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Vasudeva R, Mehta H, Chan WC, Majmundar M, Yarlagadda SG, Downey P, Daon E, Muehlebach G, Danter M, Zorn G, Wiley M, Tadros P, Hockstad E, Gupta K. Nationwide Trends and Outcomes for Coronary Artery Bypass Grafting in End-Stage Kidney Disease and Stable Coronary Artery Disease. Am J Cardiol 2024; 210:37-43. [PMID: 38682717 DOI: 10.1016/j.amjcard.2023.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 09/10/2023] [Accepted: 10/02/2023] [Indexed: 05/01/2024]
Abstract
Patients with end-stage kidney disease (ESKD) on dialysis have an increased burden of coronary artery disease (CAD). This study assessed the trend and outcomes for coronary artery bypass surgery (CABG) in patients with ESKD and stable CAD. We conducted a longitudinal study using the United States Renal Data System of patients with ESKD and stable CAD who underwent CABG from the years 2009 to 2017. The outcomes included in-hospital, long-term mortality, and repeat revascularization. The follow-up was until death, end of Medicare AB coverage, or December 31, 2018. A total of 11,952 patients were identified. The mean age was 62.8 years, 68% were male, and 67% were white. The common co-morbidities included hypertension (97%), diabetes mellitus (75%), and congestive heart failure (53%). A significant decrease in CABG procedures from 2.9 to 1.3 procedures per 1,000 patients with ESKD (p <0.001) was noted during the years studied. The overall in-hospital mortality rate was 5.9%, and there was a significant decrease over the study period (p = 0.01). Although the 30-day mortality rate was 6.9% and remained steady (p = 0.14), the 1-year mortality rate was 22.8% and decreased significantly (p <0.001). At 5 years, the overall survival rate was 35%, and patients with internal mammary artery grafts showed better survival than those without (36% vs 25%). In conclusion, there has been a decrease in CABG procedures performed in patients with ESKD with stable CAD with decreasing in-hospital and 1-year mortality. Those with an internal mammary artery graft do better, but the overall long-term survival remains dismal in this population. There remains need for caution and individualization of revascularization decisions in this high-risk population.
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Affiliation(s)
- Rhythm Vasudeva
- Department of Cardiovascular Medicine, University of Kansas Medical Center, Kansas City, Kansas
| | - Harsh Mehta
- Department of Cardiovascular Medicine, University of Kansas Medical Center, Kansas City, Kansas
| | - Wan-Chi Chan
- Department of Cardiovascular Medicine, University of Kansas Medical Center, Kansas City, Kansas
| | - Monil Majmundar
- Department of Cardiovascular Medicine, University of Kansas Medical Center, Kansas City, Kansas
| | - Sri G Yarlagadda
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas
| | - Peter Downey
- Department of Cardiovascular and Thoracic Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Emmanuel Daon
- Department of Cardiovascular and Thoracic Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Greg Muehlebach
- Department of Cardiovascular and Thoracic Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Matthew Danter
- Department of Cardiovascular and Thoracic Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - George Zorn
- Department of Cardiovascular and Thoracic Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Mark Wiley
- Department of Cardiovascular Medicine, University of Kansas Medical Center, Kansas City, Kansas
| | - Peter Tadros
- Department of Cardiovascular Medicine, University of Kansas Medical Center, Kansas City, Kansas
| | - Eric Hockstad
- Department of Cardiovascular Medicine, University of Kansas Medical Center, Kansas City, Kansas
| | - Kamal Gupta
- Department of Cardiovascular Medicine, University of Kansas Medical Center, Kansas City, Kansas.
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2
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Tasoudis PT, Varvoglis DN, Tzoumas A, Doulamis IP, Tzani A, Sá MP, Kampaktsis PN, Gallo M. Percutaneous coronary intervention versus coronary artery bypass graft surgery in dialysis-dependent patients: A pooled meta-analysis of reconstructed time-to-event data. J Card Surg 2022; 37:3365-3373. [PMID: 35900307 DOI: 10.1111/jocs.16805] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 07/02/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Το perform a systematic review with meta-analysis of published data comparing outcomes between a percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in dialysis-dependent patients. METHODS We searched PubMed, Scopus, and Cochrane databases for studies including dialysis-dependent patients who underwent either CABG or PCI. This meta-analysis follows the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. We conducted one-stage and two-stage meta-analysis with Kaplan-Meier-derived individual patient data for overall survival and meta-analysis with the random-effects model for the in-hospital mortality and repeat revascularization. RESULTS Twelve studies met our eligibility criteria, including 13,651 and 28,493 patients were identified in the CABG and PCI arms, respectively. Patients who underwent CABG had overall improved survival compared with those who underwent PCI at the one-stage meta-analysis (hazard ratio [HR]: 1.12, 95% confidence interval [CI]: 1.09-1.16, p < .0001) and the two-stage meta-analysis (HR: 1.15, 95% CI: 1.08-1.23, p < .001, I2 = 30.0%). Landmark analysis suggested that PCI offers better survival before the 8.5 months of follow-up (HR: 0.96, 95% CI: 0.92-0.99, p = .043), while CABG offers an advantage after this timepoint (HR: 1.3, 95% CI: 1.22-1.32, p < .001). CABG was associated with increased odds for in-hospital mortality (odds ratio [OR]: 1.70, 95% CI: 1.50-1.92, p < .001, I2 = 0.0%) and decreased odds for repeat revascularization (OR: 0.22, 95% CI: 0.14-0.34, p < .001, I2 = 58.08%). CONCLUSIONS In dialysis-dependent patients, CABG was associated with long-term survival but a higher risk for early mortality. The risk for repeat revascularization was higher with PCI.
