Short- and long-term outcome of percutaneous transluminal coronary angioplasty in chronic dialysis patients

The Impact of Pre-Procedural Renal Impairment on Outcomes Following Percutaneous Coronary Intervention: An Analysis of 45,287 Patients From the British Columbia Cardiac Registry

BACKGROUND

Renal disease confers a strong independent risk for morbidity and mortality after percutaneous coronary intervention (PCI). We evaluated the relationship between baseline pre-procedural renal function and outcomes following PCI.

METHODS

We examined 45,287 patients who underwent PCI in British Columbia. We evaluated all-cause mortality and target vessel revascularisation (TVR) at 2 years. Pre-procedural renal impairment was categorised by creatinine clearance (CrCl, mL/min): CrCl≥90 (n=14,876), 90>CrCl≥60 (n=10,219), 60>CrCl≥30 (n=14,876), 30>CrCl≥0 (n=2,594) and dialysis (n=579).

RESULTS

Declining CrCl values less than 60 mL/min were progressively associated with greater mortality: 60>eGFR≥30 (HR=2.01, 95% CI 1.71-2.37, p<0.001); 30>eGFR≥0 (HR=4.10, 95% CI 3.39-4.95, p<0.001); and dialysis (HR=6.22, 95% CI 5.07-7.63, p<0.001). A reduction in eGFR was not associated with TVR in non-dialysis patients. However, dialysis was a strong independent predictor for TVR (HR=1.69, 95% CI 1.37-2.08, p<0.001). This was confirmed in propensity-matched analyses where, dialysis was strongly associated with TVR (HR=1.53, 95% CI 1.24-1.89, p<0.001). This association was consistently seen in stratified analyses for diabetic versus non-diabetic patients; stent length >30 mm versus <30 mm; stent diameter >3 mm versus <3 mm; and receipt of bare metal stents versus drug-eluting stents.

CONCLUSIONS

This study indicates the association with declining renal function and mortality in patients undergoing PCI. Whilst renal disease was not associated with increased TVR in non-dialysis patients, dialysis-dependence was a strong independent predictor for increased TVR.

Continuous Ambulatory Peritoneal Dialysis and the Heart

Objective

To review clinical research pertaining to continuous ambulatory peritoneal dialysis (CAPD) and the heart.

Data Sources

A Medline computer search was employed to identify appropriate references from 1970 1994. Indexing terms were: continuous ambulatory peritoneal dialysis, hemodialysis, heart or cardiac, left ventricle, coronary artery disease, and survival. English and non-English language abstracts were scrutinized.

Study Selection

Forty-six studies were reviewed and utilized. Numerical data extracted are reported in this review as they were reported in the original article.

Results

This review provides a broad-based survey of studies pertaining to CAPD and the heart. Most of the studies relate to CAPD and left ventricular structure or function. Little information exists concerning CAPD and coronary artery disease, valvular disease, pericardial disease, and cardiac arrhythmias. Studies pertaining to patient survival on CAPD identify coronary artery disease and congestive heart failure as major risk factors, but in-depth quantification of these cardiovascular disorders is lacking in the literature.

Conclusions

CAPD is capable of decreasing left ventricular (LV) volume and improving LV systolic function in patients with L V enlargement and those with L V systolic dysfunction. The effect of CAPD on left ventricular hypertrophy (LVH) and LV diastolic function is variable. CAPD produces symptomatic improvement in patients with refractory congestive heart failure, but its effect on survival in such patients is uncertain. Atherogenic lipid abnormalities occur in CAPD patients. The clinical significance of these abnormalities is uncertain. Coronary artery bypass surgery can be performed safely and effectively on CAPD patients. CAPD is not arrhythmogenic. Survival of CAPD patients is similar to that of hemodialysis patients except in elderly diabetics for whom it is slightly lower.

Non-ST-Segment-Elevation Myocardial Infarction Among Patients With Chronic Kidney Disease: A Propensity Score-Matched Comparison of Percutaneous Coronary Intervention Versus Conservative Management

Background

Chronic kidney disease (CKD) remains an independent predictor of cardiovascular morbidity and mortality. CKD complicates referral for percutaneous coronary intervention (PCI) in non–ST‐segment–elevation myocardial infarction (NSTEMI) patients because of the risk for acute kidney injury and the need for dialysis, with American College of Cardiology/American Heart Association guidelines underscoring the limited data on these patients.

Methods and Results

Using the National Inpatient Sample to analyze hospitalizations in the United States from 2004 to 2014, we sought to assess PCI utilization and in‐hospital outcomes in NSTEMI admissions with CKD. NSTEMI admissions were identified by International Classification of Diseases, Ninth Edition, Clinical Modification (ICD‐9‐CM) code 410.7. CKD admissions were identified by ICD‐9‐CM code 585. Propensity score–matched cohorts of patients with NSTEMI were matched for age, sex, comorbidities, race, median household income, primary payer status, and hospital characteristics. Of 4 488 795 hospitalizations for NSTEMI, 31% underwent PCI. Overall, 89% of admissions had no CKD. In addition, 32% of NSTEMI admissions with no CKD and 23%, 14%, and 22% with CKD stages 3, 4, and 5 underwent PCI, respectively. Hospitalized NSTEMI patients with CKD stages 4 and 5 had 41% and 20% less likelihood, respectively, of undergoing PCI compared with those with no CKD. Among hospitalized NSTEMI patients with no CKD or CKD stage 3, 4, or 5, PCI‐treated groups had 63%, 57%, 39%, and 59% lower likelihood, respectively, of all‐cause, in‐hospital mortality compared with propensity score–matched medically managed groups.

Conclusions

PCI use decreased among hospitalized NSTEMI patients as CKD severity increased, and all‐cause, in‐hospital mortality was greater for NSTEMI patients admitted with more severe CKD regardless of treatment strategy.

