival and repeat coronary revascularization in dialysis patients after surgical and percutaneous coronary revascularization with drug-eluting and bare metal stents in the United States. Circulation 2013; 127:1861-9. [PMID: 23572500 DOI: 10.1161/circulationaha.112.001264] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Few published data describe long-term survival of dialysis patients undergoing surgical versus percutaneous coronary revascularization in the era of drug-eluting stents (DES). METHODS AND RESULTS Using United States Renal Data System data, we identified 23 033 dialysis patients who underwent coronary revascularization (6178 coronary artery bypass grafting, 5011 bare metal stents, 11 844 DES) from 2004 to 2009. Revascularization procedures decreased from 4347 in 2004 to 3344 in 2009. DES use decreased by 41% and bare metal stent use increased by 85% from 2006 to 2007. Long-term survival was estimated by the Kaplan-Meier method, and independent predictors of mortality were examined in a comorbidity-adjusted Cox model. In-hospital mortality for coronary artery bypass grafting patients was 8.2%; all-cause survival at 1, 2, and 5 years was 70%, 57%, and 28%, respectively. In-hospital mortality for DES patients was 2.7%; 1-, 2-, and 5-year survival was 71%, 53%, and 24%, respectively. Independent predictors of mortality were similar in both cohorts: age >65 years, white race, dialysis duration, peritoneal dialysis, and congestive heart failure, but not diabetes mellitus. Survival was significantly higher for coronary artery bypass grafting patients who received internal mammary grafts (hazard ratio, 0.83; P<0.0001). The probability of repeat revascularization accounting for the competing risk of death was 18% with bare metal stents, 19% with DES, and 6% with coronary artery bypass grafting at 1 year. CONCLUSIONS Among dialysis patients undergoing coronary revascularization, in-hospital mortality was higher after coronary artery bypass grafting, but long-term survival was superior with internal mammary grafts. In-hospital mortality was lower for DES patients, but the probability of repeat revascularization was higher and comparable to that in patients receiving a bare metal stent. Revascularization decisions for dialysis patients should be individualized.
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Affiliation(s)
- Gautam R Shroff
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis, MN, USA
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Cardiovascular disease: Is CABG really better than PCI in dialysis patients? Nat Rev Nephrol 2013; 9:197-8. [PMID: 23478421 DOI: 10.1038/nrneph.2013.41] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Abstract
The burden of cardiovascular disease is high in patients with chronic kidney disease or end-stage renal disease. The presence of kidney dysfunction affects the cardiovascular system in multiple ways, including accelerated progression of atherosclerosis and valvular disease, the exacerbation of congestive heart failure, and the development of pericardial disease. This comorbidity results not only from the concordance of shared risk factors, but also from other issues specific to this population, such as systemic inflammation and vascular calcification. Furthermore, both the sensitivity and specificity of noninvasive testing modalities, and the efficacy of several pharmacotherapeutic strategies, are diminished in this population. The exclusion of patients with severe kidney disease from many clinical trials of cardiac interventions raises various therapeutic uncertainties, and kidney disease itself is likely to alter the underlying cardiovascular physiology. In this Review, we discuss aspects of the epidemiology, pathophysiology, and diagnosis of cardiovascular disease in patients with kidney disease, and propose specific, evidence-based recommendations for pharmacological and surgical treatment.
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Chang TI, Shilane D, Kazi DS, Montez-Rath ME, Hlatky MA, Winkelmayer WC. Multivessel coronary artery bypass grafting versus percutaneous coronary intervention in ESRD. J Am Soc Nephrol 2013. [PMID: 23204445 DOI: 10.1681/asn.2012060554] [Citation(s) in RCA: 106] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Thirty to sixty percent of patients with ESRD on dialysis have coronary heart disease, but the optimal strategy for coronary revascularization is unknown. We used data from the United States Renal Data System to define a cohort of 21,981 patients on maintenance dialysis who received initial coronary revascularization with either coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) between 1997 and 2009 and had at least 6 months of prior Medicare coverage as their primary payer. The primary outcome was death from any cause, and the secondary outcome was a composite of death or myocardial infarction. Overall survival rates were consistently poor during the study period, with unadjusted 5-year survival rates of 22%-25% irrespective of revascularization strategy. Using multivariable-adjusted proportional hazards regression, we found that CABG compared with PCI associated with significantly lower risks for both death (HR=0.87, 95% CI=0.84-0.90) and the composite of death or myocardial infarction (HR=0.88, 95% CI=0.86-0.91). Results were similar in analyses using a propensity score-matched cohort. In the absence of data from randomized trials, these results suggest that CABG may be preferred over PCI for multivessel coronary revascularization in appropriately selected patients on maintenance dialysis.
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Affiliation(s)
- Tara I Chang
- Division of Nephrology, Department of Medicine, Stanford University, 780 Welch Road Suite 106, Palo Alto, CA 94304, USA.
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Sezai A, Nakata KI, Hata M, Yoshitake I, Wakui S, Hata H, Shiono M. Long-Term Results of Dialysis Patients with Chronic Kidney Disease Undergoing Coronary Artery Bypass Grafting. Ann Thorac Cardiovasc Surg 2013; 19:441-8. [DOI: 10.5761/atcs.oa.12.02028] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Predictors for Early and Late Outcomes After Coronary Artery Bypass Grafting in Hemodialysis Patients. Ann Thorac Surg 2012; 94:1940-5. [DOI: 10.1016/j.athoracsur.2012.07.037] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2012] [Revised: 07/09/2012] [Accepted: 07/12/2012] [Indexed: 11/18/2022]
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Ariyamuthu VK, Balla S, Chaudhary K. Ischemic heart disease in patients undergoing dialysis. Hosp Pract (1995) 2012; 40:33-39. [PMID: 23299034 DOI: 10.3810/hp.2012.10.1001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Cardiovascular disease is the most common cause of death in patients with end-stage renal disease (ESRD) who are undergoing chronic dialysis. Diabetes and hypertension, the 2 leading causes of ESRD, contribute to the pathogenesis of ischemic heart disease (IHD) in these patients, as do other traditional risk factors (eg, dyslipidemias, smoking, and sedentary lifestyle). However, patients with ESRD are subject to several unique risk factors that contribute to the development and progression of IHD. Chronic volume overload and anemia, leading to left ventricular hypertrophy, and deranged calcium-phosphate metabolism with vascular and coronary calcification, contribute to the pathogenesis of IHD. Other risk factors that have been implicated include oxidative stress, homocysteine, and myocardial stunning while undergoing dialysis treatment. Additional risk factors include erythropoietin use for treating anemia, as well as use of calcium-based phosphate binders. The complex pathogenesis of IHD in such patients poses unique challenges to its management. Serological biomarkers and sophisticated imaging techniques are being developed to better delineate the pathological process and enhance disease detection. A combination of medical and surgical approaches is necessary to treat IHD. In this article, we discuss the pathogenesis and management of IHD.
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