Multivessel coronary artery bypass grafting versus percutaneous coronary intervention in ESRD

Percutaneous Coronary Intervention With a Drug-Eluting Stent Versus Coronary Artery Bypass Grafting in Patients Receiving Dialysis: A National Study From Taiwan

Rationale & Objective

We aimed to study the comparative effectiveness of percutaneous coronary intervention with drug-eluting stent and coronary artery bypass grafting in patients receiving dialysis.

Study Design

This was a retrospective observational cohort study.

Setting & Participants

This population-based study identified patients receiving dialysis hospitalized for coronary revascularization between January 1, 2009 and December 31, 2015, in the Taiwan National Health Insurance Research Database.

Exposures

Patients received percutaneous coronary intervention with drug-eluting stent versus coronary artery bypass grafting.

Outcomes

The study outcomes were all-cause mortality, in-hospital mortality, and repeat revascularization.

Analytical Approach

Propensity scores were used to match patients. Cox proportional hazards models and logistic regression models were constructed to examine associations between revascularization strategies and mortality. Interval Cox models were fitted to estimate time-varying hazards during different periods.

Results

A total of 1,840 propensity score-matched patients receiving dialysis were analyzed. Coronary artery bypass grafting was associated with higher in-hospital mortality (coronary artery bypass grafting vs percutaneous coronary intervention with drug-eluting stent; crude mortality rate 12.5% vs 3.3%; adjusted OR, 5.22; 95% CI, 3.42-7.97; P < 0.001) and longer hospitalization duration (median [IQR], 20 [14-30] days vs 3 [2-8] days; P < 0.001). After discharge, repeat revascularization, acute coronary syndrome, and repeat hospitalization all occurred more frequently in the percutaneous coronary intervention with drug-eluting stent group. Importantly, with a median follow-up of 2.8 years, coronary artery bypass grafting was significantly associated with a higher risk of all-cause overall mortality (adjusted HR, 1.19; 95% CI, 1.05-1.35; P = 0.006) in the multivariable Cox proportional hazard model. Sensitivity and subgroup analyses yielded consistent results.

Limitations

This was an observational study with mainly Asian ethnicity.

Conclusions

Percutaneous coronary intervention with drug-eluting stent may be associated with better survival than coronary artery bypass grafting in patients receiving dialysis. Future studies are warranted to confirm this finding.

Standardized risk-stratified cardiac assessment and early posttransplant cardiovascular complications in kidney transplant recipients

Introduction

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in kidney transplant recipient (KTR). There is a dearth of standardized guidelines on optimal cardiovascular evaluation of transplant candidates.

Methods

This single-center cohort study aims to determine the effectiveness of our standardized risk-stratified pretransplant cardiovascular screening protocol, which includes coronary angiography (CAG), in identifying advanced CVD, the proper pretransplant management of which could lead to a reduction in the incidence of major cardiac events (MACE) in the early posttransplant period.

Results

Out of the total 776 KTR transplanted between 2017 and 2019, CAG was performed on 541 patients (69.7%), of whom 22.4% were found to have obstructive coronary artery disease (CAD). Asymptomatic obstructive CAD was observed in 70.2% of cases. In 73.6% of cases, CAG findings resulted in myocardial revascularization. MACE occurred in 5.6% (N = 44) of the 23 KTR with pretransplant CVD and 21 without pretransplant CVD. KTR with posttransplant MACE occurrence had significantly worse kidney graft function at the first year posttransplant (p = 0.00048) and worse patient survival rates (p = 0.0063) during the 3-year follow-up period compared with KTR without MACE. After adjustment, the independent significant factors for MACE were arrhythmia (HR 2.511, p = 0.02, 95% CI 1.158-5.444), pretransplant history of acute myocardial infarction (HR 0.201, p = 0.046, 95% CI 0.042-0.970), and pretransplant myocardial revascularization (HR 0.225, p = 0.045, 95% CI 0.052-0.939).

Conclusion

Asymptomatic CVD is largely prevalent in KTR. Posttransplant MACE has a negative effect on grafts and patient outcomes. Further research is needed to assess the benefits of pretransplant myocardial revascularization in asymptomatic kidney transplant candidates.

Coronary Artery Bypass Grafting in Dialysis-Dependent Patients - Key Peri-Operative Considerations

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.

Racial Disparities and Outcomes of Percutaneous Coronary Interventions in Patients Above 65 Years in America: A Systematic Review

This systematic review aims to examine the racial disparities and outcomes of percutaneous coronary interventions (PCIs) in patients above 65 years in America. The review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines 2020 and includes a comprehensive search strategy, study selection, data extraction, and quality assessment. The search strategy identified 10 relevant articles that were included in the review. The findings indicate that racial disparities exist in access to PCI, door-to-balloon (DTB) time, procedure utilization, and outcomes among elderly patients. African American and Hispanic patients were found to experience longer door-to-balloon time and lower rates of PCI utilization compared to White patients. Moreover, racial and ethnic minorities had worse clinical outcomes, including higher mortality rates and increased risk of major adverse cardiovascular events. The review also highlights the impact of Medicaid expansion on reducing disparities in access, treatment, and outcomes for patients with acute myocardial infarction (AMI). However, limitations in data availability and representation of racial and ethnic minorities in clinical trials were identified. The discussion section provides a robust analysis of the findings, exploring potential underlying factors contributing to the observed disparities. The review concludes that addressing racial disparities in PCI outcomes among elderly patients is crucial for achieving equitable healthcare delivery and improving cardiovascular health outcomes in America.