Hemodynamic Support Devices for Complex Percutaneous Coronary Intervention

High-risk percutaneous coronary intervention (PCI) encompasses a growing portion of total PCIs performed and typically includes patients with high-risk clinical and anatomic characteristics. Such patients may represent not only a high-risk group for complications but also a group who may derive the most benefit from complete revascularization. Several hemodynamic support devices are available. Trial data, consensus documents, and guidelines currently recommend high-risk PCI aided by hemodynamic support devices, and this article discusses the patient populations who would benefit from such an approach, the available devices and strategies, and expected outcomes.

Association of chronic renal insufficiency with in-hospital outcomes after percutaneous coronary intervention

Background

The association of chronic renal insufficiency with outcomes after percutaneous coronary intervention (PCI) in the current era of drug-eluting stents and modern antithrombotic therapy has not been well characterized.

Methods and Results

We queried the 2007–2011 Nationwide Inpatient Sample databases to identify all patients aged ≥18 years who underwent PCI. Multivariable logistic regression was used to compare in-hospital outcomes among patients with chronic kidney disease (CKD), patients with end-stage renal disease (ESRD), and those without CKD or ESRD. Of 3 187 404 patients who underwent PCI, 89% had no CKD/ESRD; 8.6% had CKD; and 2.4% had ESRD. Compared to patients with no CKD/ESRD, patients with CKD and patients with ESRD had higher in-hospital mortality (1.4% versus 2.7% versus 4.4%, respectively; adjusted odds ratio for CKD 1.15, 95% CI 1.12 to 1.19, P<0.001; adjusted odds ratio for ESRD 2.29, 95% CI 2.19 to 2.40, P<0.001), higher incidence of postprocedure hemorrhage (3.5% versus 5.4% versus 6.0%, respectively; adjusted odds ratio for CKD 1.21, 95% CI 1.18 to 1.23, P<0.001; adjusted odds ratio for ESRD 1.27, 95% CI 1.23 to 1.32, P<0.001), longer average length of stay (2.9 days versus 5.0 days versus 6.4 days, respectively; P<0.001), and higher average total hospital charges ($60 526 versus $77 324 versus $97 102, respectively; P<0.001). Similar results were seen in subgroups of patients undergoing PCI for acute coronary syndrome or stable ischemic heart disease.

Conclusions

In patients undergoing PCI, chronic renal insufficiency is associated with higher in-hospital mortality, higher postprocedure hemorrhage, longer average length of stay, and higher average hospital charges.

Long-term clinical outcomes after sirolimus-eluting stent implantation in dialysis patients

There is little information about long-term (> 1 year) outcomes after sirolimus-eluting stent (SES) implantation in dialysis patients. Percutaneous coronary intervention (PCI) using SES was performed in 63 dialysis patients with 77 lesions. A control group for comparison was composed of 45 consecutive dialysis patients with 62 lesions who received PCI using bare metal stents (BMS). Clinical follow-up duration was 21.7 +/- 8.4 months in the SES group and 32.1 +/- 9.2 months in the BMS group (P < 0.01). There was no significant difference in the in-segment restenosis rate (30% versus 40%, P = 0.20) between the 2 groups. The 3-year mortality (22.5% versus 22.2%, P = 0.75), myocardial infarction (3.8% versus 4.9%, P = 0.93), target lesion revascularization (24.7% versus 31.0%, P = 0.61), and stent thrombosis rates (3.8% versus 2.4%, P = 0.73) were not significantly different between the SES and BMS groups. Compared to BMS, SES do not improve long-term clinical outcomes in dialysis patients.

Gender differences in adverse outcomes after contemporary percutaneous coronary intervention: an analysis from the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2) percutaneous coronary intervention registry

BACKGROUND

Prior studies have shown a relationship between female gender and adverse outcomes after percutaneous coronary interventions (PCIs). Whether this relationship still exists with contemporary PCI remains to be determined.

METHODS

We evaluated gender differences in clinical outcomes in a large registry of contemporary PCI. Data were prospectively collected from 22,725 consecutive PCIs in a multicenter regional consortium (Blue Cross Blue Shield of Michigan Cardiovascular Consortium) between January 2002 and December 2003. The primary end point was in-hospital all-cause mortality; other clinical outcomes evaluated included in-hospital death, vascular complications, transfusion, postprocedure myocardial infarction, stroke, and a combined major cardiovascular adverse event (MACE) end point including myocardial infarction, death, stroke, emergency coronary artery bypass grafting, and repeated PCI at the same site. Independent predictors of adverse outcomes were identified using multivariate logistic regression analysis.

RESULTS

Compared with men, women were older, had a higher prevalence of comorbidities, and had a significantly higher frequency of adverse outcomes after PCI. After adjustment for baseline demographics, comorbidities, clinical presentation, and lesion characteristics, female gender was associated with an increased risk of in-hospital death, vascular complication, blood transfusion, stroke, and MACE. The relationship between female gender and increased risk of death and MACE was no longer present after further adjustment for kidney function and low body surface area.

CONCLUSIONS

Differences in mortality rates between men and women no longer exist after PCI. However, our data suggest that technological advancements have not completely offset the relationship between gender and adverse outcomes after PCI.

Perioperative outcomes among patients with end-stage renal disease following coronary artery bypass surgery in the USA

BACKGROUND

Patients with end-stage renal disease (ESRD) requiring chronic haemodialysis who undergo coronary artery bypass graft surgery (CABG) are at significant risk for perioperative mortality. However, the impact of changes in ESRD patient volume and characteristics over time on operative outcomes is unclear.

METHODS

Using the Nationwide Inpatient Sample database (1988-03), we evaluated rates of CABG surgery with and without concurrent valve surgery among ESRD patients and outcomes including in-hospital mortality, and length of hospital stay. Multivariate regression models were used to account for patient characteristics and potential cofounders.

RESULTS

From 1988 to 2003, annual rates of CABG among ESRD patients doubled from 2.5 to 5 per 1000 patient-years. Concomitantly, patient case-mix changed to include patients with greater co-morbidities such as diabetes, hypertension and obesity (all P < 0.001). Nonetheless, among ESRD patients, in-hospital mortality rates declined nearly 6-fold from over 31% to 5.4% (versus 4.7% to 1.8% among non-ESRD), and the median length of in-hospital stay dropped in half from 25 to 13 days (versus 14 to 10 days among non-ESRD).

