Coronary artery disease in patients with chronic kidney disease: a clinical update

Outcomes of ultra-low contrast percutaneous coronary intervention in patients with advanced chronic kidney disease

BACKGROUND

Coronary angiography and percutaneous coronary intervention (PCI) in patients with chronic kidney disease (CKD) is associated with increased risk of contrast induced nephropathy (CIN) and requirement for renal replacement therapy (RRT).

OBJECTIVES

We aimed to evaluate our single center experience of ultra-low contrast PCI in patients with CKD and to characterize 1 year outcomes.

METHODS

We performed a retrospective analysis of ultra-low contrast PCI at our institution between 2016 and 2022. Patients with CKD3b-5 (eGFR <45 mL/min/1.73m2), not on RRT who underwent ultra-low contrast PCI ( < 30 mL of contrast during PCI) were included. Primary outcomes included change in eGFR post-procedurally, and death, RRT requirement, and major adverse cardiac events (MACE) at 1 year follow-up.

RESULTS

One hundred patients were included in the study. The median age was 67 years old and 28% were female. The median baseline eGFR was 21.5 mL/min/1.73m2 (IQR 14.08-32.0 mL/min/1.73m2). A median of 8.0 mL (IQR 0-15 mL) of contrast was used during PCI. Median contrast use to eGFR ratio was 0.37 (IQR 0-0.59). There was no significant difference between pre-and postprocedure eGFR (p = 0.84). At 1 year, 8% of patients died, 11% required RRT and 33% experienced MACE. The average time of RRT initiation was 7 months post-PCI. Forty-four patients were undergoing renal transplant evaluation, of which 17 (39%) received a transplant.

CONCLUSIONS

In patients with advanced CKD, ultra-low contrast PCI is feasible and safe with minimal need for peri-procedural RRT. Moreover, ultra-low contrast PCI may allow for preservation of renal function in anticipation of renal transplantation.

Coronary risk factor profiles according to different age categories in premature coronary artery disease patients who have undergone percutaneous coronary intervention

Many studies have investigated the coronary risk factors (CRFs) among premature coronary artery disease (PCAD) patients. However, reports on the proportion and CRFs of PCAD according to different age cut-offs for PCAD is globally under-reported. This study aimed to determine the proportion of PCAD patients and analyse the significant CRFs according to different age cut-offs among percutaneous coronary intervention (PCI)-treated patients. Patients who underwent PCI between 2007 and 2018 in two cardiology centres were included (n = 29,241) and were grouped into four age cut-off groups that defines PCAD: (A) Males/females: < 45, (B) Males: < 50; Females: < 55, (C) Males: < 55; Females: < 60 and (D) Males: < 55; Females: < 65 years old. The average proportion of PCAD was 28%; 9.2% for group (A), 21.5% for group (B), 38.6% and 41.9% for group (C) and (D), respectively. The top three CRFs of PCAD were LDL-c level, TC level and hypertension (HTN). Malay ethnicity, smoking, obesity, family history of PCAD, TC level and history of MI were the independent predictors of PCAD across all age groups. The proportion of PCAD in Malaysia is higher compared to other studies. The most significant risk factors of PCAD are LDL-c, TC levels and HTN. Early prevention, detection and management of the modifiable risk factors are highly warranted to prevent PCAD.

Serum Lipoprotein(a) Levels as a Predictor of Aortic Stiffness in Patients on Long-Term Peritoneal Dialysis

BACKGROUND Lipoprotein (a) [Lp(a)] is associated with atherosclerosis and cardiovascular mortality in patients with kidney failure. Aortic stiffness (AS), measured primarily by carotid-femoral pulse wave velocity (cfPWV), reflects vascular aging and precedes end-organ failure. This study aimed to evaluate the association between serum Lp(a) levels and cfPWV in patients undergoing peritoneal dialysis (PD). MATERIAL AND METHODS In this cross-sectional study, which included 148 patients with long-term PD for end-stage kidney failure, cfPWV was measured using a cuff-based method. AS was defined as a cfPWV exceeding 10 m/s, and an enzyme-linked immunosorbent assay was used to determine serum Lp(a) levels. Univariate and multivariate regression analyses were performed to identify the clinical correlates of AS. RESULTS There were 32 (21.6%) patients diagnosed with AS. Based on the multivariate logistic regression analysis, the odds ratio for AS was 1.007 (95% confidence interval, 1.003-1.011; P=0.001) for every 1 mg/L increase in Lp(a) levels. Multivariate linear regression analysis showed that Lp(a) (P<0.001), age (P=0.003), waist circumference (P=0.008), systolic blood pressure (P=0.010), and diabetes mellitus (P<0.001) were positively associated with cfPWV. The area under the receiver operating characteristic curve for Lp(a) in differentiating AS from non-AS was 0.770 (95% confidence interval, 0.694-0.835; P<0.0001). CONCLUSIONS Serum Lp(a) level was independently associated with cfPWV and AS in patients with PD.

Intramural coronary artery and myocardial pathology in captive tigers (Panthera tigris) and African lions (Panthera leo)

There is limited published data regarding cardiovascular disease in nondomestic felid populations. To address this knowledge gap, necropsy cases of tigers and lions with representative myocardial samples submitted to a diagnostic laboratory were histologically assessed with hematoxylin and eosin and Sirius red stains. A total of 32 submissions (15 tigers, 17 lions) were identified in a 4-year period. All tigers and lions had some degree of coronary artery lesions in the left ventricle and/or interventricular septum. Major findings included moderate to marked arteriosclerosis in 8 tigers (53%) and 4 lions (24%) and moderate to marked perivascular fibrosis in 10 tigers (67%) and 9 lions (53%). Moreover, 10 tigers (67%) and 8 lions (47%) had coronary artery lesions with variable degrees of perivascular cardiomyocyte degeneration and/or loss. To our knowledge, this is the first report describing coronary artery pathology in captive tigers and lions.

Progress in the Application of the Residual SYNTAX Score and Its Derived Scores

The residual SYNTAX score (rSS) is employed for the quantification of residual coronary lesions and to guide revascularization. rSS can be combined with other examinations to evaluate the severity of vascular disease and play an evaluative and guiding role in various scenarios. Furthermore, combining rSS with other indicators, benefits prognosis evaluation, and rSS-derived scores have been increasingly used in clinical practice. This article reviews the progress in the clinical application of rSS and its derived scores for complex coronary arteries and other aspects, based on relevant literature.

Exploring the relation between Interleukin-6 and high-sensitive cardiac troponin T in asymptomatic hemodialysis patient: A cross-sectional study

BACKGROUND

High-sensitive cardiac troponin T (h-cTnT), which serves as a marker for myocardial damage, has also been linked to adverse outcomes in asymptomatic hemodialysis patients. This study aims to explore the correlation between interleukin-6 (IL-6) and h-cTnT in asymptomatic hemodialysis patients to unravel the relationship between inflammation and cardiovascular risk.

METHODS

A cross-sectional study involving 81 patients was conducted from November 2022 to March 2023 at An-Najah National University Hospital in Palestine. We gathered clinical data, including comorbidities, and obtained blood samples for measuring IL-6 and h-cTnT levels. We performed statistical analyses, including correlation tests and linear regression, to assess the associations between these variables.

RESULTS

The study revealed a notable increase in both h-cTnT and IL-6 levels, and a significant correlation between the two (rho = 0.463, P<0.001) in asymptomatic hemodialysis patients. Likewise, h-cTnT levels displayed positive correlations with age (rho = 0.519, P<0.001) and negative correlations with albumin (rho = -0.297, p = 0.007) and transferrin saturation (rho = -0.227, P = 0.042). IL-6 levels exhibited correlations with age (rho = 0.422, P<0.001), albumin (rho = -0.389, P<0.001), iron (rho = -0.382, P<0.001), and transferrin saturation (rho = -0.362, P = 0.001). Notably, higher h-cTnT levels were associated with diabetes, hypertension, a history of coronary artery disease, cerebrovascular accidents, older age, and male gender.

CONCLUSION

This study underscores the significant association between the inflammatory marker IL-6 and h-cTnT in asymptomatic hemodialysis patients, suggesting that inflammation may play an essential role in the elevation of h-cTnT levels. This association may have implications for predicting cardiovascular events and guiding interventions to reduce cardiovascular disease morbidity and mortality in hemodialysis patients.

What Links Chronic Kidney Disease and Ischemic Cardiomyopathy? A Comprehensive Bioinformatic Analysis Utilizing Bulk and Single-Cell RNA Sequencing Data with Machine Learning

Chronic kidney disease (CKD) emerges as a substantial contributor to various cardiovascular disorders, including ischemic cardiomyopathy (ICM). However, the underlying molecular mechanisms linking CKD and ICM remain elusive. Our study aims to unravel these connections by integrating publicly available bulk and single-cell RNA sequencing (scRNA-seq) data. Expression profiles from two ICM datasets obtained from heart tissue and one CKD with Peripheral Blood Mononuclear Cell (CKD-PBMC) dataset were collected. We initiated by identifying shared differentially expressed genes (DEGs) between ICM and CKD. Subsequent functional enrichment analysis shed light on the mechanisms connecting CKD to ICM. Machine learning algorithms enabled the identification of 13 candidate genes, including AGRN, COL16A1, COL1A2, FAP, FRZB, GPX3, ITIH5, NFASC, PTN, SLC38A1, STARD7, THBS2, and VPS35. Their expression patterns in ICM were investigated via scRNA-seq data analysis. Notably, most of them were enriched in fibroblasts. COL16A1, COL1A2, PTN, and FAP were enriched in scar-formation fibroblasts, while GPX3 and THBS2 showed enrichment in angiogenesis fibroblasts. A Gaussian naïve Bayes model was developed for diagnosing CKD-related ICM, bolstered by SHapley Additive exPlanations interpretability and validated internally and externally. In conclusion, our investigation unveils the extracellular matrix's role in CKD and ICM interplay, identifies 13 candidate genes, and showcases their expression patterns in ICM. We also constructed a diagnostic model using 13 gene features and presented an innovative approach for managing CKD-related ICM through serum-based diagnostic strategies.