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Affiliation(s)
- Panagiotis T Tasoudis
- Department of Cardiothoracic Surgery, School of Health Sciences, University of Thessaly, Larisa, Greece
| | - Dimitrios N Varvoglis
- Department of Cardiothoracic Surgery, School of Health Sciences, University of Thessaly, Larisa, Greece
| | - Andreas Tzoumas
- Department of Internal Medicine, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
| | - Ilias P Doulamis
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Aspasia Tzani
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michel P Sá
- Department of Cardiothoracic Surgery Research, Lankenau Institute for Medical Research, Wynnewood, Pennsylvania, USA
| | - Polydoros N Kampaktsis
- Department of Medicine, Division of Cardiology, New York University Langone Medical Center, New York, New York, USA
| | - Michele Gallo
- Department of Cardiac Surgery, Cardiocentro Ticino, Lugano, Switzerland
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Shroff GR, Carlson MD, Mathew RO. Coronary Artery Disease in Chronic Kidney Disease: Need for a Heart-Kidney Team-Based Approach. Eur Cardiol 2021; 16:e48. [PMID: 34950244 PMCID: PMC8674634 DOI: 10.15420/ecr.2021.30] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Accepted: 10/19/2021] [Indexed: 01/10/2023] Open
Abstract
Chronic kidney disease and coronary artery disease are co-prevalent conditions with unique epidemiological and pathophysiological features, that culminate in high rates of major adverse cardiovascular outcomes, including all-cause mortality. This review outlines a summary of the literature, and nuances pertaining to non-invasive risk assessment of this population, medical management options for coronary heart disease and coronary revascularisation. A collaborative heart-kidney team-based approach is imperative for critical management decisions for this patient population, especially coronary revascularisation; this review outlines specific periprocedural considerations pertaining to coronary revascularisation, and provides a proposed algorithm for approaching revascularisation choices in patients with end-stage kidney disease based on available literature.
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Affiliation(s)
- Gautam R Shroff
- Division of Cardiology, Department of Medicine, Hennepin Healthcare & University of Minnesota Medical School Minneapolis, MN, US
| | - Michelle D Carlson
- Division of Cardiology, Department of Medicine, Hennepin Healthcare & University of Minnesota Medical School Minneapolis, MN, US
| | - Roy O Mathew
- Division of Nephrology, Department of Medicine, Columbia VA Health Care System Columbia, SC, US
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4
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Walker JA, Richards S, Whelan SA, Yoo SB, Russell TL, Arinze N, Lotfollahzadeh S, Napoleon MA, Belghasem M, Lee N, Dember LM, Ravid K, Chitalia VC. Indoleamine 2,3-dioxygenase-1, a Novel Therapeutic Target for Post-Vascular Injury Thrombosis in CKD. J Am Soc Nephrol 2021; 32:2834-2850. [PMID: 34716244 PMCID: PMC8806102 DOI: 10.1681/asn.2020091310] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 08/16/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND CKD, characterized by retained uremic solutes, is a strong and independent risk factor for thrombosis after vascular procedures . Urem ic solutes such as indoxyl sulfate (IS) and kynurenine (Kyn) mediate prothrombotic effect through tissue factor (TF). IS and Kyn biogenesis depends on multiple enzymes, with therapeutic implications unexplored. We examined the role of indoleamine 2,3-dioxygenase-1 (IDO-1), a rate-limiting enzyme of kynurenine biogenesis, in CKD-associated thrombosis after vascular injury. METHODS IDO-1 expression in mice and human vessels was examined. IDO-1-/- mice, IDO-1 inhibitors, an adenine-induced CKD, and carotid artery injury models were used. RESULTS Both global IDO-1-/- CKD mice and IDO-1 inhibitor in wild-type CKD mice showed reduced blood Kyn levels, TF expression in their arteries, and thrombogenicity compared with respective controls. Several advanced IDO-1 inhibitors downregulated TF expression in primary human aortic vascular smooth muscle cells specifically in response to uremic serum. Further mechanistic probing of arteries from an IS-specific mouse model, and CKD mice, showed upregulation of IDO-1 protein, which was due to inhibition of its polyubiquitination and degradation by IS in vascular smooth muscle cells. In two cohorts of patients with advanced CKD, blood IDO-1 activity was significantly higher in sera of study participants who subsequently developed thrombosis after endovascular interventions or vascular surgery. CONCLUSION Leveraging genetic and pharmacologic manipulation in experimental models and data from human studies implicate IS as an inducer of IDO-1 and a perpetuator of the thrombotic milieu and supports IDO-1 as an antithrombotic target in CKD.
