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Wolff Gowdak LH, Galvão De Lima JJ, Adam EL, Kirnew Abud Manta IC, Reusing JO, David-Neto E, Machado César LA, Bortolotto LA. Coronary Artery Disease Assessment and Cardiovascular Events in Middle-Aged Patients on Hemodialysis. Mayo Clin Proc 2024; 99:411-423. [PMID: 38159095 DOI: 10.1016/j.mayocp.2023.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 04/03/2023] [Accepted: 05/01/2023] [Indexed: 01/03/2024]
Abstract
OBJECTIVE To explore whether, in younger patients on dialysis with longer life expectancy, assessment of coronary artery disease (CAD) could identify individuals at higher risk of events and revascularization might improve outcomes in selected patients contrary to what had been observed in elderly patients. METHODS From August 1997 to January 2019, 2265 patients with stage 5 chronic kidney disease were prospectively referred for cardiovascular assessment. For this study, we selected 1374 asymptomatic patients aged between 18 and 64 years. After clinical risk stratification and cardiac scintigraphy by single-photon emission computed tomography, 866 patients underwent coronary angiography. The primary end point was the composite incidence of nonfatal/fatal major adverse cardiovascular events during a follow-up period of 0.1 to 189.7 months (median, 26 months). The secondary end point was all-cause mortality. RESULTS The primary end point occurred in 327 (23.8%) patients. Clinically stratified high-risk patients had a 3-fold increased risk of the primary end point. The prevalence of abnormal findings on perfusion scans was 29.2% (n=375), and significant CAD was found in 449 (51.8%) of 866 patients who underwent coronary angiography. An abnormal finding on myocardial perfusion scan and the presence of CAD were significantly associated with a 74% and 22% increased risk of cardiovascular events, respectively. In patients undergoing percutaneous coronary intervention or coronary artery bypass grafting (n=99), there was an 18% reduction in the risk of all-cause death relative to patients receiving medical treatment (P=.03). CONCLUSION In this cohort of middle-aged, asymptomatic patients on dialysis, assessment of CAD identified individuals at higher risk of events, and coronary intervention was associated with reducing the risk of death in selected patients.
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Affiliation(s)
- Luís Henrique Wolff Gowdak
- Heart Institute (InCor), Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil.
| | - José Jayme Galvão De Lima
- Heart Institute (InCor), Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Eduardo Leal Adam
- Heart Institute (InCor), Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | | | - José Otto Reusing
- Renal Transplantation Unit, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Elias David-Neto
- Renal Transplantation Unit, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Luiz Antonio Machado César
- Heart Institute (InCor), Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Luiz Aparecido Bortolotto
- Heart Institute (InCor), Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
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Dunn AN, Huded C, Raymond R, Lincoff AM, Bajzer C, Kapadia S, Ellis SG. Successful modeling of long term outcomes in end-stage renal disease patients undergoing percutaneous coronary intervention with drug-eluting stents. Catheter Cardiovasc Interv 2021; 98:208-214. [PMID: 33913614 DOI: 10.1002/ccd.29707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 04/03/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVES The objective of this study is to identify and model risk factors for major adverse cardiac events (MACE) and all-cause mortality among patients with ESRD treated with PCI using DES. BACKGROUND Patients with end-stage renal disease (ESRD) have poor long-term outcomes after percutaneous coronary intervention (PCI) compared with non-ESRD patients. However, there is a paucity of literature regarding risk factors associated with outcomes of ESRD patients after PCI with drug-eluding stents (DES). METHODS This retrospective cohort study includes all patients with ESRD who underwent first-time PCI with DES at a single, high-volume hospital between 1/1/2005 and 12/31/2015, with follow-up through 9/1/2019. Primary outcomes were MACE (cardiac death, myocardial infarction, or unplanned revascularization) and all-cause mortality. RESULTS Five-year MACE was 83.0% and five-year morality was 77.9% in patients with ESRD (n = 285). Among ESRD patients, factors independently associated with MACE were C-reactive peptide level, SYNTAX score, peripheral vascular occlusive disease, hemoglobin, and treatment of a restenotic lesion (c-index = 0.66). Factors independently associated with mortality in ESRD patients were age, SYNTAX score, non-use of statins at baseline, insulin-dependent diabetes, chronic obstructive pulmonary disease (COPD), peripheral vascular occlusive disease, and platelet count (c-index = 0.65). CONCLUSIONS Despite relatively poor 1-and 5-year outcomes among ESRD patients after PCI, risk of MACE and mortality among this cohort can be successfully modelled, which meaningfully informs clinicians regarding management of ESRD patients with coronary artery disease (CAD). Further investigations are necessary to determine whether or not outcomes might be improved through risk profile modification.