Tachycardia Therapy Outcomes of Ischemic Versus Nonischemic Cardiomyopathy on Cardiac Resynchronization Therapy: A Propensity Score-matched Analysis

Objective

This investigation aimed to investigate differences between dilated cardiomyopathy (DCM) and ischemic cardiomyopathy (ICM) patients treated with cardiac resynchronization therapy with defibrillator (CRT-D) for tachycardia therapy-related outcomes as well as mortality during follow-up of at least 1 year.

Methods

Seventy-eight patients with DCM (n = 42) and ICM (n = 36) with implantation or upgradation to CRT-D were included in this study and analyzed for incidence of non-sustained ventricular tachycardia (NSVT), non-sustained ventricular fibrillation (NSVF), defibrillator therapies, anti-tachycardia pacing (ATP), and mortality.

Results

DCM was the underlying etiology in 42 (53.84%) and ICM in 36 (46.15%). Time to first therapy was numerically longer in DCM than in ICM (9.5 ± 2.4 vs. 7.1 ± 3.2; P-value = 0.088). DCM patients had significantly higher therapy-free survival and mortality compared with ICM patients (OR (95%CI): 0.238 (0.155-0.424); log-rank P = 0.017) and (OR (95% CI): 0.612 (0.254-0.924); log-rank P = 0.029). ICM (HR (95%CI): 0.529 (0.243-0.925); P-value = 0.014) CAD (HR (95%CI): 0.326 (0.122-0.691): P-value = 0.003), and NSVT (HR (95%CI): 0.703 (0.513-0.849): P-value = 0.005) were demonstrated as independent predictors of the primary endpoint of appropriate therapy in CRT-D and ICM (HR (95%CI): 0.421 (0.321-0.524); P-value = 0.037), chronic kidney disease (CKD; HR (95%CI): 0.289 (0.198-0.380); P-value = 0.013), and CAD (HR (95%CI): 0.786 (0.531-0.967); P-value = 0.003) were predictors of mortality.

Conclusion

The clinical course of ICM and DCM cohorts who were treated with CRT-D differs significantly during follow-up, with increased tachycardia therapy and increased incidence of mortality in ICM patients.

Diagnosis of cardiovascular disease in patients with chronic kidney disease

Patients with chronic kidney disease (CKD) are at high risk of cardiovascular disease (CVD) and cardiovascular death. Identifying and monitoring cardiovascular complications and hypertension is important for managing patients with CKD or kidney failure and transplant recipients. Biomarkers of myocardial ischaemia, such as troponins and electrocardiography (ECG), have limited utility for diagnosing cardiac ischaemia in patients with advanced CKD. Dobutamine stress echocardiography, myocardial perfusion scintigraphy and dipyridamole stress testing can be used to detect coronary disease in these patients. Left ventricular hypertrophy and left ventricular dysfunction can be detected and monitored using various techniques with differing complexity and cost, including ECG, echocardiography, nuclear magnetic resonance, CT and myocardial scintigraphy. Atrial fibrillation and other major arrhythmias are common in all stages of CKD, and ambulatory heart rhythm monitoring enables precise time profiling of these disorders. Screening for cerebrovascular disease is only indicated in asymptomatic patients with autosomal dominant polycystic kidney disease. Standardized blood pressure is recommended for hypertension diagnosis and treatment monitoring and can be complemented by ambulatory blood pressure monitoring. Judicious use of these diagnostic techniques may assist clinicians in detecting the whole range of cardiovascular alterations in patients with CKD and enable timely treatment of CVD in this high-risk population.

Intravascular Imaging in Patients With Complex Coronary Lesions and Chronic Kidney Disease

Importance

As patients with chronic kidney disease (CKD) are more likely to have complex coronary lesions, intravascular imaging guidance in percutaneous coronary intervention (PCI) for this population could be potentially beneficial.

Objectives

To investigate whether the outcomes of intravascular imaging-guided procedural optimization would be different according to the presence of CKD.

Design, Setting, and Participants

This was a prespecified substudy of RENOVATE-COMPLEX-PCI, a recently published multicenter randomized clinical trial in Korea studying the benefits of intravascular imaging for complex coronary lesions. Patients with complex coronary lesions, with or without CKD, were enrolled between May 2018 and May 2021. Data were analyzed from January to June 2023.

Interventions

PCI in each group was done either under the guidance of intravascular imaging or angiography alone.

Main Outcomes and Measures

The primary end point was target vessel failure (TVF) at the 3-year point, defined as a composite of cardiac death, target vessel-related myocardial infarction, or clinically driven target vessel revascularization.

Results

A total of 1639 patients (1300 male [79.3%]) treated with PCI for complex coronary lesions were stratified into CKD (296 participants) and non-CKD (1343 participants) groups. The mean (SD) age of each group was 70.3 (9.4) and 64.5 (10.1) years, and mean (SD) estimated serum creatinine was 2.9 (5.3) and 0.8 (0.2) mg/dL for CKD and non-CKD groups, respectively. Intravascular imaging-guided revascularization was associated with significantly lower incidence of the primary end point compared with angiography-guided revascularization in both CKD (13.3% vs 23.3%; hazard ratio [HR], 0.51; 95% CI, 0.27-0.93; P = .03) and non-CKD (6.4% vs 9.9%; HR, 0.66; 95% CI, 0.44-0.99; P = .05) groups. The significantly lower incidence of the primary end point was mainly associated with the lower risk of cardiac death or target vessel-related myocardial infarction (9.4% vs 22.2%; HR, 0.39; 95% CI, 0.20-0.76; P = .006) in the CKD group and by target vessel revascularization (3.0% vs 5.5%; HR, 0.55; 95% CI, 0.30-0.99; P = .05) in the non-CKD group. Those with a glomerular filtration rate of at least 30 mL/min/1.73m2 and less than 60 ml/kg/1.73m2 showed the greatest benefit from imaging-guided complex PCI (8.8% vs 21.2%; HR, 0.28; 95% CI, 0.11-0.68; P = .02).

Conclusions and Relevance

In this prespecified cohort substudy of the Randomized Controlled Trial of Intravascular Imaging Guidance versus Angiography-Guidance on Clinical Outcomes After Complex Percutaneous Coronary Intervention trial, intravascular imaging guidance showed clinical benefit over angiography guidance in reducing the risk of TVF, regardless of the presence of CKD. The greatest benefits of imaging-guided complex PCI were observed in stage 3 CKD.

Trial Registration

ClinicalTrials.gov Identifier: NCT03381872.

Effects of Omega-3 Fatty Acids on Flow-mediated Dilatation and Carotid Intima Media Thickness: A Meta-analysis

PURPOSE OF REVIEW

To investigate the effects of omega-3 fatty acids on flow-mediated dilatation (FMD) and carotid intima-media thickness (CIMT) and explore the factors influencing these effects.

RECENT FINDINGS

FMD was significantly higher in the omega-3 fatty acid group compared to the control group (mean difference = 0.90%; p = 0.0003). In particular, the subgroup with CHD (both EPA + DHA < 1 g/day and ≥ 1 g/day) and the subgroup without CHD but with CHD risk factors (only EPA + DHA ≥ 1 g/day) showed significantly increased FMD after supplementation of omega-3 fatty acids. CIMT was not significantly different between the omega-3 fatty acid and control groups (standardized mean difference = -0.08; p = 0.26). Subgroup analysis of CHD patients was not conducted because of the limited number of studies. Intake of omega-3 fatty acids improved FMD in patients with CHD and patients with risk factors for CHD. Further research is needed on the effects of omega-3 fatty acids on CIMT.

Outcomes Associated with Sodium-Glucose Cotransporter-2 Inhibitor Use in Acute Heart Failure Hospitalizations Complicated by AKI

Key Points

In a multicenter retrospective cohort study of adults hospitalized with acute heart failure, exposure to sodium-glucose cotransporter-2 inhibitor during AKI was associated with lower risk of 30-day mortality. Exposure to sodium-glucose cotransporter-2 inhibitor during acute heart failure–associated AKI was associated with no difference in time to renal recovery. The findings were reproducible in inverse probability-weighted analysis.

Background

Although sodium-glucose cotransporter-2 inhibitor (SGLT2i) use during acute heart failure (AHF) hospitalizations is associated with symptomatic improvement, reduction in rehospitalizations, and mortality, these medications are often withheld during AKI because of concerns about worsening GFR. We aimed to investigate the safety of SGLT2i exposure during AKI among patients hospitalized with AHF. We hypothesized that SGLT2i exposure would not worsen mortality but may prolong return of creatinine to baseline.

Methods

This was a retrospective study of adults hospitalized across five Yale New Haven Health System hospitals between January 2020 and May 2022 with AHF complicated by Kidney Disease Improving Global Outcomes–defined AKI. Patients with stage 5 CKD and those with potential contraindications to SGLT2i were excluded. We tested the association of SGLT2i use with kidney function recovery at 14 days and death at 30 days using time-varying, multivariable Cox-regression analyses.