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MESH Headings
- Animals
- Aorta
- Carotid Artery Injuries/complications
- Carotid Artery Thrombosis/etiology
- Carotid Artery Thrombosis/prevention & control
- Culture Media/pharmacology
- Enzyme Induction/drug effects
- Feedback, Physiological
- Female
- HEK293 Cells
- Humans
- Indican/physiology
- Indoleamine-Pyrrole 2,3,-Dioxygenase/antagonists & inhibitors
- Indoleamine-Pyrrole 2,3,-Dioxygenase/blood
- Indoleamine-Pyrrole 2,3,-Dioxygenase/deficiency
- Indoleamine-Pyrrole 2,3,-Dioxygenase/genetics
- Kynurenine/blood
- Kynurenine/physiology
- Mice
- Mice, Inbred C57BL
- Mice, Knockout
- Molecular Targeted Therapy
- Myocytes, Smooth Muscle/drug effects
- Postoperative Complications/blood
- Postoperative Complications/enzymology
- Postoperative Complications/etiology
- Postoperative Complications/prevention & control
- Renal Insufficiency, Chronic/drug therapy
- Renal Insufficiency, Chronic/enzymology
- Thromboplastin/metabolism
- Thrombosis/blood
- Thrombosis/enzymology
- Thrombosis/etiology
- Thrombosis/prevention & control
- Tryptophan/metabolism
- Uremia/blood
- Vascular Surgical Procedures/adverse effects
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Affiliation(s)
- Joshua A Walker
- Renal Section, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
- Whitaker Cardiovascular Institute, Boston University, Boston, Massachusetts
| | - Sean Richards
- Renal Section, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Stephen A Whelan
- Chemical Instrumentation Center, Boston University, Boston, Massachusetts
| | - Sung Bok Yoo
- Renal Section, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Teresa L Russell
- Renal Section, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Nkiruka Arinze
- Department of Surgery, Boston University School of Medicine, Boston, Massachusetts
| | - Saran Lotfollahzadeh
- Renal Section, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Marc A Napoleon
- Renal Section, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Mostafa Belghasem
- Department of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Norman Lee
- Chemical Instrumentation Center, Boston University, Boston, Massachusetts
| | - Laura M Dember
- Renal-Electrolyte and Hypertension Division, Center for Clinical Epidemiology and Biostatistics, Philadelphia, Pennsylvania
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Katya Ravid
- Whitaker Cardiovascular Institute, Boston University, Boston, Massachusetts
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Vipul C Chitalia
- Renal Section, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
- Veteran Affairs Boston Healthcare System, Boston, Massachusetts
- Institute of Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts
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5
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Shroff GR, Henry TD. Percutaneous coronary intervention in end-stage kidney disease: Trapped between a rock and a hard place. Catheter Cardiovasc Interv 2021; 98:215-216. [PMID: 34369057 DOI: 10.1002/ccd.29846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 06/14/2021] [Indexed: 11/05/2022]
Affiliation(s)
- Gautam R Shroff
- Division of Cardiology, Department of Internal Medicine, Hennepin Healthcare and University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Timothy D Henry
- The Carl and Edyth Lindner Center for Research and Education at The Christ Hospital, Cincinnati, Ohio, USA
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6
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Klein EC, Kapoor R, Lewandowski D, Mason PJ. Revascularization Strategies in Patients with Chronic Kidney Disease and Acute Coronary Syndromes. Curr Cardiol Rep 2019; 21:113. [PMID: 31471758 DOI: 10.1007/s11886-019-1213-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
PURPOSE OF REVIEW Chronic kidney disease (CKD) is a highly prevalent condition that increases the incidence and complexity of acute coronary syndrome (ACS). The purpose of this review is to summarize current evidence, uncertainties, and opportunities in the management of patients with CKD and ACS, with a focus on revascularization. RECENT FINDINGS Patients with CKD have been systematically under-represented or excluded from clinical trials in ACS. Available data, however, demonstrates that although patients with CKD and ACS benefit from revascularization, they are also less likely to receive recommended medical and revascularization therapies when compared to patients with normal kidney function. Despite the increased short-term risk of major morbidity and mortality, patients with CKD and ACS should be considered for an early invasive strategy while also trying to mitigate the risks of procedural related complications. Until evidence emerges from randomized clinical trials, the decision about revascularization strategy should involve multi-disciplinary collaboration, heart team consensus, and patient shared decision-making.
