Renal dysfunction is the most important predictor of the extent and severity of coronary artery disease in patients with diabetes mellitus

Association of pre-ESRD care education with patient outcomes in a 10-year longitudinal study of patients with CKD stages 3-5 in Taiwan

There is little comprehensive education for people with end-stage renal disease (ESRD) progress. We investigated the differences in terms of outcomes between patients with CKD stages 3-5 who enrolled and did not enroll in the pre-ESRD care education in Taiwan. This retrospective cohort study was conducted using data from the National Health Insurance Research Database (NHIRD). All patients diagnosed with CKD stages 3-5 who received the pre-ESRD care education through the pay for performance (P4P) program were enrolled. Based on whether or not they participated in the program, they were categorized into P4P or non-P4P groups. All analyses were performed from January 2006 through December 2015. Study outcomes were risk of hemodialysis dependency, hospitalization, and all-cause mortality. In this study of 29,337 patients, those with CKD stages 3-5 in the P4P group had lower events of hemodialysis, hospitalization, and all-cause mortality compared to patients in the non-P4P group. This study suggested that pre-ESRD care education is associated with increased patient outcomes, resulting in lower hemodialysis and hospitalization events and a higher overall survival rate in patients with CKD stages 3-5. Patient education could raise opportunities to improve pre-ESRD care by reaching patients outside the traditional health care setting.

ST segment change and T wave amplitude ratio in lead aVR associated with coronary artery disease severity in patients with non-ST elevation myocardial infarction: A retrospective study

Non-ST elevation myocardial infarction (NSTEMI) severity is difficult only with electrocardiogram (ECG). In most cases, NSTEMI patients are followed with cardiac enzymes without early invasive intervention if no severe chest pain exists in the emergency department (ED) or coronary intensive care unit (CICU).Our aim was to evaluate association between CAD severity and ST segment change in lead aVR (STaVR)/T wave amplitude in lead aVR (TAaVR) ratio in patients with NSTEMI.We included 306 patients with NSTEMI in the ED between 2015 and 2016. STaVR and TAaVR values were measured from 12-derivation ECG underwent on admission to the ED. The absolute values of STaVR and TAaVR were calculated and the following were obtained; ratio 1:|STaVR|/|TAaVR|, ratio 2:|TAaVR|/|STaVR|, and ratio 3: by dividing the variable with larger absolute value to other variable with smaller absolute value (|larger value|/|smaller value|). The SYNTAX score (SS) was calculated from coronary angiography in all patients.In analysis of the bivariate correlation between SS and ratios; significantly positive, strongly with ratio 3 (r = 0.692, P < .001), and only ratio 3 was determined to be an independent predictor for SS in linear regression analysis (OR: 0.642, 95% CI: 0.432-0.853, P = .001).Severity of CAD may be estimated by evaluating STaVR and TAaVR ratio in patients with NSTEMI.

Kidney Function Does Not Modify the Favorable Quality of Life Changes Associated With Revascularization for Coronary Artery Disease: Cohort Study

Background

Although patients with kidney disease have potential to benefit from revascularization, they are also at higher risk of complications, which may affect quality of life.

Methods and Results

We studied a cohort of 8198 adults who underwent coronary angiography in Alberta, between 2004 and 2008, and completed health‐related quality‐of‐life (HR‐QOL) surveys. Changes in HR‐QOL measures were most favorable among patients who received coronary artery bypass graft (CABG), but did not significantly differ by kidney function within groups of patients who received CABG, percutaneous coronary intervention (PCI), or medical therapy (P value for interaction between estimated glomerular filtration rate [eGFR] and revascularization status >0.10 for all outcomes). Among those who received CABG, the adjusted mean EuroQol 5 dimensions (EQ‐5D) utility score for those with eGFR >90 mL/min per 1.73 m² increased by 0.11 (95% CI, 0.09–0.14) and for those with eGFR <30 mL/min per 1.73m² by 0.13 (95% CI, 0.05–0.21). The adjusted mean EQ‐5D utility score also increased similarly at all levels of eGFR for those who received PCI and for those who received medical management. Mean changes in Seattle Angina Questionnaire (SAQ) scores were also similar across all levels of eGFR within each treatment group for the quality of life, angina frequency, angina stability, physical limitations, and treatment satisfaction domains of the SAQ. Among those who received CABG, the adjusted mean SAQ quality of life score for those with eGFR >90 mL/min per 1.73m² increased by 22.1 (95% CI, 18.5–25.7) and for those with eGFR <30 mL/min per 1.73m² by 14.0 (95% CI, 2.31–25.63).