Reconstruction Technique Options for Achieving Total Arterial Revascularization and Multiple Arterial Grafting

Ischemic heart disease is the leading cause of morbidity and mortality worldwide and may require coronary revascularization when more severe or symptomatic. Coronary artery bypass grafting (CABG) is the most common cardiac surgical procedure and can be performed with different bypass conduits and anastomotic techniques. Saphenous vein grafts (SVGs) are the most frequently used conduits for CABG, in addition to the left internal thoracic artery. Outcomes with a single internal thoracic artery and SVGs are favorable, and the long-term patency of SVGs may be improved through novel harvesting techniques, preservation methods, and optimal medical therapy. However, increasing evidence points towards the superiority of arterial grafts, especially in the form of multiple arterial grafting (MAG). Nevertheless, the uptake of MAG remains limited and variable, both as a result of technical complexity and a scarcity of conclusive randomized controlled trial evidence. Here, we present an overview of CABG techniques, harvesting methods, and anastomosis types to achieve total arterial revascularization and adopt MAG. We further narratively summarize the available evidence for MAG versus single arterial grafting to date and highlight remaining gaps and questions that require further study to elucidate the role of MAG in CABG.

Coronary artery bypass grafting vs. percutaneous coronary intervention in coronary artery disease patients with advanced chronic kidney disease: A Chinese single-center study

Objectives

Aims to compare the contemporary and long-term outcomes of coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) in coronary artery disease (CAD) patients with advanced chronic kidney disease (CKD).

Methods

823 CAD patients with advanced CKD (eGFR < 30 ml/min/1.73 m²) were collected, including 247 patients who underwent CABG and 576 patients received PCI from January 2014 to February 2021. The primary endpoint was all-cause death. The secondary endpoints included major adverse cardiac and cerebrovascular events (MACCEs), myocardial infarction (MI), stroke and revascularization.

Results

Multivariable Cox regression models were used and propensity score matching (PSM) was also performed. After PSM, the 30-day mortality rate in the CABG group was higher than that in the PCI group but without statistically significant (6.6% vs. 2.4%, p = 0.24). During the first year, patients referred for CABG had a hazard ratio (HR) of 1.42 [95% confidence interval (CI), 0.41-3.01] for mortality compared with PCI. At the end of the 5-year follow-up, CABG group had a HR of 0.58 (95%CI, 0.38-0.86) for repeat revascularization, a HR of 0.77 (95%CI, 0.52-1.14) for survival rate and a HR of 0.88(95%CI, 0.56-1.18) for MACCEs as compared to PCI.

Conclusions

Among patients with CAD and advanced CKD who underwent CABG or PCI, the all-cause mortality and MACCEs were comparable between the two groups in 30 days, 1-year and 5 years. However, CABG was only associated with a significantly lower risk for repeat revascularization compared with PCI at 5 years follow-up.

The prediction of in-hospital mortality in chronic kidney disease patients with coronary artery disease using machine learning models

OBJECTIVE

Chronic kidney disease (CKD) patients with coronary artery disease (CAD) in the intensive care unit (ICU) have higher in-hospital mortality and poorer prognosis than patients with either single condition. The objective of this study is to develop a novel model that can predict the in-hospital mortality of that kind of patient in the ICU using machine learning methods.

METHODS

Data of CKD patients with CAD were extracted from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. Boruta algorithm was conducted for the feature selection process. Eight machine learning algorithms, such as logistic regression (LR), random forest (RF), Decision Tree, K-nearest neighbors (KNN), Gradient Boosting Decision Tree Machine (GBDT), Support Vector Machine (SVM), Neural Network (NN), and Extreme Gradient Boosting (XGBoost), were conducted to construct the predictive model for in-hospital mortality and performance was evaluated by average precision (AP) and area under the receiver operating characteristic curve (AUC). Shapley Additive Explanations (SHAP) algorithm was applied to explain the model visually. Moreover, data from the Telehealth Intensive Care Unit Collaborative Research Database (eICU-CRD) were acquired as an external validation set.

RESULTS

3590 and 1657 CKD patients with CAD were acquired from MIMIC-IV and eICU-CRD databases, respectively. A total of 78 variables were selected for the machine learning model development process. Comparatively, GBDT had the highest predictive performance according to the results of AUC (0.946) and AP (0.778). The SHAP method reveals the top 20 factors based on the importance ranking. In addition, GBDT had good predictive value and a certain degree of clinical value in the external validation according to the AUC (0.865), AP (0.672), decision curve analysis, and calibration curve.

CONCLUSION

Machine learning algorithms, especially GBDT, can be reliable tools for accurately predicting the in-hospital mortality risk for CKD patients with CAD in the ICU. This contributed to providing optimal resource allocation and reducing in-hospital mortality by tailoring precise management and implementation of early interventions.

Percutaneous coronary intervention versus coronary artery bypass graft surgery in dialysis-dependent patients: A pooled meta-analysis of reconstructed time-to-event data

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.

The Chasm in Percutaneous Coronary Intervention and In-Hospital Mortality Rates Among Acute Myocardial Infarction Patients in Rural and Urban Hospitals in China: A Mediation Analysis

Objectives: To determine to what extent the inequality in the ability to provide percutaneous coronary intervention (PCI) translates into outcomes for AMI patients in China.

Methods: We identified 82,677 patients who had primary diagnoses of AMI and were hospitalized in Shanxi Province, China, between 2013 and 2017. We applied logistic regressions with inverse probability weighting based on propensity scores and mediation analyses to examine the association of hospital rurality with in-hospital mortality and the potential mediating effects of PCI.