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Affiliation(s)
- Evan C Klein
- Medical College of Wisconsin, Milwaukee, WI, USA
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7
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Charytan DM, Natwick T, Solid CA, Li S, Gong T, Herzog CA. Comparative Effectiveness of Medical Therapy, Percutaneous Revascularization, and Surgical Coronary Revascularization in Cardiovascular Risk Subgroups of Patients With CKD: A Retrospective Cohort Study of Medicare Beneficiaries. Am J Kidney Dis 2019; 74:463-473. [PMID: 31255335 DOI: 10.1053/j.ajkd.2019.04.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 04/10/2019] [Indexed: 11/12/2022]
Abstract
RATIONALE & OBJECTIVE Prior studies suggesting that medical therapy is inferior to percutaneous (percutaneous coronary intervention [PCI]) or surgical (coronary artery bypass grafting [CABG]) coronary revascularization in chronic kidney disease (CKD) have not adequately considered medication optimization or baseline cardiovascular risk and have infrequently evaluated progression to kidney failure. We compared, separately, the risks for kidney failure and death after treatment with PCI, CABG, or optimized medical therapy for coronary disease among patients with CKD stratified by cardiovascular disease risk. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS 34,385 individuals with CKD identified from a national 20% Medicare sample who underwent angiography or diagnostic stress testing without (low risk) or with (medium risk) prior cardiovascular disease or who presented with acute coronary syndrome (high risk). EXPOSURES PCI, CABG, or optimized medical therapy (defined by the addition of cardiovascular medications in the absence of coronary revascularization). OUTCOMES Death, kidney failure, composite outcome of death or kidney failure. ANALYTICAL APPROACH Adjusted relative rates of death, kidney failure, and the composite of death or kidney failure estimated from Cox proportional hazards models. RESULTS Among low-risk patients, 960 underwent PCI, 391 underwent CABG, and 6,426 received medical therapy alone; among medium-risk patients, 1,812 underwent PCI, 512 underwent CABG, and 9,984 received medical therapy alone; and among high-risk patients, 4,608 underwent PCI, 1,330 underwent CABG, and 8,362 received medical therapy alone. Among low- and medium-risk patients, neither CABG (HRs of 1.22 [95% CI, 0.96-1.53] and 1.08 [95% CI, 0.91-1.29] for low- and medium-risk patients, respectively) nor PCI (HRs of 1.14 [95% CI, 0.98-1.33] and 1.02 [95% CI, 0.93-1.12], respectively) were associated with reduced mortality compared with medical therapy, but in low-risk patients, CABG was associated with a higher rate of the composite, death or kidney failure (HR, 1.25; 95% CI, 1.02-1.53). In high-risk patients, CABG and PCI were associated with lower mortality (HRs of 0.57 [95% CI, 0.51-0.63] and 0.70 [95% CI, 0.66-0.74], respectively). Also, in high-risk patients, CABG was associated with a higher rate of kidney failure (HR, 1.40; 95% CI, 1.16-1.69). LIMITATIONS Possible residual confounding; lack of data for coronary angiography or left ventricular ejection fraction; possible differences in decreased kidney function severity between therapy groups. CONCLUSIONS Outcomes associated with cardiovascular therapies among patients with CKD differed by baseline cardiovascular risk. Coronary revascularization was not associated with improved survival in low-risk patients, but was associated with improved survival in high-risk patients despite a greater observed rate of kidney failure. These findings may inform clinical decision making in the care of patients with both CKD and cardiovascular disease.
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Affiliation(s)
| | - Tanya Natwick
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN
| | - Craig A Solid
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN
| | - Shuling Li
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN
| | - Tingting Gong
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN
| | - Charles A Herzog
- Department of Medicine, Hennepin Healthcare and University of Minnesota, Minneapolis, MN
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Sattar S, Ahmed N, Akhter Z, Aijaz S, Lakhani S, Malik R, Pathan A. In-Hospital outcomes in acute coronary syndrome patients with concomitant severe chronic kidney disease undergoing percutaneous coronary intervention. Pak J Med Sci 2019; 35:291-297. [PMID: 31086503 PMCID: PMC6500806 DOI: 10.12669/pjms.35.2.276] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective To determine in-hospital mortality and major adverse cardiac events (MACE) in acute coronary syndrome (AMI) patients with underlying severe chronic kidney disease (CKD) undergoing percutaneous coronary intervention (PCI). Methods We conducted a retrospective cohort study from June'2013-December'2017 at Tabba Heart Institute, Karachi. Data was drawn from institutes' database modeled after US National Cardiovascular data CathPCI registry. All AMI (STEMI: ST-elevation myocardial infarction and NSTEMI: non-ST-elevation myocardial infarction) patients undergoing PCI with creatinine clearance <30ml/min or ESRD on hemodialysis were included in the study. Results During 54 months study period, 160 severe CKD patients underwent PCI. Mean age was 62.9±12.2 years. Men were 61.9%, hypertensive (81.3%) and diabetic (63.8%). Excluding dialysis patients, Creatinine clearance was 21.1±6.6ml/min/1.73m2. STEMI were 46.9% and 61.9% were Killip I. Mean SYNTAX score was 16.6±7.3. MACE occurred in 32.5% patients, of which 6(11.5%) had new hemodialysis and mortality: 17.5% were deceased. MACE predictor were cardiogenic shock (OR: 2.81, 95%CI: 1.17-6.74) and prior heart failure (OR: 6.84, 95%CI: 1.39-33.74), Predictor of mortality was cardiogenic shock or cardiac arrest (OR: 7.90, 95%CI: 2.95-21.17). Conclusion Severe CKD patients undergoing PCI for AMI have drastically poor outcomes therefore individualization and patient-centric care management is mandatory.