Results

Of 3305 individuals hospitalized with AHF and AKI, 356 received SGLT2i after AKI diagnosis either as initiation or continuation. The rate of renal recovery was not significantly different among those exposed and unexposed to SGLT2i after AKI (adjusted hazard ratio, 0.94; 95% confidence interval, 0.79 to 1.11; P = 0.46). SGLT2i exposure was associated with lower risk of 30-day mortality (adjusted hazard ratio, 0.45; 95% confidence interval, 0.23 to 0.87; P = 0.02). Sensitivity analyses using an inverse probability-weighted time-varying Cox regression analysis and using alternate definitions of AHF with different NT-proBNP cutoffs yielded similar results. Rates of renal recovery were similar between the exposed and unexposed cohorts regardless of the proximity of SGLT2i exposure to AKI diagnosis.

Conclusion

In adults experiencing AHF-associated AKI, exposure to SGLT2i was associated with decreased mortality and no delay in renal recovery. Prospective studies are needed to elucidate the effect of SGLT2i exposure during AKI, particularly during heart failure hospitalizations.

The Relationship Between C-reactive Protein Albumin Ratio and Long-Term Mortality in Patients With Acute Coronary Syndrome

Background Coronary artery disease (CAD) is one of the leading causes of death worldwide. CRP/albumin ratio is a sensitive indicator of inflammatory status. It has been shown that this parameter may be associated with poor short-term outcomes in CAD. In this study, we investigated the relationship between long-term mortality and the CRP/albumin ratio in patients with acute coronary syndromes (ACS). Material and methods This study was conducted on patients who applied to our hospital between January 2015 and December 2019 and were diagnosed with ACS. A total of 1689 patients were included in the study. Patients were divided into two groups according to mortality status, and long-term mortality predictors were investigated. Results The average follow-up period was 38.9±10.3 months. The mean age of the entire study group was 56.6±12.2 years, and 1440 (80.5%) of the patients were male. Comorbid diseases and blood parameters were significant between the two groups. In the regression analysis, creatine, hemoglobin, white blood cell count (WBC), neutrophil-lymphocyte ratio (NLR), and CRP albumin ratio (CAR) were found to be independent predictors. In the ROC analysis, it was observed that CAR had the best predictive value. Discussion An increased CAR level is an independent predictor of long-term mortality in ACS patients. It can be used in both short-term and long-term risk stratification for ACS patients.

Complete surgical myocardial revascularization in patients with declined renal functions: 12-month outcomes

INTRODUCTION

This retrospective observational study aimed to evaluate the feasibility and effectiveness of complete revascularization coronary artery bypass grafting (CABG) in patients with multi-vessel disease (MVD)-CAD and declined renal functions, addressing the knowledge gap regarding optimal treatment strategies and outcomes in this specific patient population.

METHODS

Between 2020 and 2022, a total of 58 patients underwent on-pump coronary artery bypass grafting surgery for complete myocardial revascularization in this study. To assess overall survival, Kaplan-Meier with the log-rank test was conducted for statistical analysis.

RESULTS

The mean age of cohort was 60.7. The findings showed a high prevalence of medical conditions such as hypertension (50.0%), diabetes (50.0%), and anaemia (41.4%) among the participants. Intraoperatively, low cardiac output syndrome was reported in 5.2% of cases, while perioperative outcomes indicated a need for transfusions in 53.5% of cases and an in-hospital mortality rate of 3.4%. At the 12-month follow-up, no redo revascularization or renal replacement therapy was required, but cardiac mortality was 5.2% and all-cause mortality was 6.9%.

CONCLUSIONS

The study concluded that complete revascularization is safe for these patients and highlights the potential benefits, emphasizing the need for further research in optimizing revascularization techniques for this population.

Genome-wide meta-analysis identifies new candidate genes for sickle cell disease nephropathy

Sickle cell disease nephropathy (SCDN), a common SCD complication, is strongly associated with mortality. Polygenic risk scores calculated from recent transethnic meta-analyses of urinary albumin-to-creatinine ratio and estimated glomerular filtration rate (eGFR) trended toward association with proteinuria and eGFR in SCD but the model fit was poor (R2 < 0.01), suggesting that there are likely unique genetic risk factors for SCDN. Therefore, we performed genome-wide association studies (GWAS) for 2 critical manifestations of SCDN, proteinuria and decreased eGFR, in 2 well-characterized adult SCD cohorts, representing, to the best of our knowledge, the largest SCDN sample to date. Meta-analysis identified 6 genome-wide significant associations (false discovery rate, q ≤ 0.05): 3 for proteinuria (CRYL1, VWF, and ADAMTS7) and 3 for eGFR (LRP1B, linc02288, and FPGT-TNNI3K/TNNI3K). These associations are independent of APOL1 risk and represent novel SCDN loci, many with evidence for regulatory function. Moreover, GWAS SNPs in CRYL1, VWF, ADAMTS7, and linc02288 are associated with gene expression in kidney and pathways important to both renal function and SCD biology, supporting the hypothesis that SCDN pathophysiology is distinct from other forms of kidney disease. Together, these findings provide new targets for functional follow-up that could be tested prospectively and potentially used to identify patients with SCD who are at risk, before onset of kidney dysfunction.

Coronary Artery Disease in CKD-G5D Patients: An Update

Patients with chronic kidney disease treated by dialysis (CKD-G5D) are characterized by a high prevalence of coronary artery disease (CAD). Such patients differ from non-uremic CAD patients and have been excluded from several clinical CAD trials. CKD-G5D patients may be asymptomatic for their CAD, making their risk stratification and management challenging. This review will focus on the incidence, epidemiology, pathophysiology, screening tools, and management/treatment of CAD in CKD-G5D patients. It will also review recent studies concerning the screening tools and management strategies available for these patients. The need for improved evaluation of cardiovascular risk factors, screening and early intervention for symptomatic CAD in CKD-G5D patients will be highlighted.

Intravascular Ultrasound Guidance During Peripheral Vascular Interventions: Long-term Clinical Outcomes and Costs From the Japanese Perspective

PURPOSE

The value of intravascular ultrasound (IVUS) guidance during peripheral vascular revascularization procedures is incompletely understood. Moreover, data on long-term clinical outcomes and costs are limited. The objective of this study was to compare outcomes and costs between IVUS and contrast angiography alone in patients undergoing peripheral revascularization procedures in Japan.

MATERIALS AND METHODS

This retrospective comparative analysis was performed using the Japanese Medical Data Vision insurance claims database. All patients undergoing revascularization for peripheral artery disease (PAD) between April 2009 and July 2019 were included. Patients were followed until July 2020, death, or a subsequent revascularization procedure for PAD. Two patient groups were compared: one undergoing IVUS imaging or the other contrast angiography alone. The primary end point was major adverse cardiac and limb events, including all-cause-mortality, endovascular thrombolysis, subsequent revascularization procedures for PAD, stroke, acute myocardial infarction, and major amputations. Total health care costs were documented over the follow-up and compared between groups, using a bootstrap method.

RESULTS

The study included 3956 patients in the IVUS group and 5889 in the angiography alone group. Intravascular ultrasound was significantly associated with reduced risk of a subsequent revascularization procedure (adjusted hazard ratio: 0.25 [0.22-0.28]) and major adverse cardiac and limb events (0.69 [0.65-0.73]). The total costs were significantly lower in the IVUS group, with a mean cost saving over follow-up of $18 173 [$7 695-$28 595] per patient.

CONCLUSION

The use of IVUS during peripheral revascularization provides superior long-term clinical outcomes at lower costs compared with contrast angiography alone, warranting wider adoption and fewer barriers to IVUS reimbursement for patients with PAD undergoing routine revascularization.

CLINICAL IMPACT

Intravascular ultrasound (IVUS) guidance during peripheral vascular revascularization has been introduced to improve the precision of the procedure. However, questions over the benefit of IVUS in terms of long-term clinical outcome and over cost have limited its use in everyday clinical practice. This study, performed in a Japanese health insurance claims database, demonstrates that use of IVUS provides a superior clinical outcome over the long term at a lower cost compared to angiography alone. These findings should encourage clinicians to use IVUS in routine peripheral vascular revascularization procedures and encourage providers to reduce barriers to use.

Two-Dimensional Transthoracic Echocardiography-Based Diagnosis of Right Ventricular Aneurysm: A Neglected Issue in Patients with Coronary Artery Disease: Case Series and Literature Review

Right ventricular (RV) aneurysm is a very rare ventricular lesion. An aneurysm is formed mainly as a complication of myocardial infarction (MI). As an RV aneurysm is a potentially life-threatening occurrence, its appropriate diagnosis is of great significance. However, right-sided heart diseases, especially RV aneurysms, have been neglected for years. Recent studies in the literature have elucidated the role of the right side of the heart in patients' prognosis and response to treatment. However, RV aneurysm has been scarcely investigated, and most of the attention has been given to the left ventricular aneurysm in patients with ischemic heart diseases (IHD). Herein, we investigated a total of 625 patients with IHD referred for two-dimensional transthoracic echocardiography (2D TTE), among whom 18 were diagnosed with RV aneurysms through precise examination of several TTE views. The characteristics of these cases, including demographics, medical history, and results of cardiac tests (which the patients underwent previously), were recorded and presented. This study emphasized the importance of performing a meticulous 2D TTE evaluation and a thorough examination of different views by an expert echocardiographer, with special attention to the presence of an RV aneurysm in a patient suffering from IHD who presented either with acute coronary syndrome, including MI, or chronic IHD. The scarcity of information, especially in terms of complications and the most appropriate diagnostic methods, calls for further studies in this regard.

