Death, coronary revascularization choices, and chronic kidney disease.
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ABSTRACT:
SUBMITTER: Solomon RJ
PROVIDER: S-EPMC6555142 | biostudies-literature | 2018 Jan
REPOSITORIES: biostudies-literature
Publications
Death, coronary revascularization choices, and chronic kidney disease.
Solomon Richard J RJ Brown Jeremiah R JR
Coronary artery disease 20180101 1
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Project description:Revascularization by coronary artery bypass graft (CABG) surgery or percutaneous coronary intervention (PCI) is frequently deferred in patients with chronic kidney disease (CKD) to avoid precipitating end-stage renal disease (ESRD), but reliable estimates of absolute and relative risks of death and ESRD after CABG and PCI are unavailable.CKD patients undergoing CABG (n=4547) or PCI (n=8620) were identified and tracked using the 5% Medicare sample. The cumulative incidence of ESRD and death were reported for observed events. A Cox model with the Fine-Gray method was used to account for competing risks in assessing relative hazards of death and ESRD. Three-year cumulative incidence of ESRD was lower (CABG, 6.8%; PCI, 5.4%) than death (CABG, 28.3%; PCI, 32.8%). The adjusted hazard ratio of death was higher during the first 3 months after CABG than after PCI (1.25; 95% confidence interval, 1.12-1.40; P<0.001), but lower from 6 months onward (0.61; 95% confidence interval, 0.55-0.69). Conversely, risk of ESRD after CABG was higher during the first 3 months (1.59; 95% confidence interval, 1.27-2.01; P<0.001), but was not statistically significant from 3 months onward. The adjusted hazard ratio of combined death or ESRD was similar to death.Among CKD patients undergoing coronary revascularization, death is more frequent than ESRD. The incidence of ESRD was lower throughout follow-up after PCI, but long-term risks of death or combined death and ESRD were lower after CABG. Our data suggest better overall clinical outcomes with CABG than with PCI in CKD patients.
| S-EPMC3560931 | biostudies-literature
Project description:Patients with chronic kidney disease are at elevated risk for adverse events after traditional coronary angiography and percutaneous intervention with contrast media. The case presented in this report highlights the potential benefits of zero-contrast multivessel percutaneous coronary intervention in a patient presenting with a non-ST-segment elevation acute coronary syndrome. (Level of Difficulty: Beginner.).
| S-EPMC8288793 | biostudies-literature
Project description:ObjectivesTo compare outcomes of two different revascularization strategies in chronic kidney disease (CKD) patients: coronary artery bypass grafting (CABG) versus percutaneous coronary intervention (PCI).MethodsWe conducted this meta-analysis according to Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines and registered with PROSPERO (CRD42021238659), evaluated studies comparing CABG and PCI in patients with CAD and CKD (defined by KDIGO guidelines). Data were extracted from PubMed, EMBASE and Cochrane from 2000 to 2023. The primary end-point was long-term major adverse cardiovascular and cerebrovascular event rates, with secondary end-points including 30-day mortality, stroke, myocardial infarction (MI) and repeat revascularization. Statistical analyses included Kaplan-Meier estimations, Cox regression, and meta-regression to address heterogeneity. Publication bias was assessed via funnel plots. No funding was received, and the authors report no conflicts of interest.ResultsWe included 33 studies with 402 300 patients (eGFR <60 ml/min/1.73 m2). The cohort comprised 132 314 coronary artery bypass graft and 269 986 PCI patients. Over 3 years, coronary artery bypass group provided protection against major adverse cardiac and cerebrovascular events, MI, and repeat revascularization compared to PCI. However, PCI showed better short-term outcomes, including lower 30-day mortality. Coronary artery bypass group was linked to a higher stroke risk over the 3-year follow-up.ConclusionsRevascularization strategies for CKD and coronary artery disease patients should balance PCI's short-term benefits with CABG's long-term advantages.