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Affiliation(s)
- Saadia Sattar
- Saadia Sattar, M.Sc Epi-Bio. Research Consultant, Department of Clinical Research, Cardiology, Tabba Heart Institute, Karachi, Pakistan
| | - Naseer Ahmed
- Naseer Ahmed, MBBS Cardiology Fellow, Department of Cardiology, Tabba Heart Institute, Karachi, Pakistan
| | - Zohaib Akhter
- Zohaib Akhter, M.Sc Epi-Bio. Research Consultant, Department of Clinical Research, Cardiology, Tabba Heart Institute, Karachi, Pakistan
| | - Saba Aijaz
- Saba Aijaz, FCPS. Consultant Cardiologist, Cardiology, Tabba Heart Institute, Karachi, Pakistan
| | - Shakir Lakhani
- Shakir Lakhani, FCPS. Consultant Cardiologist, Cardiology, Tabba Heart Institute, Karachi, Pakistan
| | - Rehan Malik
- Rehan Malik, Research Officer, Department of Cardiology, Tabba Heart Institute, Karachi, Pakistan
| | - Asad Pathan
- Asad Pathan, FACC. Consultant Cardiologist, Cardiology, Tabba Heart Institute, Karachi, Pakistan
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9
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Numasawa Y, Inohara T, Ishii H, Yamaji K, Hirano K, Kohsaka S, Sawano M, Kuno T, Kodaira M, Uemura S, Kadota K, Amano T, Nakamura M. An overview of percutaneous coronary intervention in dialysis patients: Insights from a Japanese nationwide registry. Catheter Cardiovasc Interv 2018; 94:E1-E8. [PMID: 30467967 DOI: 10.1002/ccd.27986] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Revised: 10/17/2018] [Accepted: 10/29/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVES This study sought to provide an overview of percutaneous coronary intervention (PCI) in dialysis patients from a Japanese nationwide registry. BACKGROUND Little is known about dialysis patients undergoing PCI because few are enrolled in clinical trials. METHODS We analyzed 624,900 PCI cases including 41,384 dialysis patients (6.6%) from 1,017 Japanese hospitals between 2014 and 2016. We investigated differences in characteristics and in-hospital outcomes between dialysis and nondialysis patients, and assessed factors associated with an increased risk of adverse outcomes. RESULTS Dialysis patients had more comorbidities than nondialysis patients and higher rates of complications including in-hospital mortality (3.3% vs. 1.5%, respectively, in the acute coronary syndrome [ACS] cohort, 0.2% vs. 0.1% in the non-ACS cohort) and bleeding complications requiring blood transfusion (1.1% vs. 0.4% in ACS, 0.5% vs. 0.2% in non-ACS). Dialysis was significantly associated with an increased risk of in-hospital mortality (odds ratio [OR]: 1.42, 95% confidence interval [CI]: 1.24-1.62 in ACS, OR: 2.25, 95% CI: 1.66-3.05 in non-ACS) and bleeding (OR: 1.60, 95% CI: 1.30-1.96 in ACS, OR: 1.55, 95% CI: 1.27-1.88 in non-ACS). For dialysis patients, age, acute heart failure, and cardiogenic shock were associated with an increased risk of in-hospital mortality in the ACS cohort, whereas age, female gender, and history of heart failure were associated with higher in-hospital mortality in the non-ACS cohort. CONCLUSIONS PCI was widely performed for dialysis patients with either ACS or non-ACS in Japan. Dialysis patients had a greater risk of adverse outcomes than nondialysis patients after PCI.