Results: In multivariate models where PCI was not adjusted for, rural hospitals were associated with a significantly higher risk of in-hospital mortality (odds ratio [OR]: 1.19, 95% confidence interval [CI]: 1.03–1.37). However, this association was nullified (OR: 0.94, 95% CI: 0.81–1.08) when PCI was included as a covariate. Mediation analyses revealed that PCI significantly mediated 132.3% (95% CI: 104.1–256.6%) of the effect of hospital rurality on in-hospital mortality. The direct effect of hospital rurality on in-hospital mortality was insignificant.

Conclusion: The results highlight the need to improve rural hospitals’ infrastructure and address the inequalities of treatments and outcomes in rural and urban hospitals.

Chronic Renal Failure and Cardiovascular Disease: A Comprehensive Appraisal

Coronary artery disease is highly prevalent in patients with chronic kidney disease. The concomitant renal disease often poses a major challenge in decision making as symptoms, cardiac biomarkers and noninvasive studies for evaluation of myocardial ischemia have different sensitivity and specificity thresholds in this specific population. Moreover, the effectiveness and safety of intervention and medical treatment in those patients is of great doubt as most clinical studies exclude patients with advance CKD. In the present paper, we discuss and review the literature in the diagnosis, treatment and prevention of CAD in the acute and chronic setting, in patients with CKD.

Outcomes of cardiac surgery in patients with end-stage renal disease: Insights from the Israel national registries

BACKGROUND

End-stage renal disease (ESRD) has been shown to be associated with increased mortality in patients undergoing cardiac surgery. We aimed to compare the short- and mid-term mortality after cardiac surgery of patients with dialysis-dependent ESRD (DD-ESRD) to patients with normal renal function (NRF), using national registries: the ESRD registry, the adult cardiac surgery registry (ACSR), and the National Mortality Registry.

METHODS

The study population comprised 8207 adult patients who underwent either isolated coronary artery bypass grafting (CABG), isolated aortic valve replacement (AVR), isolated mitral valve replacement (MVR), or CABG + valve-related procedure, between January 2017 and April 2019. Data were retrospectively extracted and reported to the ACSR by the department of medical records of each medical center.

RESULTS

One hundred and four DD-ESRD patients (mean age 63.2 ± 8.8 years, 83.7% males) were compared with 8103 NRF patients (mean age 64.9 ± 9.8 years, 77.6% males). Median follow-up for the total cohort was of 32.0 months (IQR; 25.0, 40.0). In DD-ESRD compared to NRF patients, 30-day mortality was higher (14.4% vs. 2.3%, respectively, p = 0.0001) and 4-year survival was significantly lower (44% ± 0.06 vs. 91% ± 0.04, respectively, p = 0.0001). Fifty-three percent of DD-ESRD 30-day mortality was caused by sepsis. Risk factors associated with reduced midterm survival included: DD-ESRD patients (HR = 4.7, 95% CI; 1.2-18.2), MVR procedure (HR = 1.5, 95% CI; 1.04-2.1) and combined CABG + valve-related procedure (HR = 1.6, 95% CI; 1.2-2.04).

CONCLUSIONS

Preoperative DD-ESRD was associated with a significant increase in 30-day and mid-term mortality after cardiac surgery. The highest mortality rate was observed in valvular and combined procedures.

Cardiovascular risk stratification in the noncardiac solid organ transplant candidate

PURPOSE OF REVIEW

Solid organ transplantation (SOT) has become a widely accepted therapy for end-stage disease across the spectrum of thoracic and abdominal organs. With contemporary advances in medical and surgical therapies in transplantation, candidates for SOT are increasingly older with a larger burden of comorbidities, including cardiovascular disease (CVD). CVD, in particular, is a leading cause of morbidity and mortality in SOT candidates with end-stage disease of noncardiac organs [1].

RECENT FINDINGS

Identification of coronary artery disease (CAD), heart failure, and valvular disease are important in noncardiac SOT to ensure both appropriate peri-transplant management and equitable organ allocation. Although the American College of Cardiology (ACC) and the American Heart Association (AHA) have published guidelines and recommendations for the perioperative cardiovascular evaluation of patients undergoing noncardiac surgery, the implications of both symptomatic and asymptomatic CVD differ in patients with end-stage organ failure being considered for SOT when compared to the general population.

SUMMARY

Herein, we review the epidemiology, diagnosis, and evidence for the management of CVD in kidney and liver transplantation, combining current guidelines from the 2012 ACC/AHA scientific statement on cardiac disease evaluation in SOT with more contemporary evidenced-based algorithms.

Coronary Artery Disease in Chronic Kidney Disease: Need for a Heart-Kidney Team-Based Approach

Chronic kidney disease and coronary artery disease are co-prevalent conditions with unique epidemiological and pathophysiological features, that culminate in high rates of major adverse cardiovascular outcomes, including all-cause mortality. This review outlines a summary of the literature, and nuances pertaining to non-invasive risk assessment of this population, medical management options for coronary heart disease and coronary revascularisation. A collaborative heart-kidney team-based approach is imperative for critical management decisions for this patient population, especially coronary revascularisation; this review outlines specific periprocedural considerations pertaining to coronary revascularisation, and provides a proposed algorithm for approaching revascularisation choices in patients with end-stage kidney disease based on available literature.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

RESEARCH DESIGN & METHODS

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

RESULTS

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

CONCLUSION

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

Prophylactic dialysis improves short-term clinical outcome in patients with non-dialysis-dependent chronic kidney disease undergoing cardiac surgery: a meta-analysis of randomized controlled trials

Background

Several studies have reported that prophylactic dialysis can reduce the mortality of non-dialysis-dependent chronic kidney disease (CKD) patients after cardiac surgery. However, the results of complications in these randomized controlled trials (RCTs) were not consistent. We aimed to perform a meta-analysis to systematically evaluate the effect of prophylactic dialysis in these non-dialysis-dependent CKD patients.