| S-EPMC11897794 | biostudies-literature
Project description:BackgroundRandomized trials of percutaneous coronary intervention (PCI) versus coronary artery bypass graft (CABG) routinely exclude patients with chronic kidney disease (CKD).ObjectivesThis study evaluated outcomes of PCI versus CABG in patients with CKD.MethodsPatients with CKD who underwent PCI using everolimus-eluting stents were propensity-score matched to patients who underwent isolated CABG for multivessel coronary disease in New York. The primary outcome was all-cause mortality. Secondary outcomes were myocardial infarction (MI), stroke, and repeat revascularization.ResultsOf 11,305 patients with CKD, 5,920 patients were propensity-score matched. In the short term, PCI was associated with a lower risk of death (hazard ratio [HR]: 0.55; 95% confidence interval [CI]: 0.35 to 0.87), stroke (HR: 0.22; 95% CI: 0.12 to 0.42), and repeat revascularization (HR: 0.48; 95% CI: 0.23 to 0.98) compared with CABG. In the longer term, PCI was associated with a similar risk of death (HR: 1.07; 95% CI: 0.92 to 1.24), higher risk of MI (HR: 1.76; 95% CI: 1.40 to 2.23), a lower risk of stroke (HR: 0.56; 95% CI: 0.41 to 0.76), and a higher risk of repeat revascularization (HR: 2.42; 95% CI: 2.05 to 2.85). In the subgroup with complete revascularization with PCI, the increased risk of MI was no longer statistically significant (HR: 1.18; 95% CI: 0.67 to 2.09). In the 243 matched pairs of patients with end-stage renal disease on hemodialysis, PCI was associated with significantly higher risk of death (HR: 2.02; 95% CI: 1.40 to 2.93) and repeat revascularization (HR: 2.44; 95% CI: 1.50 to 3.96) compared with CABG.ConclusionsIn patients with CKD, CABG is associated with higher short-term risk of death, stroke, and repeat revascularization, whereas PCI with everolimus-eluting stents is associated with a higher long-term risk of repeat revascularization and perhaps MI, with no long-term mortality difference. In the subgroup on dialysis, the results favored CABG over PCI.
| S-EPMC4944845 | biostudies-literature
Project description:Fractional flow reserve (FFR)-guided percutaneous coronary intervention has shown favorable long-term clinical outcomes. However, limited data exist evaluating the FFR assessment among the chronic kidney disease (CKD) population. The aim of this study was to evaluate the long-term clinical outcomes of FFR-guided coronary revascularization in patients with CKD. A total of 242 CKD patients who underwent FFR assessment were retrospectively analyzed. Patients were divided into two groups: revascularization (FFR ≤ 0.80) and non-revascularization (FFR > 0.80). The primary endpoint was the composite of cardiac death, non-fatal myocardial infarction, and target vessel failure (TVF). The key secondary endpoint was TVF. The Cox regression model was used for risk evaluation. With 91% of the ischemic vessels revascularized, the revascularization group had higher risks for both the primary endpoint (adjusted hazard ratio [aHR]: 2.06; 95% confidence interval [CI], 1.07-3.97; p = 0.030) and key secondary endpoint (aHR: 2.19, 95% CI: 1.10-4.37; p = 0.026), during a median follow-up of 2.9 years. This result was consistent among different CKD severities. In patients with CKD, functional ischemia in coronary artery stenosis was associated with poor clinical outcomes despite coronary revascularization.
| S-EPMC8781197 | biostudies-literature
Project description:BackgroundAs a strong risk factor for coronary artery disease (CAD), chronic kidney disease (CKD) indicates higher mortality in patients with CAD. However, the optimal treatment for the patients with two coexisting diseases is still not well defined.MethodsTo conduct a meta-analysis, PubMed, Embase, and the Cochrane database were searched for studies comparing medical treatment (MT) and revascularization [percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG)] in adults with CAD and CKD. Long-term all-cause mortality was evaluated, and subgroup analyses were performed.ResultsA total of 13 trials met our selection criteria. Long-term (with at least a 1-year follow-up) mortality was significantly lower in the revascularization arm [relative risk (RR) = 0.66; 95% CI = 0.60-0.72] by either PCI (RR = 0.61; 95% CI = 0.55-0.68) or CABG (RR = 0.62; 95% CI = 0.46-0.84). The results were consistent in dialysis patients (RR = 0.68; 95% CI = 0.59-0.79), patients with stable CAD (RR = 0.75; 95% CI = 0.61-0.92), patients with acute coronary syndrome (RR = 0.62; 95% CI = 0.58-0.66), and geriatric patients (RR = 0.57; 95% CI = 0.54-0.61).ConclusionIn patients with CKD and CAD, revascularization is more effective in reducing mortality than MT alone. This observed benefit is consistent in patients with stable CAD and elderly patients. However, future randomized controlled trials (RCTs) are required to confirm these findings.