Evaluation of transitions from early hypertension to hypertensive chronic kidney disease, coronary artery disease, stroke and mortality: a Thai real-world data cohort

Objective

Systemic arterial hypertension (HT) is a major modifiable risk factor for cardiovascular disease (CVDs), associated with all-cause death (ACD). Understanding its progression from the early state to late complications should lead to more timely intensification of treatment. This study aimed to construct a real-world cohort profile of HT and to estimate transition probabilities from the uncomplicated state to any of these long-term complications; chronic kidney disease (CKD), coronary artery disease (CAD), stroke, and ACD.

Methods

This real-world cohort study used routine clinical practice data for all adult patients diagnosed with HT in the Ramathibodi Hospital, Thailand from 2010 to 2022. A multi-state model was developed based on the following: state 1-uncomplicated HT, 2-CKD, 3-CAD, 4-stroke, and 5-ACD. Transition probabilities were estimated using Kaplan-Meier method.

Results

A total of 144,149 patients were initially classified as having uncomplicated HT. The transition probabilities (95% CI) from the initial state to CKD, CAD, stroke, and ACD at 10-years were 19.6% (19.3%, 20.0%), 18.2% (17.9%, 18.6%), 7.4% (7.1%, 7.6%), and 1.7% (1.5%, 1.8%), respectively. Once in the intermediate-states of CKD, CAD, and stroke, 10-year transition probabilities to death were 7.5% (6.8%, 8.4%), 9.0% (8.2%, 9.9%), and 10.8% (9.3%, 12.5%).

Conclusions

In this 13-year cohort, CKD was observed as the most common complication, followed by CAD and stroke. Among these, stroke carried the highest risk of ACD, followed by CAD and CKD. These findings provide improved understanding of disease progression to guide appropriate prevention measures. Further investigations of prognostic factors and treatment effectiveness are warranted.

Association between urinary chloride excretion and progression of coronary artery calcification in patients with nondialysis chronic kidney disease: results from the KNOW-CKD study

BACKGROUND

Urine chloride has recently been suggested as a biomarker of renal tubule function in patients with nondialysis chronic kidney disease (CKD), as low urinary chloride concentration is associated with an increased risk of CKD progression. We investigate the association between urinary chloride excretion and the progression of coronary artery calcification (CAC).

METHODS

A total of 1,065 patients with nondialysis CKD were divided into tertiles by spot urine chloride-to-creatinine ratios. The 1st, 2nd, and 3rd tertiles were defined as low, moderate, and high urinary chloride excretion, respectively. The study outcome was CAC progression, which was defined as an increase in coronary artery calcium score of more than 200 Agatston units during the 4-year follow-up period.

RESULTS

Compared to moderate urinary chloride excretion, high urinary chloride excretion was associated with decreased risk of CAC progression (adjusted odds ratio, 0.379; 95% confidence interval, 0.190-0.757), whereas low urinary chloride excretion was not associated with risk of CAC progression. Restricted cubic spine depicted an inverted J-shaped curve, with a significant reduction in the risk of CAC progression in subjects with high spot urine chloride-to-creatinine ratios.

CONCLUSION

High urinary chloride excretion is associated with decreased risk of CAC progression in patients with nondialysis CKD.

Combined assessment of frailty and nutritional status can be a prognostic indicator after percutaneous coronary intervention

The cardiac prognosis of patients with frailty and malnutrition remains poorly investigated. This study aimed to investigate the impact of frailty and malnutrition on cardiac prognosis by combining the clinical frailty scale (CFS) and the geriatric nutritional risk index (GNRI) in patients who underwent percutaneous coronary intervention (PCI). In this study, 608 patients who underwent PCI for stable angina pectoris between January 2018 and December 2020 were included. CFS scores of ≥ 4 were defined as high CFS and patients with these scores were considered frail. GNRI scores of ≤ 98.0 were defined as low GNRI and patients with these scores were considered to have malnutrition. Patients were categorized into low-risk (n = 267, low CFS and high GNRI), intermediate-risk (n = 200, high CFS or low GNRI), and high-risk (n = 141, high CFS and low GNRI) groups. Major adverse clinical events (MACEs), including all-cause death, nonfatal myocardial infarction, revascularization, hospitalization for heart failure, and stroke, were assessed. The median follow-up period was 529 days. During the follow-up, MACEs were found in 135 patients. The high-risk group were older (77.0 ± 9.2 vs 71.4 ± 10.7 vs 65.0 ± 10.1 years, p < 0.001), had higher prevalence rates of chronic kidney disease [61.7% (87/141) vs 37.5% (75/200) vs 16.9% (45/267); p < 0.001] and heart failure [47.5% (67/141) vs 22.5% (45/200) vs 12.4% (33/267), p < 0.001], and had higher C-reactive protein levels (1.64 ± 2.66 vs 1.00 ± 2.02 vs 0.34 ± 0.90 mg/dL; p < 0.001) than the intermediate-risk and low-risk groups. The high-risk group [hazard ratio (HR), 4.39; 95% confidence interval (CI), 2.87-6.72; p < 0.001] was an independent predictor of MACEs. In conclusion, patients with both frailty and malnutrition had a higher risk of MACEs after PCI than patients with frailty or malnutrition. Post-PCI patients should be evaluated for combined frailty and malnutrition.

Performance of the 2019 ESC/EASD guideline strategy for the screening of silent coronary artery disease in patients with diabetes

BACKGROUND

The 2019 guidelines for cardiovascular risk stratification by the European Society of Cardiology and European Association for the Study of Diabetes (ESC-EASD) suggested screening for silent coronary disease in very high risk patients with severe target organ damage (TOD) (i.e. peripheral occlusive arterial disease or severe nephropathy) or high coronary artery calcium (CAC) score. This study aimed to test the validity of this strategy.

METHODS

In this retrospective study, we included 385 asymptomatic patients with diabetes and no history of coronary disease but with TOD or ≥ 3 risk factors in addition to diabetes. CAC score was measured using computed tomography scan and a stress myocardial scintigraphy was performed to detect silent myocardial ischemia (SMI), with subsequent coronary angiography in those with SMI. Various strategies to select patients to be screened for SMI were tested.

RESULTS

CAC score was ≥ 100 Agatston units (AU) in 175 patients (45.5%). SMI was present in 39 patients (10.1%) and among the 30 patients who underwent angiography, 15 had coronary stenoses and 12 had a revascularization procedure. The most effective strategy consisted in performing myocardial scintigraphy in the 146 patients with severe TOD and, among the 239 other patients without severe TOD, in those with CAC ≥ 100 AU: this strategy provided 82% sensitivity for SMI diagnosis, and identified all the patients with stenoses.

CONCLUSION

The ESC-EASD guidelines suggesting SMI screening in asymptomatic patients with very high risk assessed by severe TOD or high CAC score appears effective and could identify all the patients with stenoses eligible for revascularization.

Downregulation of Circulating Hsa-miR-200c-3p Correlates with Dyslipidemia in Patients with Stable Coronary Artery Disease

Coronary heart disease (CHD), one of the leading causes of disability and death worldwide, is a multifactorial disease whose early diagnosis is demanding. Thus, biomarkers predicting the occurrence of this pathology are of great importance from a clinical and therapeutic standpoint. By means of a pilot study on peripheral blood cells (PBMCs) of subjects with no coronary lesions (CTR; n = 2) and patients with stable CAD (CAD; n = 2), we revealed 61 differentially methylated regions (DMRs) (18 promoter regions, 24 genes and 19 CpG islands) and 14.997 differentially methylated single CpG sites (DMCs) in CAD patients. MiRNA-seq results displayed a peculiar miRNAs profile in CAD patients with 18 upregulated and 32 downregulated miRNAs (FC ≥ ±1.5, p ≤ 0.05). An integrated analysis of genome-wide DNA methylation and miRNA-seq results indicated a significant downregulation of hsa-miR-200c-3p (FCCAD = −2.97, p ≤ 0.05) associated to the hypermethylation of two sites (genomic coordinates: chr12:7073122-7073122 and chr12:7072599-7072599) located intragenic to the miR-200c/141 genomic locus (encoding hsa-miR-200c-3p) (p-value = 0.009) in CAD patients. We extended the hsa-miR-200c-3p expression study in a larger cohort (CAD = 72, CTR = 24), confirming its reduced expression level in CAD patients (FCCAD = −2; p = 0.02). However, when we analyzed the methylation status of the two CpG sites in the same cohort, we failed to identify significant differences. A ROC curve analysis showed good performance of hsa-miR-200c-3p expression level (AUC = 0.65; p = 0.02) in distinguishing CAD from CTR. Moreover, we found a significant positive correlation between hsa-miR-200c-3p expression and creatinine clearance (R2 = 0.212, p < 0.005, Pearson r = 0.461) in CAD patients. Finally, a phenotypic correlation performed in the CAD group revealed lower hsa-miR-200c-3p expression levels in CAD patients affected by dyslipidemia (+DLP, n = 58) (p < 0.01). These results indicate hsa-miR-200c-3p as potential epi-biomarker for the diagnosis and clinical progression of CAD and highlight the importance of deeper studies on the expression of this miRNA to understand its functional role in coronary artery disease development.