CONCLUSIONS

Since 1988, an increasing number of patients with ESRD have been receiving CABG in the USA. Despite increasing co-morbidities, operative mortality rates and length of in-hospital stay have declined substantially. Nonetheless, mortality rates remain almost 3-fold higher compared to non-ESRD patients indicating a need for ongoing improvement.

Review article: Coronary artery stenoses: detection and revascularization in renal disease

Cardiovascular events are markedly elevated in those with all degrees of renal impairment compared to the general population. There are well established guidelines in the general population for the management of coronary artery disease, however, similar guidelines have not been established in the renal population. This review examines the current published work on the detection of coronary artery stenoses in addition to summarizing the outcomes of revascularization in patients with kidney disease. Testing for coronary artery disease in the renal population most commonly occurs in dialysis patients as part of their assessment for renal transplantation. While a positive myocardial stress test for the detection of significant coronary artery stenoses is associated with an increased risk of cardiac events, there is no clear information currently showing that cardiovascular testing itself reduces the rate of adverse cardiac events after transplantation. Revascularization of coronary artery stenoses is associated with higher morbidity and mortality in all groups with kidney disease than in the general population, with the exception of renal transplant recipients where the mortality is likely to be similar to that of the general population. There appears to be a benefit in coronary artery bypass surgery compared to percutaneous intervention in those on dialysis and after renal transplant. Currently, there is little data to support coronary artery intervention prior to transplantation in those with asymptomatic coronary artery disease.

Impact of significant chronic kidney disease on long-term clinical outcomes after drug-eluting stent versus bare metal stent implantation

BACKGROUND

Higher rates of clinical and angiographic restenosis have been reported after coronary stenting in patients with significant chronic kidney disease (CKD). Whether drug-eluting stents (DES) can reduce long-term clinical events in CKD patients compared with bare metal stents (BMS) has not been established.

METHODS

The study enrolled 104 consecutive significant CKD patients (estimated creatinine clearance <60 ml/min) treated with DES for 142 de novo coronary lesions, comprising 76 patients treated with sirolimus-eluting stents (SES) for 106 lesions and 28 patients treated with paclitaxel-eluting stents (PES) for 36 lesions. Data from these patients were compared to those from a control group comprising 50 patients treated with BMS during the preceding 1 year.

RESULTS

There were no differences in terms of baseline clinical characteristics except that the patients of the DES group were older, had a higher ratio of insulin treatment for diabetes mellitus, and had a more frequent history of previous percutaneous coronary intervention. The patients in the DES group had more unfavorable lesion characteristics with smaller reference vessel diameter (2.8 mm versus 3.3 mm; P<0.001) and longer lesion length (28.8 mm versus 20.5 mm; P<0.001) than those in the BMS group. Compared to BMS, DES implantation had a lower 1-year major adverse cardiac events rate (cardiac death, non-fatal myocardial infarction or target vessel revascularization) (12% versus 26%; P=0.042). There were no significant differences between the SES and PES groups in terms of clinical outcomes.

CONCLUSIONS

DES implantation for de novo coronary lesions in significant CKD patients reduces 1-year clinical events compared with BMS implantation.

Coronary revascularization in end-stage renal disease

Advanced coronary artery disease and acute cardiac events are the most common causes of death in patients with end-stage renal disease. Because of their heightened risk, end-stage renal disease patients are frequently referred for coronary revascularization. However, these patients are almost always excluded from trials examining various innovations in medical and revascularization interventions for cardiovascular conditions. Extrapolation of trial conclusions regarding dialysis patients can be misleading because the risk-benefit ratios of various interventions in this patient population can be markedly different. Thus, clinical decisions regarding the need for (and type of) coronary revascularization are based on retrospective outcome analyses from various databases. This article reviews the data available in the literature on the morbidity, mortality, and outcomes of dialysis patients undergoing surgical or percutaneous revascularization, particularly with the addition of drug-eluting stents to the available therapeutic options.

The impact of renal function on the long-term clinical course of patients who underwent percutaneous coronary intervention

OBJECTIVES

To determine the impact of the level of kidney function on the extended (>5 years) long-term clinical course of patients undergoing percutaneous coronary intervention (PCI).

BACKGROUND

Chronic kidney disease (CKD) has been significantly associated with an increased in-hospital and 1-year mortality following PCI.

METHODS

In this single-centre retrospective study, glomerular filtration rate (GFR) at baseline was estimated in 371 patients not on dialysis, who underwent successful PCI between mid-1995 and mid-1999. Baseline demographic and angiographic characteristics, and long-term major adverse cardiac events and symptoms were compared for patients with GFR > or =60 ml/min/1.73 m(2) (normal or mildly impaired renal function) and GFR > or = 60 ml/ min/1.73 m(2) (CKD). The independent effect of GFR, modelled both as a categorical and a continuous variable, on long-term clinical outcomes was also investigated using multivariate Cox regression analysis.

RESULTS

Nine-year all-cause and cardiac mortality rates were significantly higher in the CKD group (45.9% vs. 10.6%, P < 0.0001 and 35.4% vs. 7.1%, P < 0.0001 respectively), while there was no difference in the repeat revascularization (P = 0.27) and nonfatal Q-wave myocardial infarction (P = 0.74) rates. Multivariate analysis demonstrated an independent impact of the level of GFR on long-term mortality; adjusted 9-year all-cause and cardiac mortality increased by approximately 16% and 11%, respectively for a decrease of GFR from 120 to 60 ml/min/1.73 m(2) and by approximately 14% and 9%, respectively for a decrease of GFR from 60 to 30 ml/min/1.73 m(2).

CONCLUSIONS

The level of renal function is a strong determinant of long-term all-cause and cardiac mortality after successful PCI.

Impact of Drug-Eluting Stents on Clinical and Angiographic Outcomes in Dialysis Patients

BACKGROUND

It remains unclear whether sirolimus-eluting stents (SES) have an advantage over bare metal stents (BMS) in patients on dialysis.