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Affiliation(s)
- Yohei Numasawa
- Department of Cardiology, Japanese Red Cross Ashikaga Hospital, Ashikaga, Japan
| | - Taku Inohara
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina.,Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Hideki Ishii
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kyohei Yamaji
- Division of Cardiology, Kokura Memorial Hospital, Japan
| | - Keita Hirano
- Department of Nephrology, Japanese Red Cross Ashikaga Hospital, Ashikaga, Japan
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Mitsuaki Sawano
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Toshiki Kuno
- Department of Cardiology, Japanese Red Cross Ashikaga Hospital, Ashikaga, Japan
| | - Masaki Kodaira
- Department of Cardiology, Japanese Red Cross Ashikaga Hospital, Ashikaga, Japan
| | - Shiro Uemura
- Department of Cardiology, Kawasaki Medical School, Kurashiki, Japan
| | - Kazushige Kadota
- Department of Cardiology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Tetsuya Amano
- Department of Cardiology, Aichi Medical University, Nagakute, Japan
| | - Masato Nakamura
- Division of Cardiovascular Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
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10
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Wang Y, Zhu S, Gao P, Chen Y, Zhang Q. Drug-Eluting Stents Versus Bare-Metal Stents in Patients With End-Stage Renal Disease. Am J Med Sci 2018; 355:331-341. [PMID: 29661346 DOI: 10.1016/j.amjms.2017.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 10/07/2017] [Accepted: 10/13/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND The clinical outcomes of drug-eluting stents versus bare-metal stents in end-stage renal disease patients remains controversial. METHODS A comprehensive literature search of Pubmed, Embase and Cochrane Library from January 2000 until November 2016 was conducted to identify relevant articles. We pooled the odds ratios (OR) from individual studies and conducted heterogeneity, quality assessment and publication bias analyses. RESULTS A total of 18 studies with 44,194 patients were identified. Compared with bare-metal stent-treated patients, drug-eluting stent-treated patients had significantly lower short-term and long-term all-cause mortality (OR = 0.56; 95% CI: 0.48-0.65; P < 0.00001; OR = 0.78; 95% CI: 0.66-0.92; P = 0.004, respectively), myocardial infarction (OR = 0.69; 95% CI: 0.53-0.88; P = 0.003) and major adverse cardiac events (OR = 0.72; 95% CI: 0.58-0.90; P = 0.004), with no detectable difference regarding stent thrombosis (OR = 0.80; 95% CI: 0.43-1.49; P = 0.47), cardiac mortality (OR = 0.95; 95% CI: 0.89-1.02; P = 0.14) and repeat revascularization (OR = 0.81; 95% CI: 0.62-1.06; P = 0.13). CONCLUSIONS In patients with end-stage renal disease, the use of drug-eluting stents could significantly reduce the rates of mortality, myocardial infarction and major adverse cardiac events without increased risk of stent thrombosis. It poses imperative demands for future prospective randomized studies to define the optimal stent choice in this high-risk population.
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Affiliation(s)
- Yushu Wang
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Sui Zhu
- Department of Epidemiology and Biostatistics, School of Public Health, Sichuan University, Chengdu, Sichuan, China
| | - Peijuan Gao
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yucheng Chen
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Qing Zhang
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
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11
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Engelbertz C, Reinecke H, Breithardt G, Schmieder RE, Fobker M, Fischer D, Schmitz B, Pinnschmidt HO, Wegscheider K, Pavenstädt H, Brand E. Two-year outcome and risk factors for mortality in patients with coronary artery disease and renal failure: The prospective, observational CAD-REF Registry. Int J Cardiol 2017; 243:65-72. [PMID: 28526542 DOI: 10.1016/j.ijcard.2017.05.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 04/19/2017] [Accepted: 05/05/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Chronic kidney disease (CKD) and coronary artery disease (CAD) are strongly associated. CAD is the most frequent cause of cardiovascular death in patients with CKD. METHODS The prospective observational nationwide multicenter Coronary Artery Disease and REnal Failure (CAD-REF) Registry enrolled 3352 patients with angiographically documented CAD classified according to their baseline estimated glomerular filtration rate (eGFR) into 5 groups according to the K/DOQI-guidelines. Patients were followed for two years. The aim of this study was the analysis of outcome and the identification of risk factors for two-year mortality in patients with both CKD and CAD. RESULTS With decreasing renal function, patients had more often diabetes mellitus, hypertension, peripheral artery disease, and previous cardiovascular events and interventions. The amount of diseased vessels increased with decreasing renal function. For the whole cohort, two-year mortality was 6.5%. Kaplan-Meier-curves showed highest mortality in patients with CKD stages 4 and 5 (22.4%). In multivariate Cox-regression analyses, significant risk factors for two-year all-cause mortality were lower eGFR, current smoking, left ventricular ejection fraction, diabetes mellitus treated with oral medication or insulin, age, and peripheral artery disease. Coronary status missed the level of statistical significance as a risk factor for mortality in multivariable regression analysis. An eGFR reduction of 10ml/min/1.73m2 increased the risk of mortality by 19% regardless of other risk factors. CONCLUSIONS Two-year morbidity and mortality increased with the degree of renal impairment. To improve survival of patients with CAD and CKD, nephroprotection is urgently needed especially for patients with atherosclerotic burden. CLINICAL TRIAL REGISTRATION NUMBER NCT00679419, http://clinicaltrials.gov/.
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Affiliation(s)
- Christiane Engelbertz
- Division of Vascular Medicine, Department of Cardiovascular Medicine, University Hospital Muenster, Muenster, Germany
| | - Holger Reinecke
- Division of Vascular Medicine, Department of Cardiovascular Medicine, University Hospital Muenster, Muenster, Germany
| | - Günter Breithardt
- Division of Vascular Medicine, Department of Cardiovascular Medicine, University Hospital Muenster, Muenster, Germany
| | - Roland E Schmieder
- Department of Nephrology and Hypertension, University of Erlangen-Nuernberg, Erlangen, Germany
| | - Manfred Fobker
- Center of Laboratory Medicine, University Hospital Muenster, Muenster, Germany
| | - Dieter Fischer
- Division of Cardiology, Department of Cardiovascular Medicine, University Hospital Muenster, Muenster, Germany
| | - Boris Schmitz
- Institute of Sports Medicine, Molecular Genetics of Cardiovascular Disease, University Hospital Muenster, Muenster, Germany
| | - Hans O Pinnschmidt
- Department of Medical Biometry and Epidemiology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Karl Wegscheider
- Department of Medical Biometry and Epidemiology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Hermann Pavenstädt
- Department of Nephrology, Hypertension, and Rheumatology, University Hospital Muenster, Muenster, Germany
| | - Eva Brand
- Department of Nephrology, Hypertension, and Rheumatology, University Hospital Muenster, Muenster, Germany.