Methods

We systematically searched Medline, Embase, Cochrane’s Library and other online sources for related RCTs. Effects of prophylactic dialysis on the incidence of 30 days’ mortality and postoperative complications were analyzed.

Results

Four RCTs comprising 395 patients were included, all of them treated by coronary artery bypass grafting. Treatment of preoperative and intraoperative prophylactic dialysis significantly reduced the rate of 30-day all-cause mortality (risk ratio [RR]: 0.27, 95% confidence interval [CI], 0.13–0.58, P < 0.001, I² = 0%) and the incidence of pulmonary complications (RR: 0.39, 95% CI, 0.20–0.77, P = 0.007, I² = 0%), low cardiac output (RR: 0.29, 95% CI, 0.09–0.99, P = 0.05, I² = 0%), and acute kidney injury (RR: 0.19, 95% CI: 0.07–0.52, P = 0.001, I² = 0%). However, there were no statistically significant differences between the dialysis group and the control group in gastrointestinal bleeding, sepsis or multiple organ failure, wound infection, arrhythmia, transient neurologic deficit, stroke and re-exploration for bleeding.

Conclusion

Prophylactic dialysis can improve the 30-day clinical outcomes of non-dialysis-dependent CKD patients undergoing cardiac surgery, it was associated with the 30-day mortality benefit and led to a decrease in the incidence of pulmonary complications, as well as low cardiac output, and acute kidney injury.

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

Background:

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

Methods:

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

Results:

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

Conclusions:

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

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

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

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

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

Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting in Patients With Versus Without Chronic Kidney Disease

Chronic kidney disease (CKD) might be an important determinant in choosing percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG). However, there is a scarcity of studies evaluating the effect of CKD on long-term outcomes after PCI relative to CABG in the population including severe CKD. Among 30257 consecutive patients patients who underwent first coronary revascularization with PCI or isolated CABG in the CREDO-Kyoto PCI/CABG registry Cohort-2 (n = 15330) and Cohort-3 (n = 14,927), we identified the current study population of 12,878 patients with multivessel or left main disease, and compared long-term clinical outcomes between PCI and CABG stratified by the subgroups based on the stages of CKD (no CKD: eGFR >=60 ml/min/1.73m², moderate CKD: 60> eGFR >=30 ml/min/1.73m², and severe CKD: eGFR <30 ml/min/1.73m² or dialysis). There were 6,999 patients without CKD (PCI: n = 5,268, and CABG: n = 1,731), 4,427 patients with moderate CKD (PCI: n = 3,226, and CABG: n = 1,201), and 1,452 patients with severe CKD (PCI: n = 989, and CABG: n = 463). During median 5.6 years of follow-up, the excess mortality risk of PCI relative to CABG was significant regardless of the stages of CKD without interaction (no CKD: HR, 1.36; 95%CI, 1.12 to 1.65; p = 0.002, moderate CKD: HR, 1.40; 95%CI, 1.17 to 1.67; p <0.001, and severe CKD: HR, 1.33; 95%CI, 1.09 to 1.62; p = 0.004, Interaction p = 0.83). There were no significant interactions between CKD and the effect of PCI relative to CABG for all the outcome measures evaluated. In conclusion, PCI compared with CABG was associated with significantly higher risk for all-cause death regardless of the stages of CKD without any significant interaction.

Percutaneous Coronary Intervention Versus Coronary Artery Bypass Graftinge Among Patients with Unprotected Left Main Coronary Artery Disease in the New-Generation Drug-Eluting Stents Era (From the CREDO-Kyoto PCI/CABG Registry Cohort-3)

Long-term safety of percutaneous coronary intervention (PCI) as compared with coronary artery bypass grafting (CABG) is still controversial in patients with unprotected left main coronary artery disease (ULMCAD), and there is a scarcity of real-world data on the comparative long-term clinical outcomes between PCI and CABG for ULMCAD in new-generation drug-eluting stents era. The CREDO-Kyoto PCI/CABG registry Cohort-3 enrolled 14927 consecutive patients undergoing first coronary revascularization with PCI or isolated CABG between January 2011 and December 2013, and we identified 855 patients with ULMCAD (PCI: N = 383 [45%], and CABG: N = 472 [55%]). The primary outcome measure was all-cause death. Median follow-up duration was 5.5 (interquartile range: 3.9 to 6.6) years. The cumulative 5-year incidence of all-cause death was not significantly different between the PCI and CABG groups (21.9% vs 17.6%, Log-rank p = 0.13). After adjusting confounders, the excess risk of PCI relative to CABG remained insignificant for all-cause death (HR, 1.00; 95% CI, 0.68 to 1.47; p = 0.99). There were significant excess risks of PCI relative to CABG for myocardial infarction and any coronary revascularization (HR, 2.07; 95% CI, 1.30 to 3.37; p = 0.002, and HR, 2.96; 95% CI, 1.96 to 4.46; p < 0.001), whereas there was no significant excess risk of PCI relative to CABG for stroke (HR, 0.85; 95% CI, 0.50 to 1.41; p = 0.52). In conclusion, there was no excess long-term mortality risk of PCI relative to CABG, while the excess risks of PCI relative to CABG were significant for myocardial infarction and any coronary revascularization in the present study population reflecting real-world clinical practice in Japan.