METHODS AND RESULTS

Percutaneous coronary intervention (PCI) using SES was performed in 54 dialysis patients with 69 lesions. A control group for comparison comprised 54 consecutive dialysis patients with 58 lesions who underwent PCI using BMS. Angiographic and clinical follow-ups were scheduled at 9 months. After the procedure, minimum lumen diameter (MLD) was similar between the 2 groups. At follow-up, the SES group had a higher MLD than the BMS group (1.98+/-0.83 mm vs 1.50+/-0.78 mm, p<0.01). In-stent restenosis rate was lower in lesions treated with SES than in those with BMS (22% vs 40%, p=0.048). However, there was no significant difference between the 2 groups for in-segment restenosis (31% vs 43%, p=0.3). During follow-up, there was no significant difference in the incidence of death, myocardial infarction or target lesion revascularization (TLR) (14% vs 21%, p=0.4) between the SES and BMS groups.

CONCLUSIONS

In this retrospective study, SES, in comparison with BMS, reduced in-stent restenosis in patients on dialysis. However, in-segment restenosis and TLR were not statistically different between lesions treated with SES and those with BMS.

Systemic immunosuppressive therapy inhibits in-stent restenosis in patients with renal allograft

BACKGROUND

Cyclosporine is used routinely for prophylaxis for renal allograft rejection. In experimental animal studies, cyclosporine had been shown to inhibit smooth muscle cell proliferation during the arterial response to injury. We investigated whether systemic immunosuppression may inhibit in-stent restenosis in renal transplant patients undergoing coronary stenting.

METHODS

From 1993 to 2003, 33 renal transplant patients with 45 coronary lesions and 37 dialysis patients with 52 lesions underwent coronary stenting using bare metal stents at our center. We followed all patients clinically for a mean period of 37 +/- 31 months and 40 patients angiographically at 14 +/- 15 months after coronary intervention. Cyclosporine was combined with corticosteroids in 32 patients and one patient received tacrolimus instead of cyclosporine.

RESULTS

The baseline clinical and angiographical characteristics were similar and the success rate of the procedure was 100% in both groups. In renal transplant group, the mean dose of cyclosporine was 192.5 +/- 68 mg/day and the blood cyclosporine level at the time of procedure was 152.9 +/- 51.5 ng/mL. The rate of in-stent restenosis was 7.1% in renal transplant group and 57.1% in dialysis group (P < 0.0001). The mean late loss was 0.47 +/- 0.57 mm in renal transplant group when compared with 1.51 +/- 1.09 mm in dialysis group (P = 0.004). The overall rate of major adverse cardiac events (MACEs) was 6.1% in renal transplant group and 35.1% in dialysis group (P < 0.0001).

CONCLUSIONS

Renal transplant patients receiving combined immunosuppressive agents showed markedly low rates of in-stent restenosis and MACE after coronary revascularization with stent. We consider that this result may be related to the ability of combined immunosuppressive therapy to inhibit inflammatory reaction and vascular smooth muscle cell proliferation induced by coronary stenting.

Early invasive treatment benefits patients with renal dysfunction in unstable coronary artery disease

BACKGROUND

Few studies have investigated the effects of an early revascularization in relation to renal function in patients with unstable coronary artery disease (CAD).

METHODS

Patients (n = 2457) with unstable CAD randomized to a noninvasive or invasive treatment strategy in the Fast Revascularisation during InStability in Coronary artery disease (FRISC-II) trial were stratified according to tertiles of creatinine clearance (CrCl < 69 mL/min, CrCl 69-90 mL/min, CrCl > 90 mL/min) and followed for 2 years regarding death and/or myocardial infarction (MI).

RESULTS

In the noninvasive cohort, the rate of death or MI at 2 years was 22.4% at CrCl < 69 mL/min, 14.6% at CrCl 60-90 mL/min, and 11.6% at CrCl > 90 mL/min. In the invasive cohort, the rate of death or MI was reduced to 14.6% (P = .003) at CrCl < 69 mL/min and to 9.9% (P = .048) at CrCl 69 to 90 mL/min, but no significant reduction (11.2%) at CrCl > 90 mL/min. In a logistic regression analysis adjusting for other important covariables, CrCl < 69 mL/min remained independently associated with the risk of the combined end point in the noninvasively treated group (odds ratio, 1.96; 95% confidence interval, 1.12-3.42) but not in the invasively treated group (odds ratio, 1.09; 95% confidence interval, 0.56-2.14). When the interaction term for treatment strategy and CrCl group was included in the analysis, the interaction between treatment strategy and CrCl <90 mL/min was independently associated with the risk of future MI (P = .006).

CONCLUSION

In unstable CAD, an early invasive treatment strategy reduces the long-term risk of future death and MI in patients with mildly to moderately reduced CrCl.

Clinical Benefits of Drug-Eluting Stents

Drug-eluting stents have revolutionized interventional cardiology by incorporating drug and device therapy to reduce rates of restenosis. Early trials have addressed the safety and efficacy of drug-eluting stents. Recent studies have evaluated the use of drug-eluting stents in high-risk populations that were not initially randomized in the early trials. These stents have shown promising outcomes in diabetes, in-stent restenosis, and multivessel disease. The clinical benefits of these stents have been systematically quantified across multiple trials; however, there is a growing debate regarding restenosis and late-stent thrombosis after implantation. Given the expanding indications for drug-eluting stents, the American Heart Association identified it as one of the Top 10 Research Advances for 2005. The purpose of this article is to summarize the current debate surrounding late-stent thrombosis, examine the evidence from leading stent trials, and outline the clinical benefits of drug-eluting stents.

Metabolic syndrome is associated with severe coronary artery disease and poor cardiac outcome in end-stage renal disease patients with acute coronary syndrome

OBJECTIVE

People with either end-stage renal disease or metabolic syndrome (MS) are at increased risk for developing coronary artery disease. The impact of MS on coronary artery disease in end-stage renal disease patients, however, remained unclear. We therefore evaluated whether the presence of MS is associated with more coronary lesions and a worse cardiac outcome in end-stage renal disease patients with acute coronary syndrome.