Conclusions

Changes in HR‐QOL do not vary by kidney function among patients selected for CABG, PCI, or medical management of coronary disease.

Increased detection of coronary atherosclerosis on 320-slice computed tomographic angiography with burden of cardiovascular risk factors and complications in patients with type 2 diabetes

AIMS

The cardiovascular risk factors and diabetic complications are related to coronary atherosclerosis. However, the evaluation of the prevalence of coronary atherosclerosis based on their accumulation remains to be determined.

METHODS

247 consecutive Chinese subjects with type 2 diabetes but without history of coronary heart disease (CHD) underwent 320-slice computed tomographic coronary angiography, including no coronary atherosclerosis, non-obstructive atherosclerosis (<50% stenosis) and obstructive atherosclerosis (≥50% stenosis). Conventional cardiovascular risk factors, albuminuria, renal dysfunction and diabetic retinopathy (DR) were determined. Framingham Risk Score (FRS) was used to assess the 10-year CHD risk.

RESULTS

Increase in burden of cardiovascular risk factors and diabetic complications were significantly associated with the likelihood of being a higher coronary atherosclerosis category. In the analysis for trend through the categories of burden score or FRS stratification, the percentage of obstructive atherosclerosis was increased and the percentage of no atherosclerosis decreased as the burden score and FRS increased (all p<0.005), respectively. The areas under the receiver operator curve for the burden score versus FRS were greater at predicting coronary atherosclerosis and obstructive atherosclerosis (p=0.004 and p=0.002), respectively.

CONCLUSIONS

The prevalence of coronary atherosclerosis was increased with the accumulation of cardiovascular risk factors and diabetic complications. The burden of these clinical and biochemical risk factors has increased ability for prediction of the presence and severity of coronary atherosclerosis over FRS in type 2 diabetic patients.

Correlation analysis between eGFRcys and SXscore in patients with diabetes

The aim of the present study was to explore the association between the cystatin C-based estimated glomerular filtration rate (eGFR_cys) and the SYNTAX score (SXscore) in patients with diabetes. To the best of our knowledge, this correlation has not been reported previously. The eGFR_cys and SXscore from 612 consecutive patients with diabetes were retrospectively included in this study. The patients were angiographically diagnosed with coronary artery disease (CAD) between July 2010 and March 2012 at the Department of Endocrinology. The SXscore was calculated using a previously described SXscore algorithm. Pearson correlations were used to analyze the correlation between eGFR_cys and SXscore. Patients with renal dysfunction were older, more often female and more likely to have a history of hypertension when compared with those with normal renal function. The eGFR_cys values were significantly lower and the cystatin C levels were significantly higher in the highest SXscore group than those in other groups (P<0.001). Correlation analysis indicated that eGFR_cys was negatively correlated with the SXscore (r=−0.7918, P<0.001). In addition, a significantly positive correlation was identified between levels of cystatin C and the SXscore (r=0.8891, P<0.001). In conclusion, eGFR_cys is an independent predictor of SXscore in patients with diabetes. The eGFR_cys-estimating method may be considered important in the assessment of the SXscore in patients with diabetes.

Decreased renal function is an independent predictor of severity of coronary artery disease: an application of Gensini score

Coronary artery disease (CAD) is the leading cause of death in patients with chronic kidney disease (CKD).Although many studies have shown a higher prevalence of CAD among these patients, the association between the spectrum of renal dysfunction and severity of CAD remains unclear. In this study, we investigate the association between renal function and the severity of CAD. We retrospectively reviewed the medical records of 1,192 patients who underwent elective coronary angiography (CAG). The severity of CAD was evaluated by Gensini score according to the degree of luminal narrowing and location(s) of obstruction in the involved main coronary artery. In all patients, the estimated glomerular filtration rate (eGFR) was independently associated with Gensini score (β=-0.27, P < 0.001) in addition to diabetes mellitus (β=0.07, P = 0.02), hypertension (β=0.12, P < 0.001), low density lipoprotein (LDL)-cholesterol (β=0.08, P = 0.003), and hemoglobin (β=-0.07, P = 0.03) after controlling for other confounding factors. The result of this study demonstrates that decreased renal function is associated not only with the prevalence, but also the severity, of CAD.