Coronary artery bypass graft surgery versus stenting for patients with chronic kidney disease and complex coronary artery disease: a systematic review and meta-analysis

BACKGROUND

The relative role of coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) with stent implantation in patients with chronic kidney disease (CKD) and complex coronary artery disease (CAD) remains debatable due to the lack of randomized controlled trials (RCTs). We therefore performed this meta-analysis to compare the outcomes of the two strategies in CKD patients with multivessel and/or left main disease.

METHODS

Electronic databases including PubMed, EMBASE and Cochrane Library were comprehensively searched to identify the eligible subgroup analysis of RCTs and propensity-matched registries. The primary endpoint was all-cause mortality during the longest follow-up.

RESULTS

Five subgroup analyses of RCTs and six propensity-matched registries involving 26,441 patients were analyzed. Overall, the strategy of CABG was associated with lower risks of long-term mortality [odds ratio (OR) 0.83, 95% confidence interval (CI) 0.74-0.93], myocardial infarction (OR, 0.41; 95% CI, 0.27-0.62), and repeat revascularization (OR, 0.25; 95% CI, 0.16-0.39) compared with PCI in CKD patients with complex CAD. However, CABG was slightly associated with higher risk of stroke than PCI (OR, 1.33; 95% CI, 1.00-1.77). Nonetheless, the higher stroke risk in the CABG group no longer existed during long-term follow-up (OR, 0.92; 95% CI, 0.37-2.25) (>3 years).

CONCLUSION

This meta-analysis supports the current guideline advising CABG for patients with CKD and complex CAD. At the expense of slightly increased risk of stroke, CABG reduces the incidences of long-term all-cause death, myocardial infarction and repeat revascularization compared with PCI.

Intradialytic Hypotension and Newly Recognized Peripheral Artery Disease in Patients Receiving Hemodialysis

RATIONALE & OBJECTIVE

Intradialytic hypotension (IDH) may decrease systemic circulation to the legs, exacerbating symptoms of peripheral artery disease (PAD). We sought to evaluate the relationship between IDH and newly recognized lower extremity PAD among hemodialysis patients.

STUDY DESIGN

Retrospective cohort study.

SETTING & PARTICIPANTS

Linking data from the US Renal Data System to the electronic health records of a large dialysis provider, we identified adult patients (≥18 years of age) with Medicare Parts A and B who initiated dialysis (2006-2011) without previously recognized PAD.

EXPOSURE

The time-varying proportion of hemodialysis sessions with IDH defined as the nadir intradialytic systolic blood pressure <90 mm Hg. We categorized the proportion of sessions with IDH within serial 30-day intervals as 0%, >0% to <15%, 15% to <30%, and ≥30%.

OUTCOMES

Newly recognized PAD was ascertained using PAD diagnostic and procedure codes for amputation or revascularization, in serial 30-day intervals subsequent to each 30-day exposure interval.

ANALYTICAL APPROACH

To account for the competing risks of death and kidney transplantation, we estimated unadjusted and adjusted subdistribution hazard ratios using the Kaplan-Meier multiple imputation method in combination with the extended Cox model to account for IDH as a time-varying exposure.

RESULTS

Among 45,591 patients, those with more frequent baseline IDH had a higher prevalence of cardiovascular diseases. During 61,725 person-years of follow-up, 7,886 patients had newly recognized PAD. We found a graded, direct association between IDH and newly recognized PAD. For example, having IDH in ≥30% of dialysis sessions during a given 30-day interval (vs 0%) was associated with a 24% (95% CI, 17%-32%) higher hazard than having newly recognized PAD in the subsequent 30 days.

LIMITATIONS

Unmeasured confounding; ascertainment of PAD from claims.

CONCLUSIONS

Patients receiving hemodialysis who had more frequent IDH had higher rates of newly recognized PAD. Patients with frequent IDH may warrant careful examination for PAD.

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

Objectives

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

Methods

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

Results

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

Conclusions

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

Long-term prognosis in patients with end-stage renal disease after coronary artery bypass grafting

Background

Cardiovascular disease is a major cause of morbidity and mortality in patients with end-stage renal disease (ESRD). Coronary artery bypass grafting (CABG) is beneficial in selected patients with ESRD. This study investigates the survival outcomes and prognostic factors in ESRD patients who underwent CABG.

Methods

A retrospective analysis was performed for 149 patients with ESRD who underwent isolated CABG between 2006 and 2015.

Results

Mean age was 59.4±8.7 years and 106 patients (71.1%) were male. Operative mortality occurred in 20 patients (13.4%). Overall survival was 81.1%±3.2% at 1 year, 41.5%±4.3% at 5 years and 19.2%±4.2% at 10 years. Median survival was 4.3 years. Multivariable analysis identified age [P=0.001, odds ratio (OR): 1.15 per 1-year increase, 95% confidence interval (CI): 1.06-1.25], preoperative left ventricular ejection fraction (LVEF) (P=0.020, OR: 0.94, 95% CI: 0.89-0.99) and non-elective status of operation (P=0.049, OR: 3.34, 95% CI: 1.00-11.1) as predictors of operative mortality. Cox regression analysis identified age [P<0.001, hazard ratio (HR): 1.05 per 1-year increase, 95% CI: 1.03-1.08], New York Heart Association (NYHA) class III or IV status (P=0.010, HR: 1.75, 95% CI: 1.15-2.67) and the use of a left internal mammary artery (LIMA) to left anterior descending artery (LIMA-LAD) graft (P=0.029, HR: 0.42, 95% CI: 0.19-0.92) as factors influencing long-term survival.