METHODS

We retrospectively examined 76 consecutive end-stage renal disease patients who experienced acute coronary syndrome and underwent cardiac catheterization. Cardiovascular events were compared between the MS and non-MS group.

RESULTS

MS was found in 58 patients and coronary artery disease was found in 63 patients [52 with MS (accounting for 90% of the MS group); 11 without MS (61% of the non-MS); MS vs. non-MS, P=0.01]. Patients with MS had more multi-vessel coronary artery disease (P<0.001) than those without MS. Sixty-nine (MS, 51; non-MS, 18) patients survived the acute coronary syndrome. During the follow-up period (MS, 17.6+/-13.8; non-MS, 19.9+/-11.7 months), 12 patients with MS (24%) and none without MS died owing to cardiovascular events (MS vs. non-MS, P=0.028). Regarding major cardiac events, including cardiac death, repeat non-fatal myocardial infarction, and repeat revascularization, the non-MS group had a higher probability of event-free survival (P<0.0001).

CONCLUSIONS

In patients with end-stage renal disease complicated by acute coronary syndrome, MS is frequently seen and associated with a higher probability of coronary artery disease involving multiple coronary branches and a higher probability of cardiac death and major cardiac events. Therefore, detection of MS in such patients is useful for risk stratification.

Human gastroepiploic artery has greater chymase activity than the internal thoracic artery

OBJECTIVE

Recent reports have demonstrated that long-term patency of the gastroepiploic artery (GEA) in coronary artery bypass grafting (CABG) is less satisfactory compared with the internal thoracic artery (ITA). However, the reason has not been fully elucidated. Angiotensin II is known to play an important role in the development of intimal hyperplasia, we hypothesized that the GEA is different from the ITA with respect to angiotensin II-forming ability. Accordingly, we measured activities of angiotensin II-forming enzymes, angiotensin-converting enzyme (ACE) and chymase, in human GEA and ITA.

METHODS

Remnant of the GEAs and ITAs were obtained from 24 patients who underwent CABG in which both conduits were used simultaneously. Activities of ACE and chymase were measured by using the extract form the GEA or ITA. Sections of the GEA or ITA were immunohistochemically stained with anti-human chymase antibody.

RESULTS

The ACE activity of the GEA (0.28+/-0.16 mU/mg protein) was greater than that of the ITA (0.18+/-0.11, p < 0.001). The chymase activity of the GEA (11.11+/-7.15 mU/mg protein) was also greater than that in the ITA (7.13+/-4.89, p < 0.001). The density of chymase-positive cells in the GEA (3.8+/-4.2 cells/mm2) was greater than that in the ITA (1.1+/-1.2, p < 0.01).

CONCLUSION

Activities of both ACE and chymase were significantly greater in the GEA compared with the ITA. The GEA may be different from the ITA with respect to potential ability of angiotensin II-formation.

Percutaneous Coronary Intervention in Patients with End-Stage Renal Disease

Patients with end-stage renal disease (ESRD) represent a growing number of patients in the cardiac catheterization laboratories worldwide. This is a consequence of the growing absolute number of ESRD patients in developed countries, better noninvasive diagnostic tools, better catheterization facilities and last-but-not-least better education of referring physicians about the incidence and prognosis of coronary artery disease (CAD) for patients with ESRD. There is growing evidence of the positive impact of coronary revascularization on long-term outcome of these patients. ESRD patients have a high comorbidity and are therefore better candidates for the less invasive approach using percutaneous coronary intervention (PCI) rather than coronary artery bypass surgery (CABG). From the view of the interventional cardiologist, ESRD patients represent one of the most challenging patient cohort concerning technical challenges and potential risk of complication for the patient. Percutaneous coronary intervention (PCI) including debulking techniques and stent implantation is the current standard therapy for patients with symptomatic single-vessel disease (SVD) and the preferred therapy for most patients with focal, polyfocal or even diffuse multi-vessel disease (MVD). Coronary bypass surgery is reserved for a decreasing number of patients with mechanically untreatable coronary lesions and unprotected left main stem stenosis. The problem of restenosis and subsequent target lesion revascularization has been decreased to a minimum by the use of drug-eluting stents (DES), even though prospective randomized trials including ESRD patients are lacking. In case of acute coronary syndromes, the need for immediate coronary angiography and subsequent revascularization by means of PCI should be pointed out.

Impact of renal dysfunction on outcomes of coronary artery bypass surgery: results from the Society of Thoracic Surgeons National Adult Cardiac Database

BACKGROUND

Although patients with end-stage renal disease are known to be at high risk for mortality after coronary artery bypass graft (CABG) surgery, the impact of lesser degrees of renal impairment has not been well studied. The purpose of this study was to compare outcomes in patients undergoing CABG with a range from normal renal function to dependence on dialysis.

METHODS AND RESULTS

We reviewed 483,914 patients receiving isolated CABG from July 2000 to December 2003, using the Society of Thoracic Surgeons National Adult Cardiac Database. Glomerular filtration rate (GFR) was estimated for patients with the use of the Modification of Diet in Renal Disease study formula. Multivariable logistic regression was used to determine the association of GFR with operative mortality and morbidities (stroke, reoperation, deep sternal infection, ventilation >48 hours, postoperative stay >2 weeks) after adjustment for 27 other known clinical risk factors. Preoperative renal dysfunction (RD) was common among CABG patients, with 51% having mild RD (GFR 60 to 90 mL/min per 1.73 m2, excludes dialysis), 24% moderate RD (GFR 30 to 59 mL/min per 1.73 m2, excludes dialysis), 2% severe RD (GFR <30 mL/min per 1.73 m2, excludes dialysis), and 1.5% requiring dialysis. Operative mortality rose inversely with declining renal function, from 1.3% for those with normal renal function to 9.3% for patients with severe RD not on dialysis and 9.0% for those who were dialysis dependent. After adjustment for other covariates, preoperative GFR was one of the most powerful predictors of operative mortality and morbidities.

CONCLUSIONS

Preoperative RD is common in the CABG population and carries important prognostic importance. Assessment of preoperative renal function should be incorporated into clinical risk assessment and prediction models.