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Affiliation(s)
- Aaron N Dunn
- Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, USA
| | - Chetan Huded
- Saint Luke's Mid America Heart Institute, Kansas city, Missouri, USA
| | - Russell Raymond
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - A Michael Lincoff
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Christopher Bajzer
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Samir Kapadia
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Stephen G Ellis
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
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De Lima JJG, Gowdak LHW, David-Neto E, Bortolotto LA. Diabetes, Cardiovascular Disease, and Cardiovascular Risk in Patients with Chronic Kidney Disease. High Blood Press Cardiovasc Prev 2021; 28:159-165. [PMID: 33548022 DOI: 10.1007/s40292-021-00434-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 01/22/2021] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION It is unclear whether the increased risk associated with diabetes in patients on dialysis is due to diabetes or a consequence of associated cardiovascular disease (CVD). AIM The purpose of this work was to answer the question: do diabetes and CVD have a similar impact on the incidence of cardiovascular events in patients undergoing maintenance hemodialysis? METHODS A prespecified protocol was used to prospectively evaluate and follow up 310 diabetic patients on hemodialysis without clinical evidence of CVD and 395 nondiabetic patients with CVD. Endpoint was the incidence of composite CV events and coronary events. RESULTS The incidence of composite CV events (log-rank = 0.540) and coronary events (log-rank = 0.400) did not differ between groups. Because of the potential influence of occult CVD in patients with diabetes, we repeated the analysis excluding subjects with altered ejection fraction, a myocardial perfusion scan defect, and coronary artery disease in the group of patients with diabetes. Again we found no difference between groups (log-rank = 0.657). CONCLUSION In patients on hemodialysis, diabetes and CVD carry similar risks for CV events. These results are congruent with the diabetes mellitus-CVD equivalence risk concept reported in the general population.
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Affiliation(s)
- Jose J G De Lima
- Heart Institute (InCor), Hospital das Clínicas, University of São Paulo Medical School, Rua Enas Carvalho Aguiar 44, São Paulo, SP, 05403-000, Brazil.
| | - Luis Henrique W Gowdak
- Heart Institute (InCor), Hospital das Clínicas, University of São Paulo Medical School, Rua Enas Carvalho Aguiar 44, São Paulo, SP, 05403-000, Brazil
| | - Elias David-Neto
- Renal Transplant Unit, Urology, Hospital das Clínicas, University of São Paulo Medical School, Rua Eneas Carvalho Aguiar 23, São Paulo, SP, 05403-000, Brazil
| | - Luiz A Bortolotto
- Heart Institute (InCor), Hospital das Clínicas, University of São Paulo Medical School, Rua Enas Carvalho Aguiar 44, São Paulo, SP, 05403-000, Brazil
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Deak AT, Ionita F, Kirsch AH, Odler B, Rainer PP, Kramar R, Kubatzki MP, Eberhard K, Berghold A, Rosenkranz AR. Impact of cardiovascular risk stratification strategies in kidney transplantation over time. Nephrol Dial Transplant 2021; 35:1810-1818. [PMID: 33022711 PMCID: PMC7538198 DOI: 10.1093/ndt/gfaa131] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 04/22/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Kidney transplant recipients exhibit a dramatically increased cardiovascular (CV) risk. In 2007, Austrian centres implemented a consensus of comprehensive CV screening programme prior to kidney transplantation (KT). The consensus placed a particular emphasis on screening for coronary artery disease (CAD) with cardiac computed tomography (CT) or coronary angiography (CAG) in patients with diabetes mellitus, known CAD or those having multiple conventional CV risk factors. Here, we investigate if this affected risk stratification and post-transplant CV outcomes. METHODS In a retrospective chart review, we evaluated 551 KTs performed from 2003 to 2015 in our centre. Patients were categorized into three groups: KT before (2003-07), directly after (2008-11) and 5 years after (2012-15) implementation of the consensus. We analysed clinical characteristics, the rate of cardiac CTs and CAGs prior to KT as well as major adverse cardiac events (MACEs) during a 2-year follow-up after KT. RESULTS The three study groups showed a homogeneous distribution of comorbidities and age. Significantly more cardiac CTs (13.6% versus 10.2% versus 44.8%; P = 0.002) and CAGs (39.6% versus 43.9% versus 56.2%; P = 0.003) were performed after the consensus. Coronary interventions were performed during 42 out of 260 CAGs (16.2%), the cumulative 2-year MACE incidence was 8.7%. Regarding MACE occurrence, no significant difference between the three groups was found. CONCLUSION CV risk stratification has become more rigorous and invasive after the implementation of the consensus; however, this was not associated with an improvement in CV outcome.
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Affiliation(s)
- Andras T Deak
- Department of Internal Medicine, Division of Nephrology, Medical University of Graz, Graz, Austria
| | - Francesca Ionita
- Department of Internal Medicine, Division of Nephrology, Medical University of Graz, Graz, Austria
| | - Alexander H Kirsch
- Department of Internal Medicine, Division of Nephrology, Medical University of Graz, Graz, Austria
| | - Balazs Odler
- Department of Internal Medicine, Division of Nephrology, Medical University of Graz, Graz, Austria
| | - Peter P Rainer
- Department of Internal Medicine, Division of Cardiology, Medical University of Graz, Graz, Austria
| | - Reinhard Kramar
- Austrian Dialysis and Transplant Registry, Innsbruck, Austria
| | - Michael P Kubatzki
- Department of Internal Medicine, Division of Nephrology, Medical University of Graz, Graz, Austria
| | - Katharina Eberhard
- Core Facility Computational Bioanalytics, Medical University of Graz, Graz, Austria
| | - Andrea Berghold
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Alexander R Rosenkranz
- Department of Internal Medicine, Division of Nephrology, Medical University of Graz, Graz, Austria
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