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Comparative efficacy and safety of oral P2Y 12 inhibitors for patients with chronic kidney disease and acute coronary syndrome: a network meta-analysis. Hellenic J Cardiol 2021; 63:40-65. [PMID: 34274518 DOI: 10.1016/j.hjc.2021.06.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 06/13/2021] [Accepted: 06/29/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Currently, there is a paucity of data concerning the safety and effectiveness of P2Y12 inhibitors in the acute coronary syndrome (ACS) with chronic kidney disease (CKD) population. The aim of this study is to compare the different oral P2Y12 inhibitors in terms of efficacy and safety, focusing exclusively on patients with CKD who were treated for ACS. METHODS We systematically searched PubMed, CENTRAL, and Web of Science to identify studies that compared different oral P2Y12 inhibitors (clopidogrel, prasugrel, and ticagrelor) in patients with ACS with CKD. Efficacy outcomes included the major adverse cardiovascular events composite outcome and safety outcomes included major bleedings and major or minor bleedings combined. We performed a frequentist network meta-analysis. RESULTS Twelve studies were included in the systematic review, 7 CKD subgroup analyses of RCTs (8878 patients) and 5 observational studies (20175 patients). After the exclusion of studies with conservative management, prasugrel resulted in significant primary endpoint reduction versus clopidogrel (HR 0.80 and 95% CI 0.64 - 0.99), while ticagrelor did not (HR 0.88 and 95% CI 0.73 - 1.06). Major bleedings did not differ between the interventions. Ticagrelor resulted in more major or minor bleedings than clopidogrel (HR 1.21 and 95% CI 1.06 - 1.38), whereas prasugrel did not (HR 1.12 and 95% CI 0.84 - 1.49). CONCLUSION In patients with ACS with underlying CKD, who are intended to receive invasive management, there may be a significant reduction of the primary efficacy outcome with prasugrel as compared to clopidogrel but not with ticagrelor as compared to clopidogrel. There probably exists no difference among interventions in the major bleedings. Dedicated RCTs are needed to confirm these results.
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Koutroumpakis E, Gosmanova EO, Stahura H, Jou S, Alreshq R, Ata A, Sidhu MS, Philbin E, Boden WE, Lyubarova R. Attainment of Guideline-Directed Medical Treatment in Stable Ischemic Heart Disease Patients With and Without Chronic Kidney Disease. Cardiovasc Drugs Ther 2020; 33:443-451. [PMID: 31123935 DOI: 10.1007/s10557-019-06883-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Stable ischemic heart disease (SIHD) is prevalent in patients with chronic kidney disease (CKD); however, whether guideline-directed medical therapy (GDMT) is adequately implemented in patients with SIHD and CKD is unknown. HYPOTHESIS Use of GDMT and achievement of treatment targets would be higher in SIHD patients without CKD than in patients with CKD. METHODS This was a retrospective study of 563 consecutive patients with SIHD (mean age 67.8 years, 84% Caucasians, 40% females). CKD was defined as an estimated glomerular filtration rate (eGFR) of < 60 mL/min/1.73m2 using the four-variable MDRD Study equation. We examined the likelihood of achieving GDMT targets (prescription of high-intensity statins, antiplatelet agents, renin-angiotensin-aldosterone system inhibitors (RAASi), and low-density lipoprotein cholesterol levels < 70 mg/dL, blood pressure < 140/90 mmHg, and hemoglobin A1C < 7% if diabetes) in patients with (n = 166) and without CKD (n = 397). RESULTS Compared with the non-CKD group, CKD patients were significantly older (72 vs 66 years; p < 0.001), more commonly female (49 vs 36%; p = 0.002), had a higher prevalence of diabetes (46 vs 34%; p = 0.004), and left ventricular systolic ejection fraction (LVEF) < 40% (23 vs. 10%, p < 0.001). All GDMT goals were achieved in 26% and 24% of patients with and without CKD, respectively (p = 0.712). There were no between-group differences in achieving individual GDMT goals with the exception of RAASi (CKD vs non-CKD: adjusted risk ratio 0.73, 95% CI 0.62-0.87; p < 0.001). CONCLUSIONS Attainment of GDMT goals in SIHD patients with CKD was similar to patients without CKD, with the exception of lower rates of RAASi use in the CKD group.
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Affiliation(s)
- Efstratios Koutroumpakis
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Elvira O Gosmanova
- Division of Nephrology and Hypertension, Department of Medicine, Albany Medical College, Albany, NY, USA.,Nephrology Section, Stratton VA Medical Center, Albany, NY, USA
| | - Heather Stahura
- Division of Cardiology, Department of Medicine, Albany Medical College, 43 New Scotland Avenue, A2 wing, Albany, NY, 12208, USA
| | - Stephanie Jou
- Division of Cardiology, Department of Medicine, Albany Medical College, 43 New Scotland Avenue, A2 wing, Albany, NY, 12208, USA
| | - Rabah Alreshq
- Division of Cardiology, Department of Medicine, Albany Medical College, 43 New Scotland Avenue, A2 wing, Albany, NY, 12208, USA
| | - Ashar Ata
- Department of General Surgery, Albany Medical College, Albany, NY, USA
| | - Mandeep S Sidhu
- Division of Cardiology, Department of Medicine, Albany Medical College, 43 New Scotland Avenue, A2 wing, Albany, NY, 12208, USA
| | - Edward Philbin
- Division of Cardiology, Department of Medicine, Albany Medical College, 43 New Scotland Avenue, A2 wing, Albany, NY, 12208, USA
| | - William E Boden
- Massachusetts Veterans Epidemiology, Research, and Informatics Center (MAVERIC), VA New England Healthcare System, Boston, MA, USA.,Boston University School of Medicine, Boston, MA, USA
| | - Radmila Lyubarova
- Division of Cardiology, Department of Medicine, Albany Medical College, 43 New Scotland Avenue, A2 wing, Albany, NY, 12208, USA.
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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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Farkouh ME, Sidhu MS, Brooks MM, Vlachos H, Boden WE, Frye RL, Hartigan P, Siami F, Bittner VA, Chaitman BR, Mancini GJ, Fuster V. Impact of Chronic Kidney Disease on Outcomes of Myocardial Revascularization in Patients With Diabetes. J Am Coll Cardiol 2019; 73:400-411. [PMID: 30704571 DOI: 10.1016/j.jacc.2018.11.044] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 11/08/2018] [Accepted: 11/12/2018] [Indexed: 10/27/2022]
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