Relation between the GRACE score and severity of atherosclerosis in acute coronary syndrome

BACKGROUND

Patients with non-ST-elevation acute coronary syndrome are heterogeneous in terms of clinical presentation and immediate- and long-term risk of death or non-fatal ischemic events. The aim of the present study was to evaluate the relationship between the Global Registry of Acute Coronary Events (GRACE) score and severity of coronary artery disease angiographically evaluated by Gensini score in patients with non-ST-elevation acute coronary syndrome.

METHODS

A total of 245 patients with non-ST-elevation acute coronary syndrome were enrolled to the study. Based on the GRACE risk score classification system, the patients were divided into low- (n=97, 39.6%), intermediate- (n=84, 34.3%), and high- (n=64, 26.1%) risk groups. All patients underwent coronary angiography within five days after admission.

RESULTS

The Gensini scores were 26±29 in the low-risk group, 29±19 in the intermediate-risk group, and 38±23 in the high-risk group (p=0.016). The low-risk group was significantly different from the high-risk group (p=0.013), and the difference from the intermediate-risk group almost reached significance. Normal, noncritical, one and two, or multivessel disease were identified in 15 (6.1%), 31 (12.7%), 75 (30.6%), and 124 (50.6%) patients, respectively. The prevalence of multivessel disease was 28% in the low-risk group, 30% in the intermediate-risk group, and 42% in the high-risk group. The high-risk group was significantly different from the low-risk group (p<0.01).

CONCLUSION

Our study demonstrates that the GRACE score has significant value for assessing the severity and extent of coronary artery stenosis in patients with non-ST-elevation acute coronary syndrome.

Renal impairment and coronary collaterals in patients with acute coronary syndrome

OBJECTIVE

We aimed to elucidate the relationship between mild-to-moderate renal impairment and the development of coronary collateral vessels (CCV) in patients with acute coronary syndrome (ACS).

METHODS

We enrolled 461 patients with ACS who underwent coronary angiography for the first time. The development of CCV was assessed with the Rentrop score. Kidney function was classified according to the estimated glomerular filtration rate (eGFR). The Gensini score was used to show the extent of atherosclerosis.

RESULTS

The mean eGFR value was 89.9 ± 24.3 U/l for patients with no development of collaterals and 82.7 ± 20.5 for patients who had CCV. The mean age was 59 ± 11 years and 349 patients (75.7 %) were male. Rentrop classifications 1-2-3 (presence of CCV) were determined in 222 (48.1 %) patients. The presence of CCV was significantly associated with low levels of eGFR (p = 0.001), increased serum creatinine levels (p = 0.034), high levels of serum albumin (0.036), and the Gensini score (p < 0.001). Multivariate analysis showed that the Gensini score was an independent predictor of the presence of CCV (OR = 1.090, 95 % CI: 1.032-1.151, p = 0.002).

CONCLUSION

We suggest that the association between mild-to-moderate renal impairment and the presence of CCV may be explained by increased myocardial ischemia and severe CAD.

Glomerular filtration rate is associated with burden of coronary atherosclerosis in patients with acute coronary syndrome

We aimed to elucidate the relationship between mild to moderate renal impairements and burden of atherosclerosis in patients with acute coronary syndrome (ACS). A total of 380 patients with ACS were included in the study. Gensini and SYNTAX scores were also calculated. Kidney function was classified based on estimated glomerular filtration rate (eGFR) into stage 1: eGFR >90, stage 2: 60 to 89, and stage 3: 30 to 60 mL/min per 1.73 m(2). Gensini and SYNTAX scores were higher in stages 2 and 3 than in stage 1. Also, the number of diseased vessels, number of critical lesions (>50 and 70%), left main disease, and number of total occlusion vessels were higher in stages 2 and 3 than in stage 1. Multivariate linear regression analysis demonstrated that a decreased eGFR was an independent risk factor for SYNTAX and Gensini scores together with age and male gender.