Clinical Outcomes and Predictors of All-Cause Mortality After Complex High-Risk and Indicated Revascularization Using Percutaneous Coronary Intervention

The concept of complex and high-risk indicated procedures using percutaneous coronary intervention (CHIP-PCI) has recently been defined. However, few studies have investigated the prognosis of patients after CHIP-PCI. We enrolled 322 consecutive patients who underwent CHIP-PCI. CHIP-PCI was defined as a procedure satisfying at least one criterion each for both patient and procedure characteristics, as follows: patient characteristics [age ≥ 75 years old, low left ventricular ejection fraction (LVEF), diabetes mellitus, acute coronary syndrome, previous coronary artery bypass surgery, peripheral arterial disease, severe chronic kidney disease (CKD), chronic obstructive pulmonary disease (COPD), and severe valvular disease] and procedure characteristics [unprotected left main disease, degenerated saphenous or radial artery grafts, severely calcified lesions, last patent conduit, chronic total occlusions, multivessel disease, and use of mechanical circulatory support]. On Kaplan-Meier analysis, 1-, 2-, and 3-year survival rates following CHIP-PCI was 93.8%, 89.2%, and 85.4%, respectively. Moreover, on Cox multivariate hazard analysis, age (≥ 75 years old) (hazard ratio: 4.01, 95% confidence interval: 1.92-8.38, P < 0.01), COPD (hazard ratio: 2.95, 95% confidence interval: 1.38-6.32, P < 0.01), low LVEF (hazard ratio: 3.35, 95% confidence interval: 1.55-7.22, P < 0.01), severe CKD (hazard ratio: 3.02, 95% confidence interval: 1.44-6.36, P < 0.01), and use of mechanical circulatory support (hazard ratio: 5.97, 95% confidence interval: 2.72-13.10, P < 0.01) remained significant predictors of mortality. In conclusion, we revealed the clinical outcomes after CHIP-PCI. The presence of advanced age, COPD, low LVEF, severe CKD, and mechanical circulatory support use might lead to worse clinical outcomes.

Rate and Risk Factors of Acute Myocardial Infarction after Debut of Chronic Kidney Disease-Results from the KidDiCo

Chronic kidney disease (CKD) is a known risk factor for cardiovascular disease, including acute myocardial infarction. However, whether this risk is only associated with severe kidney disease or is also related to mildly impaired kidney function is still under debate. The incidence rate and risk factors of incident acute myocardial infarction (AMI) in patients with CKD are sparse. Potential differences in risk factor profiles between CKD patients with incident AMI and CKD patients with a prior AMI have not been sufficiently investigated. Furthermore, important factors such as albuminuria and socio-economic factors are often not included. The primary aim of this study was to establish the incidence rate of AMI after CKD debut. Secondly, to evaluate the importance of different CKD stages and the risk of having an AMI. Finally, to identify individuals at risk for AMI after CKD debut adjusted for prevalent AMI. Based on data from the kidney disease cohort of Southern Denmark (KidDiCo), including 66,486 CKD patients, we established incidence rates and characteristics of incident AMI among patients within a 5-year follow-up period after CKD debut. A Cox regression was performed to compute the cause-specific hazard ratios for the different risk factors. The incidence rate for CKD stage G3−5 patients suffering acute myocardial infarction is 2.5 cases/1000 people/year. In patients without a previous myocardial infarction, the risk of suffering a myocardial infarction after CKD debut was only significant in CKD stage G4 (HR = 1.402; (95% CI: 1.08−1.81); p-value = 0.010) and stage G5 (HR = 1.491; (95% CI: 1.01−2.19); p-value = 0.042). This was not the case in patients who had suffered an acute myocardial infarction prior to their CKD debut. In this group, a previous myocardial infarction was the most critical risk factor for an additional myocardial infarction after CKD debut (HR = 2.615; (95% CI: 2.241−3.05); p-value < 0.001). Irrespective of a previous myocardial infarction, age, male sex, hypertension, and a low educational level were significant risk factors associated with an acute myocardial infarction after CKD debut. The incidence rate of AMI in patients with CKD stage G3−5 was 2.5 cases/1000 people/year. Risk factors associated with incident AMI in CKD stage G3−5 patients were CKD stage, age, and hypertension. Female sex and higher educational levels were associated with a lower risk for AMI. Prior AMI was the most significant risk factor in patients with and without previous AMI before fulfilling CKD stage G3−5 criteria. Only age, sex, and a medium-long educational level were significant risk factors in this group.

Prognostic Impact of Coronary Flow Reserve in Patients With CKD

Introduction

Both coronary flow reserve (CFR) and chronic kidney disease (CKD) are known to be associated with adverse cardiac events. However, it is unclear how these prognostic factors are interrelated. This study evaluated the association between intracoronary physiologic indexes and CKD and their prognostic implications.

Methods

A total of 351 patients without left ventricular systolic dysfunction (ejection fraction ≥ 40%) and not on dialysis whose revascularization was deferred based on fractional flow reserve (FFR) > 0.80 were analyzed. Depressed CFR was defined as CFR ≤ 2.0. The primary outcome was a composite of cardiac death or hospitalization for heart failure at 3 years.

Results

Patients with CKD showed lower CFR than the non-CKD population (3.28 ± 1.77 vs. 2.60 ± 1.09, P < 0.001), mainly driven by increased resting coronary flow. There was no significant difference in hyperemic coronary flow, FFR, and index of microvascular resistance between the 2 groups. CFR was significantly associated with estimated glomerular filtration rate (eGFR) (P = 0.045), and the proportion of depressed CFR was significantly increased with higher CKD stages (P = 0.011). The risk of cardiac death or hospitalization for heart failure was the lowest in the non-CKD and preserved CFR group (11.9%) and the highest in the CKD and depressed CFR group (60.0%, overall log rank P < 0.001). Both CKD (adjusted hazard ratio [HR_adj] 2.614, 95% confidence interval [CI] 1.505-4.539, P < 0.001) and depressed CFR (HR_adj 3.237, 95% CI 2.015-5.199, P < 0.001) were independently associated with the risk of the primary outcome.

Conclusion

There was a significant association between severity of CKD and CFR. Both CKD and depressed CFR showed independent association with higher risk of cardiac death or hospitalization for heart failure.

Comparison of long-term cardiovascular and renal outcomes between percutaneous coronary intervention and coronary artery bypass grafting in multi-vessel disease with chronic kidney disease

Objective

This study aims to analyze cardiac and renal outcomes of chronic kidney disease (CKD) patients with multi-vessel disease who have undergone coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI).

Materials and methods

Chronic kidney disease patients with multi-vessel disease who underwent CABG or PCI were retrospectively selected from our database and divided into the PCI group [further stratified into PCI with complete revascularization (PCI-CR) and PCI with incomplete revascularization (PCI-IR) groups] and the CABG group. The primary endpoint was the composite of all-cause death, myocardial infarction (MI), or stroke at 5 years. The key secondary endpoint was the 5-year rate of the renal composite outcome, defined as >40% glomerular filtration rate decrease, initiation of dialysis, and/or kidney transplant. Outcomes were compared using Cox proportional hazards regression analysis, and the results were further adjusted by multivariable analyses and inverse probability weighting.

Results

Among the study population (n = 798), 443 (55.5%) patients received CABG and 355 (44.5%) patients received PCI. Compared with the CABG group, the PCI group had similar risk of the primary endpoint (CABG vs. PCI, 19.3% vs. 24.0%, HR: 1.28, 95% CI: 0.95–1.73, p = 0.11) and a lower risk of the renal composite outcome (36.6% vs. 31.2%, HR: 0.74, 95% CI 0.58–0.94, p = 0.03). In addition, PCI-IR was associated with a significantly higher risk of the primary endpoint than CABG (HR: 1.54, 95% CI: 1.11–2.13, p = 0.009) or PCI-CR (HR: 1.78, 95% CI: 1.09–2.89, p = 0.02). However, PCI-CR had a comparable 5-year death, MI, or stroke rate to CABG (HR: 0.86, 95% CI 0.54–1.38, p = 0.54).

Conclusion

Coronary artery bypass grafting showed an incidence of death, MI, or stroke similar to PCI but was associated with a higher risk of renal injury. PCI-CR had a prognosis comparable with that of CABG, while PCI-IR had worse prognosis. If PCI is chosen for revascularization in patients with CKD, achieving CR should be attempted to ensure favorable outcomes.

Clinical trial registration

[clinicaltrials.gov], identifier [NCT 03870815].

LeMeDISCO is a computational method for large-scale prediction & molecular interpretation of disease comorbidity

To understand the origin of disease comorbidity and to identify the essential proteins and pathways underlying comorbid diseases, we developed LeMeDISCO (Large-Scale Molecular Interpretation of Disease Comorbidity), an algorithm that predicts disease comorbidities from shared mode of action proteins predicted by the artificial intelligence-based MEDICASCY algorithm. LeMeDISCO was applied to predict the occurrence of comorbid diseases for 3608 distinct diseases. Benchmarking shows that LeMeDISCO has much better comorbidity recall than the two molecular methods XD-score (44.5% vs. 6.4%) and the S_AB score (68.6% vs. 8.0%). Its performance is somewhat comparable to the phenotype method-based Symptom Similarity Score, 63.7% vs. 100%, but LeMeDISCO works for far more cases and its large comorbidity recall is attributed to shared proteins that can help provide an understanding of the molecular mechanism(s) underlying disease comorbidity. The LeMeDISCO web server is available for academic users at: http://sites.gatech.edu/cssb/LeMeDISCO .

