Percutaneous Coronary Intervention Versus Optimal Medical Therapy for Stable Angina in Advanced CKD: A Decision Analysis

Differential Impact of Chronic Kidney Disease Stages on the Survival Benefit of Percutaneous Coronary Intervention: A Large Real-world Cohort Study

Chronic kidney disease (CKD) is prevalent among patients with coronary artery disease (CAD) and exacerbates myocardial ischemia. However, the survival benefit of percutaneous coronary intervention (PCI) across different stages of CKD remains controversial. CAD patients (n = 17,418) with CKD (mean age, 69.5 ± 9.9 years; 70.9% male) were included in the Cardiorenal Improvement II cohort from 2007 to 2020. Patients were grouped by PCI or medical treatment and further categorized by stages 3a-5 CKD. Multivariable Cox regression was performed to investigate the associations of cardiovascular- and all-cause mortality with PCI and CKD stage, and to compare predictors of outcomes in patients stratified by advanced CKD. During a median follow-up of 4.2 years, 4605 (26.4%) participants died. Compared with medical treatment, PCI was not associated with improved survival benefit among patients with stage 3b-5 CKD (all P > .05). Among patients with advanced CKD, hypertension, hyperfibrinogenemia and moderate-severe malnutrition were more significantly associated with increased cardiovascular mortality with relatively high attributable risk. PCI was not associated with a survival advantage among patients with advanced CKD. Hypertension, hyperfibrinogenemia and malnutrition may contribute to poor prognosis in patients with advanced kidney disease.

Cost-Effectiveness of Coronary Artery Bypass Grafting and Percutaneous Coronary Intervention in Patients With Chronic Kidney Disease and Acute Coronary Syndromes in the US Medicare Program

Background Coronary revascularization provides important long-term clinical benefits to patients with high-risk presentations of coronary artery disease, including those with chronic kidney disease. The cost-effectiveness of coronary interventions in this setting is not known. Methods and Results We developed a Markov cohort simulation model to assess the cost-effectiveness of percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in patients with chronic kidney disease who were hospitalized with acute myocardial infarction or unstable angina. Model inputs were primarily drawn from a sample of 14 300 patients identified using the Medicare 20% sample. Survival, quality-adjusted life-years, costs, and cost-effectiveness were projected over a 20-year time horizon. Multivariable models indicated higher 30-day mortality and end-stage renal disease with both PCI and CABG, and higher stroke with CABG, relative to medical therapy. However, the model projected long-term gains of 0.72 quality-adjusted life-years (0.97 life-years) for PCI compared with medical therapy, and 0.93 quality-adjusted life-years (1.32 life-years) for CABG compared with PCI. Incorporation of long-term costs resulted in incremental cost-effectiveness ratios of $65 326 per quality-adjusted life-year gained for PCI versus medical therapy, and $101 565 for CABG versus PCI. Results were robust to changes in input parameters but strongly influenced by the background costs of the population, and the time horizon. Conclusions For patients with chronic kidney disease and high-risk coronary artery disease presentations, PCI and CABG were both associated with markedly increased costs as well as gains in quality-adjusted life expectancy, with incremental cost-effectiveness ratios indicating intermediate value in health economic terms.

Prospective evaluation of the development of contrast-induced nephropathy in patients with acute coronary syndrome undergoing rotational coronary angiography vs. conventional coronary angiography: CINERAMA study

INTRODUCTION AND OBJECTIVES

Rotational coronary angiography (RCA) requires less contrast to be administered and can prevent the onset of contrast-induced nephropathy (CIN) during invasive coronary procedures. The aim of the study is to evaluate the impact of RCA on CIN (increase in serum creatinine ≥0.5mg/dl or ≥25%) after an acute coronary syndrome.

METHODS

From April to September 2016, patients suffering acute coronary syndromes who underwent diagnostic coronary angiography, with the possibility of ad hoc coronary angioplasty, were prospectively enrolled. At the operator's discretion, patients underwent RCA or conventional coronary angiography (CCA). CIN (primary endpoint), as well as analytical, angiographic and clinical endpoints, were compared between groups.

RESULTS

Of the 235 patients enrolled, 116 patients received RCA and 119 patients received CCA. The RCA group was composed of older patients (64.0±11.8 years vs. 59.7±12.1 years; p=0.006), a higher proportion of women (44.8 vs. 17.6%; p<0.001), patients with a lower estimated glomerular filtration rate (76±25 vs. 86±27ml/min/1.73 m²; p=0.001), and patients who underwent fewer coronary angioplasties (p<0.001) compared with the CCA group. Furthermore, the RCA group, received less contrast (113±92 vs. 169±103ml; p<0.001), including in diagnostic procedures (54±24 vs. 85±56ml; p<0.001) and diagnostic-therapeutic procedures (174±64 vs. 205±98ml; p=0.049) compared with the CCA group. The RCA group presented less CIN (4.3 vs. 22.7%; p<0.001) compared to the CCA group, and this finding was maintained in the regression analysis (Adjusted relative risk: 0.868; 95% CI: 0.794-0.949; p=0.002). There were no differences in clinical endpoints between the groups.

CONCLUSIONS

RCA was associated with lower administration of contrast during invasive coronary procedures in acute coronary syndrome patients, resulting in lower incidence of CIN, in comparison with CCA.