The relationship between chronic kidney disease and SYNTAX score

Chronic kidney disease (CKD) is associated with increased risk of cardiovascular disease and death. We evaluated the association between CKD and severity of coronary artery stenosis by calculating SYNTAX Score in patients with left main coronary artery and/or 3-vessel coronary artery disease. Coronary angiograms of 217 patients were assessed. Chronic kidney disease was staged using the estimated glomerular filtration rate (eGFR, mL/min per 1.73 m(2)) prior to coronary angiography. Patients were divided into 5 groups according to the National Kidney Foundation Kidney Disease Outcome Quality Initiative (NKF KDOQI) Clinical Practice Guidelines (14). Patients with eGFR >90 mL/min per 1.73 m(2) (group 1), patients with eGFR 60 to 89 mL/min per 1.73 m(2) (group 2), patients with eGFR 30 to 59 mL/min per 1.73 m(2) (group 3), patients with eGFR >15 to < 30 per 1.73 m(2) and dialysis patients with eGFR < 15 per 1.73 m(2) were combined as group 4. The risk of significant lesion complexity increased progressively with decreasing kidney function (P = .001). Estimated glomerular filtration rate was a strong predictor of higher SYNTAX Score.

Renal function is related to severity of coronary artery calcification in elderly persons: the Rotterdam study

Background

Coronary artery calcification (CAC) has been proposed to be the underlying mechanism of the increased risk of coronary heart disease with reductions in glomerular filtration rate (GFR). Since renal function diminishes with aging we examined the association between GFR and CAC in the Rotterdam Study, a population-based study of elderly individuals.

Methods

The study was performed in 1703 subjects without a history of coronary heart disease. GFR was estimated using the modification of diet in renal disease equation. We used analysis of covariance to test for mean differences in CAC between GFR tertiles.

Results

The mean CAC scores in the middle and lowest GFR tertile did not significantly differ from the mean CAC score in the highest GFR tertile (geometric mean CAC score 4.1 and 4.3 vs 4.2). In a multivariable model the mean CAC score did also not differ between the GFR tertiles. As the interaction term between age and GFR was significant (P = 0.037), we divided the population in two age categories based on median age of 70 years. Below 70 years, the mean CAC scores did not differ between the GFR tertiles. Above median age, mean CAC score in the lowest GFR tertile was significantly higher than the mean CAC score in the highest tertile in a multivariable model (CAC 4.9 vs 4.5, p = 0.010).

Conclusion

In this population-based study we observed that the association between CAC and GFR is modified by age. In participants at least 70 years of age, a decrease in GFR was associated with increased CAC.

Association between albuminuria and duration of diabetes and myocardial dysfunction and peripheral arterial disease among patients with stable coronary artery disease in the BARI 2D study

OBJECTIVE

To evaluate the effect of prior duration of diabetes, glycated hemoglobin level at study entry, and microalbuminuria or macroalbuminuria on the extent and severity of coronary artery disease (CAD) and peripheral arterial disease.

PATIENTS AND METHODS

We studied baseline characteristics of the 2368 participants of the BARI 2D (Bypass Angioplasty Revascularization Investigation 2 Diabetes) study, a randomized clinical trial that evaluates treatment efficacy for patients with type 2 diabetes and angiographically documented stable CAD. Patients were enrolled from January 1, 2001, through March 31, 2005. Peripheral arterial disease was ascertained by an ankle-brachial index (ABI) of 0.9 or less, and extent of CAD was measured by presence of multivessel disease, a left ventricular ejection fraction (LVEF) of less than 50%, and myocardial jeopardy index.

RESULTS

Duration of diabetes of 20 or more years was associated with increased risk of ABI of 0.9 or less (odds ratio [OR], 1.54; 95% confidence interval [CI], 1.04-2.26), intermittent claudication (OR, 1.61; 95% CI, 1.10-2.35), and LVEF of less than 50% (OR, 2.03; 95% CI, 1.37-3.02). Microalbuminuria was associated with intermittent claudication (OR, 1.53; 95% CI, 1.16-2.02) and ABI of 0.9 or less (OR, 1.31; 95% CI, 0.98-1.75), whereas macroalbuminuria was associated with abnormal ABI, claudication, and LVEF of less than 50%. There was a significant association between diabetes duration and extent of CAD as manifested by number of coronary lesions, but no other significant associations were observed between duration of disease, glycated hemoglobin levels, or albumin-to-creatinine ratio and other manifestations of CAD.