Association of Renal Insufficiency With In-Hospital Mortality Among Japanese Patients With Acute Myocardial Infarction Undergoing Percutaneous Coronary Interventions

It is not yet clear whether a difference in in-hospital morality between patients with and without renal insufficiency undergoing percutaneous coronary intervention (PCI) exists. Therefore, the aim of the present study was to investigate if such as association exists in Japan. Data from the Tokai Acute Myocardial Infarction Study II were used. This was a prospective study of all 3274 patients admitted with acute myocardial infarction (AMI) to the 15 participating hospitals from 2001 to 2003. We abstracted the baseline and procedural characteristics as well as in-hospital mortality from detailed chart reviews. Patients were stratified into 2 groups according to the estimated creatinine clearance on admission. The creatinine clearance values were available in 2116, 107 of whom had renal insufficiency. The patients with renal insufficiency were more likely to be older, female, not independent in their daily activities, have lower body mass index and higher heart rate values on admission, lower prevalences of hypercholesterolemia and peptic ulcers, greater prevalences of diabetes, angina, previous heart failure, previous renal failure, previous cerebrovascular disease, aortic aneurysm, worse clinical course such as bleeding, and a multivessel coronary disease. Vasopressors, an intra-aortic balloon pump, and mechanical ventilation were frequently used in the patients with renal insufficiency, while thrombolytics were used less frequently. The patients with renal insufficiency had a higher in-hospital mortality rate than those without. Multivariate analysis identified renal insufficiency as an independent predictor of in-hospital death. The results suggest that renal insufficiency is an independent predictor of in-hospital death among AMI patients undergoing PCI.

Impact of renal insufficiency on outcome after contemporary percutaneous coronary intervention

BACKGROUND

End-stage renal failure is associated with poor outcomes, including increased mortality, after percutaneous coronary intervention (PCI). The effect of milder degrees of renal insufficiency (RI) is less clear, especially with routine stenting and glycoprotein IIb/IIIa inhibitor therapy, which may be of particular benefit in patients with RI.

METHODS

Clinical, angiographic, procedural, and outcome variables of 7769 consecutive patients who underwent PCI between April 2000 and July 2004 were entered into a prospective database. Inhospital mortality and morbidity were calculated according to baseline creatinine clearance. Simple and multiple logistic regression analyses were performed to determine independent predictors of mortality.

RESULTS

Baseline creatinine clearance was available in 6840 patients. It was normal (> 80 mL/min) in 3474; 1670 had mild RI (61-80 mL/min), 1111 moderate RI (41-60 mL/min), and 585 severe RI (< or = 40 mL/min). Major adverse cardiac events (MACE) (death/myocardial infarction/revascularization) increased substantially with worsening renal function (2.4% vs 3.0% vs 4.8% vs 9.7%, P < .0001), as did mortality (0.3% vs 0.7% vs 1.5% vs 6.0%, P < .0001). Multiple logistic regression analysis identified moderate RI and severe RI as independent predictors of mortality (odds ratio [OR] 3.9, P < .001; OR 12.7, P < .0001, respectively) and morbidity (MACE) (OR 1.5, P < .05; OR 2.5, P < .0001, respectively). Mild RI trended to increase the risk of mortality but did not reach statistical significance as an independent predictor of inhospital death on multiple regression analysis (OR 2.1, P = .1) and did not increase the risk of MACE (OR 1.1, P = .6).

CONCLUSIONS

Despite routine stenting and glycoprotein IIb/IIIa inhibitor therapy, RI remains an independent predictor of increased morbidity, and particularly mortality, after PCI. However, the adverse effect of truly mild RI on outcome is limited.

Impact of moderate renal insufficiency on restenosis and adverse clinical events after paclitaxel-eluting and bare metal stent implantation: results from the TAXUS-IV Trial

BACKGROUND

Mortality and restenosis may be increased in patients with mild to moderate renal insufficiency (RI) after coronary stent implantation. Whether drug-eluting stents safely reduce restenosis and enhance event-free survival in these patients is unknown. We sought to evaluate the impact of baseline RI on clinical and angiographic outcomes in patients undergoing elective percutaneous coronary intervention using either bare metal or paclitaxel-eluting stents.

METHODS

In the TAXUS-IV trial, 1314 patients were randomized to either the polymer-based paclitaxel-eluting TAXUS stent or an identical-appearing bare metal stent. Outcomes were stratified on the basis of the presence of RI, defined as a baseline creatinine clearance < 60 cm3/min calculated by the Cockcroft-Gault formula.

RESULTS

Baseline RI was present in 223 (17.2%) patients, in whom the mean creatinine clearance was 49.6 +/- 8.5 cm3/min. Compared with bare metal stents, treatment with the TAXUS stent resulted in lower rates of 9-month angiographic restenosis rates in both patients with (2.1% vs 20.5%, P = .009) and without (9.2% vs 27.8%, P < .0001) baseline RI. Similarly, 1-year target lesion revascularization rates were reduced with the TAXUS stent in patients with (3.3% vs 12.2%, P = .01) and without (4.7% vs 15.8%, P < .0001) baseline RI. The occurrence of death, myocardial infarction, and stent thrombosis at 1 year were similar in both randomization groups, independent of renal function.

CONCLUSIONS

The polymer-based paclitaxel-eluting TAXUS stent safely reduces clinical and angiographic restenosis in patients with preserved as well as moderate impairment of baseline renal function.

Outcomes after percutaneous coronary interventions in patients with CKD: improved outcome in the stenting era

BACKGROUND

Percutaneous coronary intervention (PCI) with stenting reduces adverse events in the general population compared with balloon angioplasty. The benefit of stents in high-risk patients normally excluded from clinical trials has not been well studied. Outcomes after PCIs in patients with chronic kidney disease (CKD) before and after widespread use of stents were compared.

METHODS

All patients undergoing PCIs at our center within 2 periods selected for high and low stent use were included. Demographic, kidney and cardiac function, and PCI data were collected. Kaplan-Meier curves were constructed, and Cox proportional hazards analysis was used to assess the effect of high stent use on major adverse cardiac event, a composite of cardiac revascularization, myocardial infarction, or death 3 years after PCI.