Influence of concomitant percutaneous transluminal angioplasty with percutaneous coronary intervention on clinical outcomes of stable lower extremity artery diseases

Concomitant percutaneous transluminal angioplasty (PTA) at the time of percutaneous coronary intervention (PCI) is often performed because lower extremity artery disease (LEAD) commonly coincides with coronary artery disease. We investigated the impact of concomitant PTA on both cardiovascular and limb outcomes in the Korean National Health Insurance Service registry. Among 78,185 patients undergoing PCI, 6563 patients with stable LEAD without limb ischemia were included. After 1:5 propensity score matching was conducted, 279 patients in the PTA + PCI group and 1385 patients in the PCI group were compared. Multivariate Cox proportional hazard models showed that the risk of all-cause death was higher in the PTA + PCI group than in the PCI group, whereas the risks of myocardial infarction, repeat revascularization, stroke, cardiovascular death and bleeding events were not different between the 2 groups. In contrast, the risks of end-stage renal disease and unfavorable limb outcomes were higher in the PTA + PCI group. Mediation analyses revealed that amputation and PTA after discharge significantly mediated the association between concomitant PTA and all-cause death. Concomitant PTA was not associated with an increased risk of cardiovascular events but may increase the risk of all-cause death mediated by unfavorable renal and limb outcomes in patients with stable LEAD.

Network Embedding Across Multiple Tissues and Data Modalities Elucidates the Context of Host Factors Important for COVID-19 Infection

COVID-19 is a heterogeneous disease caused by SARS-CoV-2. Aside from infections of the lungs, the disease can spread throughout the body and damage many other tissues, leading to multiorgan failure in severe cases. The highly variable symptom severity is influenced by genetic predispositions and preexisting diseases which have not been investigated in a large-scale multimodal manner. We present a holistic analysis framework, setting previously reported COVID-19 genes in context with prepandemic data, such as gene expression patterns across multiple tissues, polygenetic predispositions, and patient diseases, which are putative comorbidities of COVID-19. First, we generate a multimodal network using the prior-based network inference method KiMONo. We then embed the network to generate a meaningful lower-dimensional representation of the data. The input data are obtained via the Genotype-Tissue Expression project (GTEx), containing expression data from a range of tissues with genomic and phenotypic information of over 900 patients and 50 tissues. The generated network consists of nodes, that is, genes and polygenic risk scores (PRS) for several diseases/phenotypes, as well as for COVID-19 severity and hospitalization, and links between them if they are statistically associated in a regularized linear model by feature selection. Applying network embedding on the generated multimodal network allows us to perform efficient network analysis by identifying nodes close by in a lower-dimensional space that correspond to entities which are statistically linked. By determining the similarity between COVID-19 genes and other nodes through embedding, we identify disease associations to tissues, like the brain and gut. We also find strong associations between COVID-19 genes and various diseases such as ischemic heart disease, cerebrovascular disease, and hypertension. Moreover, we find evidence linking PTPN6 to a range of comorbidities along with the genetic predisposition of COVID-19, suggesting that this kinase is a central player in severe cases of COVID-19. In conclusion, our holistic network inference coupled with network embedding of multimodal data enables the contextualization of COVID-19-associated genes with respect to tissues, disease states, and genetic risk factors. Such contextualization can be exploited to further elucidate the biological importance of known and novel genes for severity of the disease in patients.

Room for improvement: diagnosing and managing acute coronary syndromes in persons with reduced eGFR

Cardiovascular events are the leading cause of death in chronic kidney disease. A recent analysis from the High-Sensitivity Troponin in the Evaluation of Patients With Suspected Acute Coronary Syndrome trial focused on results in those with reduced estimated glomerular filtration rate. This commentary discusses aspects of acute coronary syndrome diagnosis in this group and the differential approach to acute coronary syndrome management that was observed between those with normal and reduced kidney function.

Dose-dependent effect of impaired renal function on all-cause mortality in patients following percutaneous coronary intervention

Objective

To determine the risk prediction of various degrees of impaired renal function on all‐cause mortality in patients following percutaneous coronary intervention (PCI).

Background

Patients with chronic kidney disease (CKD) are at high risk of all‐cause mortality after PCI. However, there are less data of various degrees of impaired renal function to predict those risks.

Methods

This was a subgroup analysis of nationwide PCI registry of 22 045 patients. Patients were classified into six CKD stages according to preprocedure estimated glomerular filtration rate (eGFR) (ml/min/1.73 m²): I (≥90), II (60−89), III (30−59), IV (15−29), or V (<15) without or with dialysis. Baseline clinical and angiographic characteristics were compared among patients in each stage. One‐year all‐cause mortality was reported with risk prediction based on CKD stages and other risk factors.

Results

Patients with CKD stage I−V without and with on dialysis were found in 26.9%, 40.8%, 23.2%, 3.9%, 1.5%, and 3.7%, respectively. PCI procedural success and complication rates ranged from 94.0% to 96.2% and 2.8% to 6.1%, respectively. One‐year overall survival among CKD stages I−V was 96.3%, 93.1%, 84.4%, 65.2%, 68.0%, and 69.4%, respectively (p < .001 by log‐rank test). After adjusting covariables, the hazard ratios of all‐cause mortality for CKD stages II−V as compared to stage I by multivariate Cox regression analysis were 1.5, 2.6, 5.3, 5.9, and 7.0, respectively, (p < .001).

Conclusion

Among patients undergoing PCI, lower preprocedure eGFR is associated in a dose‐dependent effect with decreased 1‐year survival. This finding may be useful for risk classification and to guide decision‐making.

A Newly Defined CHA2DS2-VA Score for Predicting Obstructive Coronary Artery Disease in Patients with Atrial Fibrillation-A Cross-Sectional Study of Older Persons Referred for Elective Coronary Angiography

Purpose: Atrial fibrillation (AF) can be a valuable indicator of non-obstructive coronary artery disease (CAD) among older patients indicated for elective coronary angiography (CAG). Appropriate stratification of AF patients is crucial for avoiding unnecessary complications. The objective of this study was to identify independent predictors that can allow diagnosing obstructive CAD in AF patients over 65 years who were indicated to undergo elective CAG. Patients and methods: This cross-sectional study included 452 (23.9%) AF patients over 65 years old who were directed to the Department of Invasive Cardiology at the Medical University of Bialystok for elective CAG during 2014−2016. The participants had CAD and were receiving optimal therapy (median age: 73 years, interquartile range: 69−77 years; 54.6% men). The prevalence and health correlates of obstructive CAD were determined, and a multivariate logistic regression model was generated with predictors (p < 0.1). Predictive performance was analyzed using a receiver-operating characteristic (ROC) curve analysis. Results: Stenosis (affecting ≥ 50% of the diameter of the left coronary artery stem or ≥70% of that of the other important epicardial vessels) was significant in 184 (40.7%) cases. Multivariate regression analysis revealed that only the male sex (odds ratio [OR]: 1.80, 95% confidence interval [CI]: 1.14−2.84, p = 0.01) and the newly created CHA2DS2-VA score (OR: 3.96, 95% CI: 2.96−5.31, p < 0.001) significantly increased the chance of obstructive CAD, while controlling for chronic kidney disease and anemia. The ROC curve analysis indicated that the CHA2DS2-VA scale may be a useful screening tool for the diagnosis of obstructive CAD (area under the ROC curve: 0.79, 95% CI: 0.75−0.84, p < 0.001), with ≥4 being the optimal cutoff value. Conclusions: Our study has proven that several older AF patients who are advised to undergo elective CAG have nonobstructive CAD. The CHA2DS2-VA score can contribute to improving the selection of patients for invasive diagnosis of CAD, but further investigation is required.

The removal of race from kidney function estimation: Key points for primary providers

Recent recognitions of longstanding societal effects of structural and overt acts of racism have led to calls for the elimination of race, a social construct, from medical algorithms. This accelerated a growing concern with the use of race in kidney function estimating equations. A task force sponsored by the two leading nephrology societies in the United States has reassessed the inclusion of race in glomerular filtration rate (GFR) estimation and recently put forth recommendations. New race-free equations have been developed and guides for widespread implementation have been provided. We herein review the journey of kidney function estimating equations, race in GFR estimating equations, new race-free equations and the path forward in caring for chronic kidney disease. We urge upon all primary care providers to employ concerted focus on early detection and identification of kidney dysfunction as well as risk factors including social determinants of health to prevent progression.

Cardiac imaging for the assessment of patients being evaluated for kidney transplantation

Cardiac risk assessment before kidney transplantation has become widely accepted. However, the optimal patient selection and screening tool for cardiac assessment remain controversial. Clinicians face several challenges in this process, including the ever-growing pre-transplant population, aging transplant candidates, increasing prevalence of coronary artery disease, and scarcity of donor organs. Optimizing the cardiovascular risk profile in kidney transplant candidates is necessary to better appropriate limited donor organs and improve patient outcomes. Increasing waiting times from the initial evaluation for transplant candidacy to the actual transplant raises questions regarding re-testing and re-stratification of risk. In this review, we summarize and discuss the current literature on cardiac evaluation prior to kidney transplantation. We also propose simple evidence-based evaluation algorithms for initial and follow-up CAD surveillance in patients being wait-listed for kidney transplantation.

