Management of Coronary Disease in Patients with Advanced Kidney Disease.

Abstract

BACKGROUND:

Clinical trials that have assessed the effect of revascularization in patients with stable coronary disease have routinely excluded those with advanced chronic kidney disease.

METHODS:

We randomly assigned 777 patients with advanced kidney disease and moderate or severe ischemia on stress testing to be treated with an initial invasive strategy consisting of coronary angiography and revascularization (if appropriate) added to medical therapy or an initial conservative strategy consisting of medical therapy alone and angiography reserved for those in whom medical therapy had failed. The primary outcome was a composite of death or nonfatal myocardial infarction. A key secondary outcome was a composite of death, nonfatal myocardial infarction, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest.

RESULTS:

At a median follow-up of 2.2 years, a primary outcome event had occurred in 123 patients in the invasive-strategy group and in 129 patients in the conservative-strategy group (estimated 3-year event rate, 36.4% vs. 36.7%; adjusted hazard ratio, 1.01; 95% confidence interval [CI], 0.79 to 1.29; P = 0.95). Results for the key secondary outcome were similar (38.5% vs. 39.7%; hazard ratio, 1.01; 95% CI, 0.79 to 1.29). The invasive strategy was associated with a higher incidence of stroke than the conservative strategy (hazard ratio, 3.76; 95% CI, 1.52 to 9.32; P = 0.004) and with a higher incidence of death or initiation of dialysis (hazard ratio, 1.48; 95% CI, 1.04 to 2.11; P = 0.03).

CONCLUSIONS:

Among patients with stable coronary disease, advanced chronic kidney disease, and moderate or severe ischemia, we did not find evidence that an initial invasive strategy, as compared with an initial conservative strategy, reduced the risk of death or nonfatal myocardial infarction. (Funded by the National Heart, Lung, and Blood Institute and others; ISCHEMIA-CKD ClinicalTrials.gov number, NCT01985360.).

• Authors: Sripal Bangalore, David J Maron, Sean M O'Brien, Jerome L Fleg, Evgeny I Kretov, Carlo Briguori, Upendra Kaul, Harmony R Reynolds, Tomasz Mazurek, Mandeep S Sidhu, Jeffrey S Berger, Roy O Mathew, Olga Bockeria, Samuel Broderick, Radoslaw Pracon, Charles A Herzog, Zhen Huang, Gregg W Stone, William E Boden, Jonathan D Newman, Ziad A Ali, Daniel B Mark, John A Spertus, Karen P Alexander, Bernard R Chaitman, Glenn M Chertow, Judith S Hochman, ISCHEMIA-CKD Research Group
• Journal: The New England journal of medicine (N Engl J Med) Vol. 382 Issue 17 Pg. 1608-1618 (04 23 2020) ISSN: 1533-4406 [Electronic] United States
• PMID: 32227756 (Publication Type: Comparative Study, Journal Article, Multicenter Study, Randomized Controlled Trial, Research Support, N.I.H., Extramural, Research Support, Non-U.S. Gov't)
• Copyright: Copyright © 2020 Massachusetts Medical Society.

Chemical References

• Adrenergic beta-Antagonists
• Calcium Channel Blockers

Topics

• Adrenergic beta-Antagonists (therapeutic use)
• Aged
• Calcium Channel Blockers (therapeutic use)
• Coronary Angiography
• Coronary Artery Bypass
• Exercise Test
• Female
• Follow-Up Studies
• Humans
• Male
• Middle Aged
• Myocardial Infarction (prevention & control)
• Myocardial Ischemia (complications, drug therapy, mortality, surgery)
• Percutaneous Coronary Intervention
• Renal Insufficiency, Chronic (complications)
• Risk Factors