Conclusions

CABG is associated with high operative mortality and poor long-term survival in ESRD patients. Age and NYHA class influenced late survival. LIMA-LAD grafting conferred a long-term survival advantage.

Coronary artery disease in dialysis patients: evidence synthesis, controversies and proposed management strategies

Cardiovascular disease (CVD) remains the leading cause of morbidity and mortality among patients with end-stage renal disease (ESRD). Clustering of traditional atherosclerotic and non-traditional risk factors drive the excess rates of coronary and non-coronary CVD in this population. The incidence, severity and mortality of coronary artery disease (CAD) as well as the number of complications of its therapy is higher in dialysis patients than in non-chronic kidney disease patients. Given the lack of randomized clinical trial evidence in this population, current practice is informed by observational data with a significant potential for bias. Furthermore, guidelines lack any recommendation for these patients or extrapolate them from trials performed in non-dialysis patients. Patients with ESRD are more likely to be asymptomatic, posing a challenge to the correct identification of CAD, which is essential for appropriate risk stratification and management. This may lead to "therapeutic nihilism", which has been associated with worse outcomes. Here, the ERA-EDTA EUDIAL Working Group reviews the diagnostic work-up and therapy of chronic coronary syndromes, unstable angina/non-ST elevation and ST-elevation myocardial infarction in dialysis patients, outlining unclear issues and controversies, discussing recent evidence, and proposing management strategies. Indications of antiplatelet and anticoagulant therapies, percutaneous coronary intervention and coronary artery bypass grafting are discussed. The issue of the interaction between dialysis session and myocardial damage is also addressed.

Coronary Artery Bypass Graft Patency and Survival in Patients on Dialysis

BACKGROUND

Little is known about graft patency after coronary artery bypass grafting (CABG) performed in patients on dialysis. Our aim was to assess patency of internal thoracic artery (ITA) grafts and saphenous vein grafts (SVGs) in these patients.

METHODS

From 1/1997 to 1/2018, 500 patients on dialysis underwent primary CABG with or without concomitant procedures at Cleveland Clinic, 40 of whom had 48 postoperative angiograms for recurrent ischemic symptoms. Complete follow-up was obtained on all but 1 patient lost to follow-up 1 y after CABG. Thirty-six ITA grafts and 65 SVGs were evaluable for stenosis and occlusion.

RESULTS

Two of 40 patients (5%) had emergency CABG; 3 (7.5%) with calcified aortas had a change in operative strategy to avoid ascending aortic manipulation, 2 (5%) had poor conduit quality, and 12 (30%) had severe diffuse atherosclerotic disease with calcification of the coronary targets causing technical difficulties. Thirty-three patients (82%) were bypassed with an in situ ITA and 3 (7.5%) had a free ITA graft. Three of 36 ITA grafts were occluded at 0.78, 1.8, and 9.4 y (too few to model). SVG patency was 52% and 37% at 1 and 2 y, respectively.

CONCLUSIONS

Among patients on dialysis who underwent CABG, coronary angiography for ischemic symptoms in a select subset revealed that SVG patency was lower than expected from published reports in the general CABG population and may contribute to the poor prognosis of this cohort. Further work is needed to guide graft selection and improve graft patency in dialysis patients.

Acute kidney injury following coronary revascularization procedures in patients with advanced CKD

BACKGROUND

Previous studies reported that compared with percutaneous coronary interventions (PCIs), coronary artery bypass grafting (CABG) is associated with a reduced risk of mortality and repeat revascularization in patients with mild to moderate chronic kidney disease (CKD) and end-stage renal disease (ESRD). Information about outcomes associated with CABG versus PCI in patients with advanced stages of CKD is limited. We evaluated the incidence and relative risk of acute kidney injury (AKI) associated with CABG versus PCI in patients with advanced CKD.

METHODS

We examined 730 US veterans with incident ESRD who underwent a first CABG or PCI up to 5 years prior to dialysis initiation. The association of CABG versus PCI with AKI was examined in multivariable adjusted logistic regression analyses.

RESULTS

A total of 466 patients underwent CABG and 264 patients underwent PCI. The mean age was 64 ± 8 years, 99% were male, 20% were African American and 84% were diabetic. The incidence of AKI in the CABG versus PCI group was 67% versus 31%, respectively (P < 0.001). The incidence of all stages of AKI were higher after CABG compared with PCI. CABG was associated with a 4.5-fold higher crude risk of AKI {odds ratio [OR] 4.53 [95% confidence interval (CI) 3.28-6.27]; P < 0.001}, which remained significant after multivariable adjustments [OR 3.50 (95% CI 2.03-6.02); P < 0.001].

CONCLUSION

CABG was associated with a 4.5-fold higher risk of AKI compared with PCI in patients with advanced CKD. Despite other benefits of CABG over PCI, the extremely high risk of AKI associated with CABG should be considered in this vulnerable population when deciding on the optimal revascularization strategy.