| S-EPMC8858980 | biostudies-literature
Project description:BackgroundCoronary artery bypass grafting (CABG) provides superior long-term outcomes to percutaneous coronary intervention (PCI) for complex multivessel coronary artery disease (CAD). People with chronic kidney disease (CKD) have increased prevalence of multivessel CAD, but also increased surgical risk. We investigated whether CKD predicted real-world use of CABG, versus PCI, in patients revascularized for acute coronary syndrome (ACS).MethodsEmbase, MEDLINE, Scopus and CENTRAL were searched to identify articles referring to ACS and invasive coronary intervention in high-income countries (2012 - 2023). Articles were included if CABG rates were reported in ACS patients with and without CKD receiving revascularization. CKD was defined as an estimated glomerular filtration rate < 60 mL/min/1.73 m2; proxy definitions were accepted. Random effect meta-analyses were used to determine the average effect of CKD on odds of CABG, stratified by ACS type and dialysis use.ResultsSearches generated 15,138 articles, of which 13 observational studies were included (n = 1,682,207). Amongst revascularized ACS patients, those with CKD were more likely to receive CABG than those without (pooled odds ratio (OR) = 1.50 (95% confidence interval (CI) = 1.30 - 1.72). This association was stronger following ST-elevation myocardial infarction (STEMI) than non-ST-elevation ACS (NSTE-ACS) (OR: 1.54 (95% CI: 1.23 - 1.93)) versus 1.16 (1.10 - 1.23), respectively).ConclusionsIn high-income countries, revascularized ACS patients with CKD receive CABG (versus PCI) more frequently than those without kidney disease. However, accounting for lower use of coronary angiography in the CKD population removed this association following NSTE-ACS. Greater use of invasive angiography in those with NSTE-ACS and CKD might therefore increase access to revascularization, and thereby improve outcomes.
| S-EPMC11650572 | biostudies-literature
Project description:AimsTo investigate the impact of established cardiovascular disease (CVD) on 10-year all-cause death following coronary revascularization in patients with complex coronary artery disease (CAD).MethodsThe SYNTAXES study assessed vital status out to 10 years of patients with complex CAD enrolled in the SYNTAX trial. The relative efficacy of PCI versus CABG in terms of 10-year all-cause death was assessed according to co-existing CVD.ResultsEstablished CVD status was recorded in 1771 (98.3%) patients, of whom 827 (46.7%) had established CVD. Compared to those without CVD, patients with CVD had a significantly higher risk of 10-year all-cause death (31.4% vs. 21.7%; adjusted HR: 1.40; 95% CI 1.08-1.80, p = 0.010). In patients with CVD, PCI had a non-significant numerically higher risk of 10-year all-cause death compared with CABG (35.9% vs. 27.2%; adjusted HR: 1.14; 95% CI 0.83-1.58, p = 0.412). The relative treatment effects of PCI versus CABG on 10-year all-cause death in patients with complex CAD were similar irrespective of the presence of CVD (p-interaction = 0.986). Only those patients with CVD in ≥ 2 territories had a higher risk of 10-year all-cause death (adjusted HR: 2.99, 95% CI 2.11-4.23, p < 0.001) compared to those without CVD.ConclusionsThe presence of CVD involving more than one territory was associated with a significantly increased risk of 10-year all-cause death, which was non-significantly higher in complex CAD patients treated with PCI compared with CABG. Acceptable long-term outcomes were observed, suggesting that patients with established CVD should not be precluded from undergoing invasive angiography or revascularization.Trial registrationSYNTAX: ClinicalTrials.gov reference: NCT00114972. SYNTAX Extended Survival: ClinicalTrials.gov reference: NCT03417050.
