Dr. Marc Saad (MS), from Staten Island University Hospital, Staten Island, NY, discusses his abstract for the National Kidney Foundation’s 2015 Spring Clinical Meetings (SCM15), Myocardial Infarction Management in Patients with Chronic Kidney Disease Stage 3-5, End Stage Renal Disease, and Normal Kidney Function: A Retrospective Cohort Study, with Dr. Kenar Jhaveri, AJKD Blog Editor.
AJKDblog: Why don’t you tell us a little about your research and abstract being presented at the NKF 2015 Spring Meetings?
MS: Ischemic heart disease is the most common cause of death in patients with CKD (chronic kidney disease). Patients with CKD are at higher risk for developing CAD; CKD in ACS is independently associated with increased morbidity and mortality. Despite recognizing this high-risk group, patients with CKD have been largely excluded from randomized control trials and management guidelines are not established. Moreover, traditional and unique risk factors are prevalent and constitute challenges for the standard of care.
This is retrospective chart review to analyze the management of myocardial infarction by the degree of renal failure. We reviewed all patients admitted to Staten Island University Hospital with a diagnosis of myocardial infarction between January 2005 and December 2012. Patients were stratified into groups based on kidney function, defined as normal (glomerular filtration rate (GFR) ≥60mL/min/1.73m2), moderate CKD (GFR 30-59mL/min/1.73m2) and severe CKD (GFR <30mL/min/1.73m2). We hypothesized that there is no difference among the three groups of patients with respect to medical therapy and invasive cardiac procedures (such as cardiac catheterization and/or coronary artery bypass graft (CABG) if indicated). 334 patients (mean age 67.2±13.9) were included. Medical management (ASA, Platelets Inhibitor, ACE-I, ARB, beta blockers, statins) was achieved at high rates in our study and was similar irrespective of kidney function. However, Patients with ESRD were less likely to be offered coronary angiography compared to non CKD (45.6% vs 93.9%). CABG did not differ among the three groups. To note, ESRD were more likely to go to CABG when catheterization was performed.
Physicians are overcoming challenges based on individual cases. The current challenge is to study the CAD patient with CKD in prospective randomized trials to provide an evidence-based approach to therapy. In the absence of such information, aggressive control of CAD risk factors and timely intervention for symptomatic CAD is suggested.
AJKDblog: Why do you think less cardiac catheterization was performed in HD patients?
MS: Percutaneous coronary revascularization improves long-term survival when compared to medical therapy; yet we found that ESRD patient on HD are getting less catheterization then the other two groups. Unique risk factors are present in these patients putting them at once at high risk of CAD and of procedural complications. ESRD patients have extended small vessel disease that we believe is frequently responsible of their ischemic heart disease. Thus, there will be less interventions to fix distal small lesion within calcified vessel. In addition, ESRD will frequently have type 2 MI in a setting of significant deconditioning precipitated by prevalent comorbidities.
AJKDblog: Do you think CABG should be preferred in HD patients over cardiac stents?
MS: No evidence based guidelines are available to direct the care for HD patients. Coronary artery bypass graft (CABG) surgery and percutaneous coronary intervention (PCI) either can be used to treat multivessel coronary artery disease. In a recent study, ESRD patients on HD with multivessel and/or left main disease had reduced risk of cardiac death, sudden death and myocardial infarction and any revascularization in 5-year follow-up when they underwent CABG compared to PCI. However, the risk of all-cause death was not different. In an anecdotal approach, those with low EF, ostial or left main disease, with calcified extended lesions or tendancy to bleed are preferably managed with CABG preventing PCI-related complications.
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