Kidney transplantation and cardiomyopathy: Concepts and controversies in clinical decision-making

Increasing comorbidities and an aging population have led to a tremendous increase in the burden of both kidney and cardiac dysfunction. Concomitant cardiomyopathy exposes the patients with kidney disease to further physiological, hemodynamic, and pathologic alterations. Kidney transplantation imposes lesser anesthetic and surgical complexities compared to another solid organ transplant. The surgical decision-making remains an unsettled issue in these conditions. The surgical choices, techniques, and sequences in kidney transplant and cardiac surgery depend on the pathophysiological perturbations and perioperative outcomes. The absence of randomized controlled trials eludes us from suggesting definite management protocol in patients with end-stage kidney disease with cardiomyopathy. Nevertheless, in this review, we extracted data from published literature to understand the pathophysiologic interactions between end-stage renal diseases with cardiomyopathy and also proposed the management algorithm in this challenging scenario. The proposed management algorithm would ensure consensus across all stakeholders involved in decision-making. Our simplistic evidence-based approach would augur future randomized trials and would further ensure refinement in our management approach after the emergence of more definitive evidence.

Antidiabetic medication use in patients with type 2 diabetes and chronic kidney disease

AIMS

To quantify patterns of conventional and newer antidiabetic medication use in patients with type 2 diabetes mellitus (T2DM) and chronic kidney disease (CKD).

METHODS

We used data from a large claims and integrated dataset that includes employed and commercially insured patients in the US to select patients who had T2DM and CKD with information on laboratory values and prescriptions for antidiabetic medications from January 1, 2014 to January 1, 2015. We stratified the analyses by sociodemographic variables.

RESULTS

In a cohort of 38,577 patients with T2DM and CKD, we found wide variation in the treatment of T2DM by CKD stage as well as by several sociodemographic factors. Although metformin was the most commonly prescribed medication, only about half of patients in the cohort and fewer than two-thirds of patients with early stage CKD were prescribed metformin. Approximately 10.6% of patients with CKD stage 4 and 2.1% of the patients with CKD stage 5 were prescribed metformin. Sulfonylureas with active metabolites that accumulate with impaired kidney function were prescribed in more than one-third of patients with CKD stages 3b, 4, and 5. Only 3.4% and 12.3% of patients were prescribed GLP-1 and DPP-4 respectively.

CONCLUSIONS

Prescriptions for metformin were lower than expected among patients with mild to moderate CKD. Prescriptions for newer antidiabetic medications with known safety and efficacy across the spectrum of CKD remained low. Prescriptions for agents contraindicated in advanced CKD continued to be written in a sizeable fraction of patients.

Revascularization Strategies in Patients with Chronic Kidney Disease and Acute Coronary Syndromes

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.

Care of Patients With Chronic Kidney Disease Presenting With Acute Coronary Syndrome: Improved, But Not Good Enough

See Article by Bagai et al

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

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

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

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

Characteristics of coronary artery disease in chronic kidney disease

Patients with chronic kidney disease (CKD) commonly experience cardiovascular disease (CVD), and a major cause of death in these patients is CVD. Therefore, the prevention of CVD progression is very crucial in patients with CKD. Recently, this relationship between CKD and CVD has increasingly been examined, and a concept termed “cardiorenal syndrome” has been advocated. Coronary artery disease (CAD) and myocardial injury are crucial factors that contribute to the occurrence of CVD. The initial step CAD is endothelial dysfunction that can be detected as a decrease in the coronary flow reserve (CFR). The previous studies have reported that decreased CFR is significantly correlated to coronary events and mortality. Furthermore, CFR reduces with a decline in the kidney function. Another important presentation of CAD is coronary artery calcification. Vascular calcification is a crucial pathophysiological state, particularly in patients with CKD, and it affects the stability of coronary atherosclerotic plaque. In CKD, not only the traditional risk factors but also CKD-related non-traditional risk factors play key roles in CVD progression. Therefore, the mechanisms responsible for CVD progression are very complex; however, their clarification is crucial to improve the prognosis in patients with CKD.

Predialysis coronary revascularization and postdialysis mortality

Objectives

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

Methods

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

Results

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

Conclusion

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

The Relationship between Intradialytic Hypotension and Hospitalized Mesenteric Ischemia: A Case-Control Study

BACKGROUND AND OBJECTIVES

Mesenteric ischemia is a rare but devastating condition caused by insufficient blood supply to meet the demands of intestinal metabolism. In patients with ESKD, it can be difficult to diagnose and has a >70% mortality rate. Patients on hemodialysis have a high prevalence of predisposing conditions for mesenteric ischemia, but the contribution of intradialytic hypotension, a potential modifiable risk factor, has not been well described.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We used data from the US Renal Data System to identify 626 patients on hemodialysis with a hospitalized mesenteric ischemia event (cases). We selected 2428 controls in up to a 1:4 ratio matched by age, sex, black race, incident dialysis year, diabetes mellitus, coronary artery disease, and peripheral artery disease. We used six different definitions of intradialytic hypotension on the basis of prior studies, and categorized patients as having had intradialytic hypotension if ≥30% of hemodialysis sessions in the 30 days before the event met the specified definition.

RESULTS

The proportion of patients with intradialytic hypotension varied depending on its definition: from 19% to 92% of cases and 11% to 94% of controls. Cases had a higher adjusted odds (1.82; 95% confidence interval, 1.47 to 2.26) of having had intradialytic hypotension in the preceding 30 days than controls when using nadir-based intradialytic hypotension definitions such as nadir systolic BP <90 mm Hg. To examine a potential dose-response association of intradialytic hypotension with hospitalized mesenteric ischemia, we categorized patients by the proportion of hemodialysis sessions having intradialytic hypotension, defined using the Nadir90 definition (0%, 1%-9%, 10%-29%, 30%-49%, and ≥50%), and found a direct association of proportion of intradialytic hypotension with hospitalized mesenteric ischemia (P-trend<0.001).