| S-EPMC8484091 | biostudies-literature
Project description:ImportanceCoronary artery calcification (CAC) is highly prevalent in dialysis-naive patients with chronic kidney disease (CKD). However, there are sparse data on the association of CAC with subsequent risk of cardiovascular disease and all-cause mortality in this population.ObjectiveTo study the prospective association of CAC with risk of cardiovascular disease and all-cause mortality among dialysis-naive patients with CKD.Design, setting, and participantsThe prospective Chronic Renal Insufficiency Cohort study recruited adults with an estimated glomerular filtration rate of 20 to 70 mL/min/1.73 m2 from 7 clinical centers in the United States. There were 1541 participants without cardiovascular disease at baseline who had CAC scores.ExposuresCoronary artery calcification was assessed using electron-beam or multidetector computed tomography.Main outcomes and measuresIncidence of cardiovascular disease (including myocardial infarction, heart failure, and stroke) and all-cause mortality were reported every 6 months and confirmed by medical record adjudication.ResultsDuring an average follow-up of 5.9 years in 1541 participants aged 21 to 74 years, there were 188 cardiovascular disease events (60 cases of myocardial infarction, 120 heart failures, and 27 strokes; patients may have had >1 event) and 137 all-cause deaths. In Cox proportional hazards models adjusted for age, sex, race, clinical site, education level, physical activity, total cholesterol level, high-density lipoprotein cholesterol level, systolic blood pressure, use of antihypertensive treatment, current cigarette smoking, diabetes status, body mass index, C-reactive protein level, hemoglobin A1c level, phosphorus level, troponin T level, log N-terminal pro-B-type natriuretic peptide level, fibroblast growth factor 23 level, estimated glomerular filtration rate, and proteinuria, the hazard ratios associated with per 1 SD log of CAC were 1.40 (95% CI, 1.16-1.69; P < .001) for cardiovascular disease, 1.44 (95% CI, 1.02-2.02; P = .04) for myocardial infarction, 1.39 (95% CI, 1.10-1.76; P = .006) for heart failure, and 1.19 (95% CI, 0.94-1.51; P = .15) for all-cause mortality. In addition, inclusion of CAC score led to an increase in the C statistic of 0.02 (95% CI, 0-0.09; P < .001) for predicting cardiovascular disease over use of all the above-mentioned established and novel cardiovascular disease risk factors.Conclusions and relevanceCoronary artery calcification is independently and significantly related to the risks of cardiovascular disease, myocardial infarction, and heart failure in patients with CKD. In addition, CAC improves risk prediction for cardiovascular disease, myocardial infarction, and heart failure over use of established and novel cardiovascular disease risk factors among patients with CKD; however, the changes in the C statistic are small.
| S-EPMC5798875 | biostudies-literature
Project description:Coronary atherosclerotic disease is highly prevalent in chronic kidney disease (CKD). Although revascularization improves outcomes, procedural risks are increased in CKD, and unbiased data comparing coronary artery bypass grafting (CABG) and percutaneous intervention (PCI) in CKD are sparse. To compare outcomes of CABG and PCI in stage 3 to 5 CKD, we identified randomized trials comparing these procedures. Investigators were contacted to obtain individual, patient-level data. Ten of 27 trials meeting inclusion criteria provided data. These trials enrolled 3993 patients encompassing 526 patients with stage 3 to 5 CKD of whom 137 were stage 3b-5 CKD. Among individuals with stage 3 to 5 CKD, mortality through 5 years was not different after CABG compared with PCI (hazard ratio [HR] 0.99, 95% confidence interval [CI] 0.67-1.46) or stage 3b-5 CKD (HR 1.29, CI 0.68-2.46). However, CKD modified the impact on survival free of myocardial infarction: it was not different between CABG and PCI for individuals with preserved kidney function (HR 0.97, CI 0.80-1.17), but was significantly lower after CABG in stage 3-5 CKD (HR 0.49, CI 0.29-0.82) and stage 3b-5 CKD (HR 0.23, CI 0.09-0.58). Repeat revascularization was reduced after CABG compared with PCI regardless, of baseline kidney function. Results were limited by unavailability of data from several trials and paucity of enrolled patients with stage 4-5 CKD. Thus, our patient-level meta-analysis of individuals with CKD randomized to CABG versus PCI suggests that CABG significantly reduces the risk of subsequent myocardial infarction and revascularization without affecting survival in these patients.
| S-EPMC4947016 | biostudies-literature