CONCLUSION

Duration of diabetes and microalbuminuria or macroalbuminuria are important predictors of severity of peripheral arterial disease and left ventricular dysfunction in a cohort of patients selected for the presence of CAD.

Reduced glomerular filtration rate and its association with clinical outcome in older patients at risk of vascular events: secondary analysis

BACKGROUND

Reduced glomerular filtration rate (GFR) is associated with increased cardiovascular risk in young and middle aged individuals. Associations with cardiovascular disease and mortality in older people are less clearly established. We aimed to determine the predictive value of the GFR for mortality and morbidity using data from the 5,804 participants randomized in the Prospective Study of Pravastatin in the Elderly at Risk (PROSPER).

METHODS AND FINDINGS

Glomerular filtration rate was estimated (eGFR) using the Modification of Diet in Renal Disease equation and was categorized in the ranges ([20-40], [40-50], [50-60]) >or= 60 ml/min/1.73 m(2). Baseline risk factors were analysed by category of eGFR, with and without adjustment for other risk factors. The associations between baseline eGFR and morbidity and mortality outcomes, accrued after an average of 3.2 y, were investigated using Cox proportional hazard models adjusting for traditional risk factors. We tested for evidence of an interaction between the benefit of statin treatment and baseline eGFR status. Age, low-density lipoprotein (LDL) and high-density lipoprotein (HDL) cholesterol, C-reactive protein (CRP), body mass index, fasting glucose, female sex, histories of hypertension and vascular disease were associated with eGFR (p = 0.001 or less) after adjustment for other risk factors. Low eGFR was independently associated with risk of all cause mortality, vascular mortality, and other noncancer mortality and with fatal and nonfatal coronary and heart failure events (hazard ratios adjusted for CRP and other risk factors (95% confidence intervals [CIs]) for eGFR < 40 ml/min/1.73m(2) relative to eGFR >or= 60 ml/min/1.73m(2) respectively 2.04 (1.48-2.80), 2.37 (1.53-3.67), 3.52 (1.78-6.96), 1.64 (1.18-2.27), 3.31 (2.03-5.41). There were no nominally statistically significant interactions (p < 0.05) between randomized treatment allocation and eGFR for clinical outcomes, with the exception of the outcome of coronary heart disease death or nonfatal myocardial infarction (p = 0.021), with the interaction suggesting increased benefit of statin treatment in subjects with impaired GFRs.

CONCLUSIONS

We have established that, in an elderly population over the age of 70 y, impaired GFR is associated with female sex, with presence of vascular disease, and with levels of other risk factors that would be associated with increased risk of vascular disease. Further, impaired GFR is independently associated with significant levels of increased risk of all cause mortality and fatal vascular events and with composite fatal and nonfatal coronary and heart failure outcomes. Our analyses of the benefits of statin treatment in relation to baseline GFR suggest that there is no reason to exclude elderly patients with impaired renal function from treatment with a statin.

Traditional Risk Factors Are Predictive on Segmental Localization of Coronary Artery Disease

The aim of this study was to investigate the relationship between established risk factors and segmental localization of coronary artery disease. A total of 2760 patients who underwent coronary angiography were enrolled into the study. Coronary angiographic segmental evaluation was performed according to the scheme of American Heart Association. Patients were classified into 2 groups (group 1: normal coronary artery segments, group 2: coronary artery segments with coronary artery disease). Smoking was highly related with left main coronary artery disease (odds ratio = 7.5; P = .005). Diabetes mellitus and male sex increased the risk of atherosclerosis in all coronary vasculature (odds ratio = 2.7-2.2; P < .001- P < .001). Hypertension was correlated with distal coronary artery (odds ratio = 1.4; P < .001) and family history with distal circumflex lesions (odds ratio = 4.5; P = .005) High triglyceride levels were associated with right coronary artery lesions (odds ratio = 1.00; P =.03). The effect of advanced age was small (odds ratio = 1.08; P < .001). Risk factors may be predictive for segmental localization.