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12
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Abstract
Cardiovascular disease is a major concern for patients with end-stage renal disease (ESRD), especially those on hemodialysis. ESRD patients with coronary artery disease often do not have symptoms or present with atypical symptoms. Coronary lesions in ESRD patients are characterized by increased media thickness, infiltration and activation of macrophages, and marked calcification. Several studies showed worsened clinical outcomes after coronary revascularization, which were dependent on the severity of renal dysfunction. ESRD patients on hemodialysis have the most severe renal dysfunction; thus, the clinical outcomes are worse in these patients than in those with other types of renal dysfunction. Medications for primary or secondary cardiovascular prevention are also insufficient in ESRD patients. Efficacy of drug-eluting stents is inferior in ESRD patients, compared to the excellent outcomes observed in patients with normal renal function. Unsatisfactory outcomes with trials targeting cardiovascular disease in patients with ESRD emphasize a large potential to improve outcomes. Thus, optimal strategies for diagnosis, prevention, and management of cardiovascular disease should be modified in ESRD patients.
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Affiliation(s)
- Jiro Aoki
- Division of Cardiology, Mitsui Memorial Hospital, Tokyo, Japan
| | - Yuji Ikari
- Department of Cardiovascular Medicine, Tokai University School of Medicine, Isehara, Kanagawa, Japan
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13
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Lu R, Tang F, Zhang Y, Zhu X, Zhu S, Wang G, Jiang Y, Fan Z. Comparison of Drug-Eluting and Bare Metal Stents in Patients With Chronic Kidney Disease: An Updated Systematic Review and Meta-Analysis. J Am Heart Assoc 2016; 5:e003990. [PMID: 27821401 PMCID: PMC5210359 DOI: 10.1161/jaha.116.003990] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 09/30/2016] [Indexed: 01/12/2023]
Abstract
BACKGROUND Drug-eluting stents (DESs) and bare metal stents (BMSs) are both recommended to improve coronary revascularization and to treat coronary artery disease in patients with chronic kidney disease (CKD). However, the potential superiority of DESs over BMSs for reducing the incidence of long-term major adverse cardiovascular events and mortality in CKD patients has not been established, and the results remain controversial. We aimed to systematically assess and quantify the total weight of evidence regarding the use of DESs versus BMSs in CKD patients. METHODS AND RESULTS In this systematic review and conventional meta-analysis, electronic studies published in any language until May 20, 2016, were systematically searched through PubMed, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials. We included randomized controlled trials and observational studies comparing outcomes in CKD patients with DESs versus BMSs and extracted data in a standard form. Pooled odd ratios and 95% CIs were calculated using random- and fixed-effects models. Finally, 38 studies involving 123 396 patients were included. The use of DESs versus BMSs was associated with significant reductions in major adverse cardiovascular events (pooled odds ratio 0.75; 95% CI, 0.64-0.88; P<0.001), all-cause mortality (odds ratio 0.81; 95% CI, 0.73-0.90; P<0.001), myocardial infarction, target-lesion revascularization, and target-vessel revascularization. The superiority of DESs over BMSs for improving clinical outcomes was attenuated in randomized controlled trials. CONCLUSIONS The use of DESs significantly improves the above outcomes in CKD patients. Nevertheless, large-sized randomized controlled trials are necessary to determine the real effect on CKD patients and whether efficacy differs by type of DES.