Chronic Kidney Disease Progression Risk in Patients With Diabetes Mellitus Using Dihydropyridine Calcium Channel Blockers: A Nationwide, Population-Based, Propensity Score Matching Cohort Study

Background: Whether diabetes mellitus (DM) patients with chronic kidney disease (CKD) can glean individual renal benefit from dihydropyridine calcium channel blockers (DCCBs) remains to be determined. We conducted a nationwide, population-based, propensity score matching cohort study to examine the effect of DCCBs on CKD progression in DM patients with CKD.

Methods: One million individuals were randomly sampled from Taiwan’s National Health Insurance Research Database. The study cohort consisted of DM patients with CKD who used DCCBs. The comparison cohort was propensity-matched for demographic characteristics and comorbidities. The endpoint was advanced CKD or end-stage renal disease (ESRD). The Cox proportional hazards model was used to calculate the risks.

Results: In total, 9,761 DCCB users were compared with DCCB nonusers at a ratio of 1:1. DCCB users had lower risk of advanced CKD and ESRD than nonusers—with adjusted hazard ratio [aHR; 95% confidence interval (CI)] of 0.64 (0.53–0.78) and 0.59 (95% CI, 0.50–0.71) for advanced CKD and ESRD, respectively. DCCB users aged ≥65 years had the lowest incidence rates of advanced CKD and ESRD—with aHR (95% CI) of 0.47 (0.34–0.65) and 0.48 (0.35–0.65) for advanced CKD and ESRD, respectively. Finally, cumulative DCCB use for >1,100 days was associated with the lowest advanced CKD and ESRD risks [(aHR, 0.29 (95% CI, 0.19–0.44)].

Conclusion: DM patients with CKD who used DCCBs had lower risk of progression to advanced CKD and ESRD than nonusers did.

Impact of Left Main Calcium With Chronic Kidney Disease on Outcomes After Percutaneous Coronary Intervention for Left Main Narrowings (from the Milan and New-Tokyo Registry)

Limited data are available about the association between coronary artery calcification and chronic kidney disease severity on clinical outcomes after percutaneous coronary intervention (PCI). This study aimed to assess the association between coronary artery calcification and chronic kidney disease severity on clinical outcomes after PCI. We identified 1,391 patients treated with drug-eluting stent for unprotected left main distal bifurcation lesions (ULMD), including 604 without calcified lesions (noncalcified left main group) and 787 with calcified ULMD (calcified left main group) in Japan and Italy. We divided the calcified group into the following 2 groups: estimated glomerular filtration rate (eGFR) ≥30 (n = 687) and <30 (n = 100) and compared the clinical outcomes. The primary end point was target lesion failure (TLF) at 3 years. TLF was defined as a composite of cardiac death, target lesion revascularization, and myocardial infarction. TLF occurred more frequently in the calcified group (adjusted hazard ratio 1.36, 95% confidence interval 1.08 to 1.71, p = 0.01), especially in calcified ULMD with eGFR <30 (adjusted hazard ratio relative to the other 2 groups 2.59, 95% confidence interval 1.60 to 4.18, p <0.001). In conclusion, the calcified ULMD treated with PCI was associated with poorer clinical outcomes than noncalcified ULMD, especially in those with eGFR <30.

Prasugrel Dose De-escalation Therapy After Complex Percutaneous Coronary Intervention in Patients With Acute Coronary Syndrome: A Post Hoc Analysis From the HOST-REDUCE-POLYTECH-ACS Trial

Importance

De-escalation of dual-antiplatelet therapy through dose reduction of prasugrel improved net adverse clinical events after acute coronary syndrome (ACS), mainly through the reduction of bleeding without an increase in ischemic outcomes. However, whether such benefits are similarly observed in those receiving complex procedures is unknown.

Objective

To investigate whether the benefits of prasugrel dose de-escalation therapy are maintained in the complex percutaneous coronary intervention (PCI) subgroup.

Design, Setting, and Participants

This was a post hoc analysis of the HOST-REDUCE-POLYTECH-ACS trial, a randomized, open-label, adjudicator-blinded, multicenter trial performed at 35 hospitals in South Korea. Study participants included patients with ACS who were receiving PCI. Data were collected from September 30, 2014, to December 18, 2015, and analyzed from September 17, 2020, to June 15, 2021.

Interventions and Exposures

Patients were randomized to a prasugrel dose de-escalation (5 mg daily) at 1 month post-PCI group or a conventional (10 mg daily) group. Complex PCI was defined as having at least 1 of the following features: 3 or more stents implanted, 3 or more lesions treated, bifurcation PCI, total stent length 60 mm or larger, left main PCI, or heavy calcification.

Main Outcomes and Measures

The main analysis end points were MACE (major adverse cardiac event, a composite of cardiovascular death, nonfatal myocardial infarction, stent thrombosis, and repeat revascularization) at 1 year for ischemic outcomes, and BARC (Bleeding Academic Research Consortium) class 2 or higher bleeding events at 1 year for bleeding outcomes.

Results

Of 2271 patients (mean [SD] age, 58.9 [9.0] years; 2024 [89%] male patients) for whom full procedural data were available, 705 patients received complex PCI, and 1566 patients received noncomplex PCI. Complex PCI was associated with higher rates of ischemic outcomes but not with bleeding outcomes. Prasugrel dose de-escalation did not increase the risk of MACE (hazard ratio [HR], 0.88; 95% CI, 0.47-1.66; P = .70 in complex PCI; HR, 0.81; 95% CI, 0.45-1.46; P = .48 in noncomplex PCI; P for interaction = .84) but decreased BARC class 2 or higher bleeding events (HR, 0.25; 95% CI, 0.10-0.61; P = .002 in complex PCI; HR, 0.62; 95% CI, 0.38-1.00; P = .05 in noncomplex PCI; P for interaction = .08), albeit with wide 95% CIs.

Conclusions and Relevance

In this post hoc analysis of patients with ACS, prasugrel dose de-escalation compared with conventional therapy was not associated with an increased risk of ischemic outcomes but may reduce the risk of minor bleeding events at 1 year, irrespective of PCI complexity.

Trial Registration

ClinicalTrials.gov Identifier: NCT02193971.

Abdominal Aortic Calcification and Cardiovascular Outcomes in Chronic Kidney Disease: Findings from KNOW-CKD Study

To investigate the association between abdominal aortic calcification score (AACS) assessed by plain radiograph of the lateral abdomen and the risk of cardiovascular (CV) events in patients with pre-dialysis chronic kidney disease (CKD), a total of 2090 pre-dialysis CKD patients from the Korean Cohort Study for Outcome in Patients with Chronic Kidney Disease (KNOW-CKD) were categorized by AACS into 0, 1–2, 3–4, 5–6, and ≥7. The primary outcome of the study was the composite CV events, defined as a composite of non-fatal CV events and all-cause death. The risk of composite CV events was significantly higher in the subjects with AACS ≥ 7 (adjusted hazard ratio (HR) 1.888, 95% confidence interval (CI) 1.219 to 2.923), compared to that of the subjects with AACS 0. The risks of fatal and non-fatal CV events (adjusted HR 1.052, 95% CI 1.030 to 1.073) and all-cause death (adjusted HR 1.949, 95% CI 1.073 to 3.539) were also significantly higher in the subjects with AACS ≥ 7. In conclusion, AACS assessed by plain radiograph is independently associated with adverse CV outcomes in patients with pre-dialysis CKD. A simple radiographic examination of the lateral abdomen may help CV risk stratification in this population.

Cardiac Rehabilitation Improves Long-Term Prognosis for People with Chronic Kidney Disease Undergoing Percutaneous Coronary Intervention: A Propensity Matching Analysis

OBJECTIVES

According to researches, many people with chronic kidney disease (CKD) had the higher incidence rate and mortality rate of coronary artery disease (CAD) after percutaneous coronary intervention than those who did not receive percutaneous coronary intervention, while coronary rehabilitation was beneficial for patients who received percutaneous coronary intervention I. This study aims to analyze whether coronary rehabilitation was beneficial to patients with CKD after percutaneous coronary intervention. Patients and Methods. A retrospective survey was used to collect clinical data of patients undergoing percutaneous coronary intervention due to CAD, and CKD patients were screened for further analysis. According to whether patients had received coronary rehabilitation treatment, research subjects were divided into two groups, the coronary rehabilitation group and the noncoronary rehabilitation group. The baseline characteristics of the propensity score matching between the two groups were compared. Survival analysis used the Cox hazard ratio (HR) model as regression method to compare the relative risk of the endpoints in the coronary rehabilitation group and the noncoronary rehabilitation group.

RESULTS

From January 2007 to January 2012, a total of 246 CKD patients treated with percutaneous coronary intervention were included in this study, and 106 of them obtained coronary rehabilitation after surgery. After propensity score matching, there were 89 pairs of patients in the two groups who had no significant difference in demographic and clinical characteristics (all P > 0.05). CKD patients receiving coronary rehabilitation had a significant reduction in all-cause mortality (HR 0.465, 95% CI 0.233-0.926, P=0.029) and cardiac complications (HR 0.532, 95% CI 0.287-0.984, P=0.044). Survival analysis showed that the survival rate of the coronary rehabilitation group was significantly higher than that of the noncoronary rehabilitation group (P=0.024).

CONCLUSIONS

For CKD patients undergoing percutaneous coronary intervention, receiving cardiac rehabilitation can significantly improve long-term survival and reduce cardiac events.

Fractional flow reserve in patients with type 1 or type 2 non-ST elevation acute myocardial infarction

AIMS

We assessed a combined strategy of fractional flow reserve (FFR) plus angiography in stratifying cardiovascular risk in patients with type 1 myocardial infarction (T1MI) or type 2 (T2MI) non-ST elevation acute myocardial infarction (NSTEMI).