RESULTS

A total of 1,879 patients (780 patients, low stent use; 1,099 patients, high stent use; 18% and 94.1% stent use, respectively) with a mean age of 63 years, 73% men, and 26% of patients with a glomerular filtration rate less than 60 mL/min were included. At baseline, there was a greater prevalence of severe CKD, cardiac risk factors, and cardiovascular disease in the high-stent-use cohort. Major adverse cardiac events were reduced in the contemporary cohort (hazard ratio, 0.61; 95% confidence interval, 0.52 to 0.72); this benefit extended across all stages of kidney function.

CONCLUSION

Patients with CKD undergoing PCI in the stenting era show improved outcomes. Additional studies are needed to determine optimal revascularization strategies in patients with CKD.

Long-Term Outcome After Coronary Angioplasty in Renal Transplant and Hemodialysis Patients

In order to determine how renal transplantation modifies in hospital and long-term outcome after coronary angioplasty, we compared dialysis and renal transplant patients with control patients without renal failure. Seventy-five consecutive dialysis patients (group D) and 37 renal transplant patients (group T) undergoing coronary angioplasty, were compared with two control groups (groups control D and control T, respectively) matched 1:1 with groups D and T for clinical and angiographic characteristics. The mean follow-up was 50 months. The rate of angiographic success was high and comparable in the four groups (P=0.7). Renal transplant patients were younger than dialysis non-transplant patients (P=0.004). The risk of 4-year cardiac death and nonfatal myocardial infarction was higher in dialysis compared to control dialysis patients (OR 2.6, 95% CI 1.35--5.01, P=0.004), in transplant patients compared to control transplant patients (OR 9.93, 95% CI 1.17--84.04, P=0.03), and there was a trend toward a higher risk in dialysis than in renal transplant patients (OR 1.6, 95% CI 0.8--3.19, P=0.08). The risk of 4-year mortality was higher in dialysis patients than in the other three groups (31% in group D versus 19% in group T, 13% in group control D, and 0% in group control T, P<0.001). After adjusting for age, diabetes, and multivessel disease, long-term mortality risk was similar in dialysis and renal transplant patients. On multivariate analysis, renal function (P=0.002), age (P=0.005), and tobacco consumption (P=0.005) were independently associated with 4-year cardiac death. In patients with end-stage renal disease who undergo coronary angioplasty, renal transplantation was not independently associated with a lower long-term mortality compared to dialysis treatment. Both dialysis and renal transplant patients show lower survival rates compared to matched control patients.

Outcome of Coronary Artery Bypass Operations in Patients With Renal Insufficiency With and Without Renal Transplantation

HYPOTHESIS

Renal insufficiency (RI) is associated with an increased risk of morbidity and mortality following coronary artery bypass graft (CABG) operations, particularly among patients who are dependent on dialysis.

DESIGN AND SETTING

A retrospective analysis of data collected at a tertiary care center.

PATIENTS

One hundred eighty-four consecutive patients with RI who underwent CABG surgery between 1992 and 2004. This group consisted of 152 patients with serum creatinine levels of > or = 1.7 mg/dL (group I) and 32 kidney transplant recipients (group II). Of the patients in group I, 90 were dialysis-free (subgroup IA) and 62 were dialysis-dependent (subgroup IB).

MAIN OUTCOME MEASURES

Demographics, perioperative data, and outcomes for each of the three groups were evaluated and compared.

RESULTS

Fifty-four percent of the patients were in New York Heart Association classes III and IV, 36% had unstable angina, and 21% had left main coronary disease. The mean ejection fraction was 38%. The median postoperative length of stay in the hospital was 10 days. Of the patients in group IB, 8% required reexploration for bleeding compared to 3% in groups IA and II (p < 0.05). Dialysis was needed postoperatively in five patients in group IA and two patients in group II (5.7%). The raw operative mortality rate was 7.6% and was higher in group IB (9.7%) compared to groups IA and II (6.7% and 6.2%, respectively; p < 0.05). The actuarial 5-year survival rate was higher in group II compared to group I (79% vs 59%, respectively; p < 0.05). The difference in survival rates was more apparent between groups II and IB (79% vs 57%, respectively; p < 0.005).

CONCLUSIONS

CABG is associated with an increased rate of perioperative complications and mortality in patients with RI. Dialysis dependence is a major risk factor for patients undergoing CABG surgery. However, with acceptable surgical results, dialysis patients should not be denied CABG surgery. A survival advantage is demonstrated among patients with previous kidney transplants compared to those patients who are dependent on dialysis.

Screening asymptomatic diabetic patients for coronary artery disease prior to renal transplantation

BACKGROUND

Coronary artery disease (CAD) is a significant contributor to excess mortality in renal transplant candidates with diabetes mellitus (DM). Prior studies relating to risk stratification for significant CAD in diabetics are confined to Caucasian type 1 DM patients.

METHODS

To assess the prevalence of clinically silent CAD and to identify variables that are associated with CAD, we retrospectively analyzed the cardiac catheterization data of 97 asymptomatic type 1 and 2 DM kidney and kidney-pancreas transplant candidates.

RESULTS

Thirty-three percent of type 1 and 48% of type 2 DM patients had significant stenosis (> or = 70%) in 1 or more coronary arteries. On multivariate logistic regression analysis, body mass index (BMI) >25 was significantly associated with CAD (relative risk = 4.8, P = 0.002). The age of the patient (7% increase in risk/year, P = 0.01; or relative risk = 3.0 if age >47 years, P = 0.032) and smoking history (2% increase in risk/pack-year of smoking, P = 0.10) were also associated with CAD. African American patients, who comprised 30% of the sample, had a 71% lower risk compared with Caucasian patients (P = 0.03). Factors that were not significantly associated with CAD included gender, type of diabetes, and whether dialyzed for >6 months prior to catheterization.