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Affiliation(s)
- Renjie Lu
- Department of Pharmacy, The Third People's Hospital of Changzhou, Jiangsu, China
| | - Fenglei Tang
- Department of Pharmacy, The Third People's Hospital of Changzhou, Jiangsu, China
| | - Yan Zhang
- Department of Internal Medicine, The Third People's Hospital of Changzhou, Jiangsu, China
| | - Xishan Zhu
- Department of Urinary Surgery, The Third People's Hospital of Changzhou, Jiangsu, China
| | - Shanmei Zhu
- Department of Pharmacy, The Third People's Hospital of Changzhou, Jiangsu, China
| | - Ganlin Wang
- Department of Urinary Surgery, The Third People's Hospital of Changzhou, Jiangsu, China
| | - Yinfeng Jiang
- Department of Urinary Surgery, The Third People's Hospital of Changzhou, Jiangsu, China
| | - Zhengda Fan
- Department of Pharmacy, The Third People's Hospital of Changzhou, Jiangsu, China
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Möckel M, Searle J, Baberg HT, Dirschedl P, Levenson B, Malzahn J, Mansky T, Günster C, Jeschke E. Revascularisation of patients with end-stage renal disease on chronic haemodialysis: bypass surgery versus PCI-analysis of routine statutory health insurance data. Open Heart 2016; 3:e000464. [PMID: 27752331 PMCID: PMC5051505 DOI: 10.1136/openhrt-2016-000464] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 07/28/2016] [Accepted: 08/08/2016] [Indexed: 11/23/2022] Open
Abstract
Objectives We aimed to analyse the short-term and long-term outcome of patients with end-stage renal disease (ESRD) undergoing percutaneous intervention (PCI) as compared to coronary artery bypass surgery (CABG) to evaluate the optimal coronary revascularisation strategy. Design Retrospective analysis of routine statutory health insurance data between 2010 and 2012. Main outcome measures Primary outcome was adjusted all-cause mortality after 30 days and major adverse cardiovascular and cerebrovascular events at 1 year. Secondary outcomes were repeat revascularisation at 30 days and 1 year and bleeding events within 7 days. Results The total number of cases was n=4123 (PCI; n=3417), median age was 71 (IQR 62–77), 30.4% were women. The adjusted OR for death within 30 days was 0.59 (95% CI 0.43 to 0.81) for patients undergoing PCI versus CABG. At 1 year, the adjusted OR for major adverse cardiac and cerebrovascular events (MACCE) was 1.58 (1.32 to 1.89) for PCI versus CABG and 1.47 (1.23 to 1.75) for all-cause death. In the subgroup of patients with acute myocardial infarction (AMI), adjusted all-cause mortality at 30 days did not differ significantly between both groups (OR 0.75 (0.47 to 1.20)), whereas in patients without AMI the OR for 30-day mortality was 0.44 (0.28 to 0.68) for PCI versus CABG. At 1 year, the adjusted OR for MACCE in patients with AMI was 1.40 (1.06 to 1.85) for PCI versus CABG and 1.47 (1.08 to 1.99) for mortality. Conclusions In this cohort of unselected patients with ESRD undergoing revascularisation, the 1-year outcome was better for CABG in patients with and without AMI. The 30-day mortality was higher in non-AMI patients with CABG reflecting an early hazard with surgery. In cases where the patient's characteristics and risk profile make it difficult to decide on a revascularisation strategy, CABG could be the preferred option.
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Affiliation(s)
- Martin Möckel
- Division of Emergency Medicine and Chest Pain Units, Department of Cardiology , Campus Virchow Klinikum and Campus Charité Mitte, Charité-Universitätsmedizin Berlin , Berlin , Germany
| | - Julia Searle
- Division of Emergency Medicine and Chest Pain Units, Department of Cardiology , Campus Virchow Klinikum and Campus Charité Mitte, Charité-Universitätsmedizin Berlin , Berlin , Germany
| | - Henning Thomas Baberg
- Department of Cardiology and Nephrology , Helios Klinikum, Berlin-Buch , Berlin , Germany
| | - Peter Dirschedl
- Medical Service of the Health Funds (MDK) Baden-Württemberg , Lahr , Germany
| | - Benny Levenson
- German Society of Cardiologists in Private Practise (BNK-Bundesverband niedergelassener Kardiologen) , München , Germany
| | - Jürgen Malzahn
- Federal Association of the Local Health Care Funds (AOK) , Berlin , Germany
| | - Thomas Mansky
- Faculty of Economics and Management, Division of Structural Development and Quality Management in Healthcare , Technische Universität Berlin , Berlin , Germany
| | - Christian Günster
- Research Institute of the Local Health Care Funds (WIdO) , Berlin , Germany
| | - Elke Jeschke
- Research Institute of the Local Health Care Funds (WIdO) , Berlin , Germany
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15
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Shroff GR, Herzog CA. Coronary Revascularization in Patients with CKD Stage 5D: Pragmatic Considerations. J Am Soc Nephrol 2016; 27:3521-3529. [PMID: 27493258 DOI: 10.1681/asn.2016030345] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Coronary revascularization decisions for patients with CKD stage 5D present a dilemma for clinicians because of high baseline risks of mortality and future cardiovascular events. This population differs from the general population regarding characteristics of coronary plaque composition and behavior, accuracy of noninvasive testing, and response to surgical and percutaneous revascularization, such that findings from the general population cannot be automatically extrapolated. However, this high-risk population has been excluded from all randomized trials evaluating outcomes of revascularization. Observational studies have attempted to address long-term outcomes after surgical versus percutaneous revascularization strategies, but inherent selection bias may limit accuracy. Compared with percutaneous strategies, surgical revascularization seems to have long-term survival benefit on the basis of observational data but associates with substantially higher short-term mortality rates. Percutaneous revascularization with drug-eluting and bare metal stents associates with a high risk of in-stent restenosis and need for future revascularization, perhaps contributing to the higher long-term mortality hazard. Off-pump coronary bypass surgery and the newest generation of drug-eluting stent platforms offer no definitive benefits. In this review, we address the nuances, complexities, and tradeoffs that clinicians face in determining the optimal method of coronary revascularization for this high-risk population.
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Affiliation(s)
- Gautam R Shroff
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis, Minnesota; and
| | - Charles A Herzog
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis, Minnesota; and .,Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
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