CONCLUSIONS

Patients with hospitalized mesenteric ischemia had significantly higher odds of having had intradialytic hypotension in the preceding 30 days than controls, as defined by nadir-based definitions.

Propensity Score-Based Methods in Comparative Effectiveness Research on Coronary Artery Disease

This review examines the conduct and reporting of observational studies using propensity score-based methods to compare coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), or medical therapy for patients with coronary artery disease. A systematic selection process identified 48 studies: 20 addressing CABG versus PCI; 21 addressing bare-metal stents versus drug-eluting stents; 5 addressing CABG versus medical therapy; 1 addressing PCI versus medical therapy; and 1 addressing drug-eluting stents versus balloon angioplasty. Of 32 studies reporting information on variable selection, 7 relied exclusively on statistical criteria for the association of covariates with treatment, and 5 used such criteria to determine whether product or nonlinear terms should be included in the propensity score model. Twenty-five (52%) studies reported assessing covariate balance using the estimated propensity score, but only 1 described modifications to the propensity score model based on this assessment. The over 400 variables used in the 48 propensity score models were classified into 12 categories and 60 subcategories; only 17 subcategories were represented in at least half of the propensity score models. Overall, reporting of propensity score-based methods in observational studies comparing CABG, PCI, and medical therapy was incomplete; when adequately described, the methods used were often inconsistent with current methodological standards.

Outcome and selection of revascularization strategy in left main coronary artery stenosis

OBJECTIVES

To investigate clinical outcome in unselected real-life patients with unprotected left main coronary artery (ULMCA) stenosis and determine factors associated with selection of revascularization strategy.

DESIGN

Consecutive patients with ULMCA stenosis at our institution in 2009-2013 (n = 308) were retrospectively analyzed with propensity score adjusted Cox proportional hazards models for outcome. Baseline characteristics in relation to selection of revascularization strategy were analyzed with multivariate logistic regression.

RESULTS

Patients that underwent PCI (n = 94) had a higher risk of major adverse cardiac and cerebrovascular events (MACCE; adjusted HR 2.13 [95% CI 1.08-4.19]) than patients that had CABG surgery but there was no difference in the combination of death and MI (adjusted HR 1.17 [95% CI 0.50-2.75]). Later year of index angiography, age, Euroscore II and angiographer favoring PCI was associated with PCI as revascularization strategy. Higher SYNTAX score, higher systolic blood pressure and angiographer favoring CABG was associated with CABG.

CONCLUSIONS

In consecutive patients with ULMCA stenosis PCI is associated with higher MACCE rates than CABG but there is no difference in death and MI. Later year of index angiography, higher age, lower systolic blood pressure, higher predicted per-procedural surgical risk, less complex coronary anatomy and angiographer favoring PCI increased the probability of revascularization with PCI instead of CABG.

Cardiovascular complications in chronic dialysis patients

PURPOSE OF REVIEW

This review article focuses on the most significant cardiovascular complications in dialysis patients [sudden cardiac death (SCD), acute coronary syndromes, heart failure, and atrial fibrillation].

RECENT FINDINGS

Current and ongoing research aims to quantify the rate and pattern of significant arrhythmia in dialysis patients and to determine the predominant mechanism of SCD. Preliminary findings from these studies suggest a high rate of atrial fibrillation and that bradycardia and asystole may be more frequent than ventricular arrhythmia as a cause of sudden death. A recently published matched cohort study in dialysis patients who received a defibrillator for primary prevention showed that there was no significant difference in mortality rates between defibrillator-treated patients and propensity-matched controls. Two randomized controlled trials are currently recruiting participants and will hopefully answer the question of whether implantable or wearable cardioverter defibrillators can prevent SCD. An observational study using United States Renal Data System data demonstrated how difficult it is to keep hemodialysis patients on warfarin, as more than two-thirds discontinued the drug during the first year. The ISCHEMIA-CKD trial may provide answers about the optimal strategy for the treatment of atherosclerotic coronary disease in patients with advanced chronic kidney disease.

SUMMARY

The article reviews the diagnosis of acute coronary syndromes in dialysis patients, current literature on myocardial revascularization, and data on fatal and nonfatal cardiac arrhythmia. The new classification of heart failure in end-stage renal disease is reviewed. Finally, available cohort studies on warfarin for stroke prevention in dialysis patients with atrial fibrillation are reviewed.

Revascularization for Left Main and Multivessel Coronary Artery Disease: Current Status and Future Prospects after the EXCEL and NOBLE Trials

Revascularization of severe left main and multivessel coronary artery disease has been shown to improve survival in both stable ischemic heart disease and acute coronary syndrome. While revascularization with coronary artery bypass surgery for these disease entities carries class I recommendation in most current guidelines, recent trials has shown potential comparable survival and cardiovascular outcomes between percutaneous and surgical interventions in patients with less complex coronary anatomy. Despite the conflicting results observed in the most recent left main revascularization trials, Everolimus-Eluting Stents or Bypass Surgery for Left Main Coronary Artery Disease (EXCEL) and Nordic-Baltic-British left main revascularization (NOBLE), both treatment strategies remain important for the management of left main disease (LMD) and multivessel disease (MVD) reflecting on the importance of heart team discussion. This review is focused on revascularization of LMD and MVD in patients who are not presenting with ST-segment elevation myocardial infarction, encompassing the evidence from historic and contemporary trials which shaped up current practices. This review discusses the heart team approach to guide decision making, including special populations that are not represented in clinical trials.