CONCLUSIONS

We conclude that a notable proportion (approximately one-third to one-half) of asymptomatic type 1 and type 2 diabetic renal transplant candidates have significant CAD. Additionally, young African American DM patients with no smoking history and a BMI </=25 are at reduced risk, and invasive tests may not be necessary in this group.

Treatment of acute coronary syndromes in patients who have chronic kidney disease

Patients with CKD and CAD have traditionally been a difficult population to diagnose and treat in the setting of ACS. In addition to having poorer outcomes post-ACS, data are lacking regarding best treatments available. Aggressive interventional and medical treatments in this group with already poor outcomes are not necessarily contraindicated and should always be considered. The appalling outcome for CKD patients post-ACS is improved by many therapies shown to benefit in the non-CKD patients. Data suggest that troponins are useful markers in CKD patients, that major bleeding is not increased with the use of GP IIb-IIIa antagonists, that thrombolytics have been used successfully in CKD patients, and that PCI electively and as a primary treatment for ACS is successful and probably more beneficial to treatment.

Impact of mild or moderate chronic kidney disease on the frequency of restenosis: results from the PRESTO trial

OBJECTIVES

The goal of this study was to determine if restenosis is increased in mild and moderate chronic kidney disease (CKD) patients after percutaneous coronary intervention (PCI).

BACKGROUND

Mortality is increased in CKD after PCI. Restenosis may contribute to increased late mortality.

METHODS

We analyzed 11,187 patients with a creatinine <1.8 mg/dl from the Prevention of REStenosis with Tranilast and its Outcomes (PRESTO) trial, grouped by estimated creatinine clearance (CrCl) (<60, 60 to 89, >89 ml/min). The Cox proportional hazards models investigated the association between CrCl group and death, myocardial infarction, and target vessel revascularization (TVR). Generalized estimating equation regression models determined the association between CrCl group and lesion-specific restenosis.

RESULTS

At 30 days, there was no difference in myocardial infarction, death, or TVR between the CrCl groups. At nine months, mortality was higher in the lowest CrCl group (2.2%, 1.2%, 0.8%; p < 0.001), which was no longer significant after adjusting for confounding variables. Myocardial infarction and TVR were not different between the groups. In patients undergoing protocol follow-up angiography, restenosis (>/=50%) was not increased with CKD (32%, 32%, 37%; p = 0.02).

CONCLUSIONS

Mortality nine months after PCI is mildly increased in mild or moderate CKD patients. However, restenosis is not and does not account for the increased mortality.

Coronary revascularization in patients with coronary artery disease and chronic kidney disease

There is a remarkable lack of randomized trial data on optimal management of coronary artery disease (CAD) in patients with chronic kidney disease (CKD). In fact, patients with CKD are often excluded from randomized trials that compare different treatment strategies for CAD. Because the most common cause of death in CKD patients is cardiovascular disease, it is crucial that studies are designed to determine the best therapy for CAD in this high-risk group. This article discusses the available data on coronary revascularization outcomes in CKD patients.

Long-term effects of quinapril with high affinity for tissue angiotensin-converting enzyme after coronary intervention in Japanese

BACKGROUND

Angiotensin-converting enzyme inhibitors have been shown experimentally to prevent restenosis after balloon injury. We previously reported that quinapril reduced the 6-month restenosis (percent diameter stenosis >or=50%) rate after percutaneous coronary intervention (PCI). However, it was not established whether this favorable outcome was maintained for longer periods.

METHODS

This study was a prospective, randomized, open, and non-placebo controlled trial. Patients with coronary artery disease were enrolled after successful coronary balloon angioplasty or stenting. Two hundred and fifty-three patients were randomly assigned to the quinapril (10-20 mg per day) or control groups. The major clinical end points included death, myocardial infarction, cerebrovascular accident, or revascularization (either coronary artery bypass grafting or repeat PCI). These were tabulated according to the intention-to-treat principle.

RESULTS

Long-term follow-up was available with a median of 4.8 (interquartile range 4.2-5.1) years after the procedure. The incidence of combined end points of mortality and morbidity (myocardial infarction and cerebrovascular accident) in the quinapril group was lower than that in the control group (6.1% vs 14.8%; relative risk [RR] 0.42, 95% CI 0.18-0.96, P =.033). The overall incidence of end-point events in patients with quinapril also occurred less frequently (29.8% vs 46.7%; RR 0.58, 95% CI 0.38-0.86, P =.007).

CONCLUSIONS

These clinical outcomes show that the benefit of quinapril in patients following PCI is maintained for 4 years.

Impact of renal insufficiency in patients undergoing primary angioplasty for acute myocardial infarction

BACKGROUND

The prognostic importance of renal insufficiency (RI) in patients undergoing primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) has not been well characterized.

METHODS AND RESULTS

PCI was performed in 2082 AMI patients without shock presenting within 12 hours of symptom onset in a prospective, multicenter randomized trial. RI was defined as a calculated (Cockroft-Gault) creatinine clearance (CrCl) < or =60 mL/min. RI at baseline was present in 18% of patients. Compared with patients without RI, patients with RI were older and were more likely to be female; to have hypertension, peripheral vascular disease, or cerebrovascular disease; and to present in heart failure. Mortality was markedly increased in patients with versus without baseline RI both at 30 days (7.5% versus 0.8%, P<0.0001) and at 1 year (12.7% versus 2.4%, P<0.0001). Mortality rates increased incrementally for every 10-mL/min decrease in baseline CrCl. By multivariate analysis, reduced baseline CrCl was a powerful independent predictor of 30-day mortality (hazard ratio, 5.77; P<0.0001) and remained associated with reduced survival at 1 year (hazard ratio, 1.98; P=0.08). Hemorrhagic complications and transfusion requirements were also increased more than 2-fold in patients with RI, as were severe restenosis (diameter stenosis > or =70%; 20.6% versus 11.8%, P=0.024) and infarct artery reocclusion (14.7% versus 7.3%, P=0.02).

CONCLUSIONS

Baseline RI in patients with AMI undergoing primary PCI is associated with a markedly increased risk of mortality, as well as bleeding and restenosis. Novel approaches are needed to improve the otherwise poor prognosis of patients with RI and AMI.