METHODS

A cohort of 150 NSTEMI patients were prospectively studied. Clinical and angiographic features guided the identification of T1MI vs T2MI and the treatment of culprit lesions. Subsequently, T1MI patients underwent FFR evaluation of nonculprit stenoses. In T2MI patients all angiographically significant stenoses were evaluated by FFR. FFR < 0.80 was an indication for revascularization. Based on FFR results, two groups were compared: patients with all lesions ≥0.80 ('defer' group, n = 87) and those with at least one lesion <0.80 ('perform' group, n = 63). The primary end point was the composite of all-cause death, nonfatal MI and unplanned coronary revascularization.

RESULTS

Median clinical follow-up was of 35 months (interquartile range 14-44). Primary end-point rates in the 'defer' and 'perform' groups were 14.5% and 30.0% at 12 months and 28% and 46% at 36 months, respectively (log-rank test: at 1 year, P = 0.007; at the end of follow-up P = 0.014). On multivariable analysis, chronic kidney disease (HR 3.50, 95% CI: 1.89-6.46, P = 0.0001) and FFR group ('perform' vs 'defer': HR 1.75 95% CI: 1.01-3.04, P = 0.046) were independent predictors of adverse events.

CONCLUSIONS

In NSTEMI patients, our results indicated that FFR combined with angiography allowed the treatment of nonfunctional significant lesions to be safely deferred and patient cardiovascular risk to be identified.

Troponin Cut-Offs for Acute Myocardial Infarction in Patients with Impaired Renal Function—A Systematic Review and Meta-Analysis

Identifying acute myocardial infarction in patients with renal disease is notoriously difficult, due to atypical presentation and chronically elevated troponin. The aim of this study was to identify a specific troponin T/troponin I cut-off value for diagnosis of acute myocardial infarction in patients with renal impairment via meta-analysis. Two investigators screened 2590 publications from MEDLINE, Embase, PubMed, Web of Science, and the Cochrane library. Only studies that investigated alternative cut-offs according to renal impairment were included. Fifteen articles fulfilled the inclusion criteria. Six studies were combined for meta-analysis. The manufacturer’s upper reference level for troponin T is 14 ng/L. Based on the meta-analyses, cut-off values for troponin in patients with renal impairment with myocardial infarction was 42 ng/L for troponin I and 48 ng/L for troponin T. For patients on dialysis the troponin T cut-off is even higher at 239 ng/L. A troponin I cut-off value for dialysis patients could not be established due to lack of data. The 15 studies analyzed showed considerable diversity in study design, study population, and the definition of myocardial infarction. Further studies are needed to define a reliable troponin cut-off value for patients with kidney disease, especially in dialysis patients, and to allow necessary subanalysis.

Healthcare resource utilisation for chronic kidney disease and other major non-communicable chronic diseases in China: a cross-sectional study

OBJECTIVE

To evaluate the healthcare resource utilisation for chronic kidney disease (CKD) and other major non-communicable chronic diseases (NCDs) in China.

DESIGN

A cross-sectional study.

SETTING

A national inpatient database of tertiary hospitals in China.

PARTICIPANTS

The study included a total of 19.5 million hospitalisations of adult patients from July 2013 to June 2014. Information on CKD and other major NCDs, including coronary heart disease (CHD), stroke, hypertension, diabetes, chronic obstructive pulmonary disease (COPD) and cancer, was extracted from the unified discharge summary form.

OUTCOME MEASURES

Cost, length of hospital stay and in-hospital mortality.

RESULTS

The percentages of hospitalisations with CKD, CHD, stroke, hypertension, diabetes, COPD and cancer were 4.5%, 9.2%, 8.2%, 18.8%, 7.9%, 2.3% and 19.4%, respectively. For each major NCD, the presence of CKD was independently associated with longer hospital stay, with increased percentages ranging from 7.69% (95% CI 7.11% to 8.28%) for stroke to 21.60% (95% CI 21.09% to 22.10%) for CHD. Hospital mortality for other NCDs was also higher in the presence of CKD, with fully adjusted relative risk ranging from 1.91 (95% CI 1.82 to 1.99) for stroke to 2.65 (95% CI 2.55 to 2.75) for cancer. Compared with other NCDs, CKD was associated with the longest hospital stay (22.1% increase) and resulted in the second highest in-hospital mortality, only lower than that of cancer (relative risk, 2.23 vs 2.87, respectively).

CONCLUSIONS

The presence of diagnosed CKD alongside each major NCD was associated with an additional burden on the healthcare system. Healthcare resource utilisation and prognosis of CKD were comparable with those of other major NCDs, which highlights the importance of CKD as a major public health burden.

Myeloid leukocytes' diverse effects on cardiovascular and systemic inflammation in chronic kidney disease

Chronic kidney disease's prevalence rises globally. Whereas dialysis treatment replaces the kidney's filtering function and prolongs life, dreaded consequences in remote organs develop inevitably over time. Even milder reductions in kidney function not requiring replacement therapy associate with bacterial infections, cardiovascular and heart valve disease, which markedly limit prognosis in these patients. The array of complications is diverse and engages a wide gamut of cellular and molecular mechanisms. The innate immune system is profoundly and systemically altered in chronic kidney disease and, as a unifying element, partakes in many of the disease's complications. As such, a derailed immune system fuels cardiovascular disease progression but also elevates the propensity for serious bacterial infections. Recent data further point towards a role in developing calcific aortic valve stenosis. Here, we delineate the current state of knowledge on how chronic kidney disease affects innate immunity in cardiovascular organs and on a systemic level. We review the role of circulating myeloid cells, monocytes and neutrophils, resident macrophages, dendritic cells, ligands, and cellular pathways that are activated or suppressed when renal function is chronically impaired. Finally, we discuss myeloid cells' varying responses to uremia from a systems immunology perspective.

Atrial fibrillation is a predictor of nonobstructive coronary artery disease in elective angiography in old age: a cross-sectional study in Poland and Russia

BACKGROUND

Significant changes in the coronary vessels are not confirmed in a large proportion of patients undergoing cardiac catheterization.

AIMS

The present study aimed to determine correlates and independent predictors of nonobstructive coronary artery disease (CAD) in older adults referred for elective coronary angiography.

METHODS

A cross-sectional study was conducted involving 2,214 patients referred to two medical centers (in Poland and Russia) between 2014 and 2016 for elective coronary angiography due to exacerbated angina, despite undergoing optimal therapy for CAD. The median age was 72 years (IQR: 68-76), and 49.5% patients were women.

RESULTS

Significant stenosis (defined as stenosis of 50% or more of the diameter of the left main coronary artery stem or stenosis of 70% or more of the diameter of the remaining major epicardial vessels) was diagnosed only in 1135 (51.3%) patients. Female sex (odds ratio [OR], 3.01; 95% confidence interval [CI], 2.44-3.72; p < 0.001) and atrial fibrillation (OR, 1.87; 95% CI 1.45-2.40; p < 0.001) were the main independent predictors of nonobstructive CAD. Significantly lower ORs were observed for diabetes (OR, 0.75; 95% CI 0.59-0.95; p = 0.02), chronic kidney disease (OR, 0.76; 95% CI 0.61-0.96; p = 0.02), and anemia (OR, 0.69; 95% CI 0.50-0.95; p = 0.02) after controlling for age, chronic heart failure, BMI, and study center.

DISCUSSION AND CONCLUSIONS

The results confirmed that nonobstructive CAD occurs in a high percentage of older patients referred for elective coronary angiography. This suggests the need to improve patient stratification for invasive diagnosis of CAD, especially for older women and patients with atrial fibrillation. Trial registration number and date of registration: NCT04537507, September 3, 2020.

Impact of Renal Insufficiency on Prognosis of Patients with Acute Coronary Syndrome

Purpose

Chronic kidney disease (CKD) is common in patients admitted with acute coronary syndrome (ACS), and it is associated with poor outcomes. However, data are limited. Hence, we examined the long-term prognostic significance of estimated glomerular filtration rate (eGFR) among Chinese patients hospitalized with ACS.

Patients and Methods

This is a multicenter, observational study that included 1860 ACS patients enrolled between March 2014 and June 2019 from 11 hospitals in Chengdu. CKD-EPI equation was used to calculate the baseline eGFR. Patients were divided into three groups: eGFR ≥ 90 mL/min (normal renal function), eGFR 60 to <90 mL/min (mild impaired renal function), and eGFR < 60 mL/min (moderate or severe renal dysfunction). The endpoint was all-cause death during follow-up.

Results

At baseline, 714 patients had normal renal function, while 746 patients had mild impaired renal function, and 400 patients had moderate or severe renal dysfunction. In the follow-up of 15 months (10 months, 22 months), 261 (14.0%) patients died;, 139 (34.8%) in the moderate or severe renal dysfunction group, 94 (12.6%) in the mild impaired renal function group, and 28 (3.9%) in the normal renal function group (log-rank p-value from Kaplan–Meier analysis <0.001). In multivariable Cox Proportional hazard analysis, age, systolic blood pressure (SBP), heart rate, eGFR, ST-elevation myocardial infarction (STEMI), and percutaneous coronary intervention (PCI) were independent predictors of all-cause death.

Conclusion

In this study, among Chinese patients with ACS, renal insufficiency was associated with unfavorable long-term prognosis. Age, SBP, heart rate, eGFR, STEMI, and PCI could identify those at risk.