Background
: Chronic kidney disease (CKD) is a risk factor for poor outcomes in patients with CAD. Optimal management of such patients is uncertain. CKD patients (especially those with diabetes) are at risk for contrast nephropathy potentially limiting the benefits of percutaneous coronary intervention (PCI).
Methods:
To evaluate the impact of adding PCI to optimal medical therapy (OMT) in CKD patients with stable CAD we analyzed outcomes stratifying by renal function in the COURAGE trial. We used the abbreviated Modification of Diet in Renal Disease equation to estimate glomerular filtration rate (GFR).
Results:
A total of 2287 patients were enrolled in COURAGE. Of those, 30% (n=536) had CKD defined as GFR <60mL/min/1.73m
2
. CKD was present in 26% of OMT patients and 21% of OMT +PCI patients. The CKD group was older (66 ±10 versus 61 ± 9.6years P<0.001) had more females (24% versus 12 % p<0.001) more hypertension (71% versus 66% p <0.03) and higher systolic blood pressure (135 ±21 versus 131 ± 19mm/Hg p =<0.001). There was a trend to more diabetes (37% versus 34% p <0.22) and 3 vessel CAD (33% versus 30% p <0.09). ACEI or ARB use was 76% in CKD patients. By 36 months there was similar and intensive risk factor control in patients with and without CKD (systolic blood pressure 125 ± 17 versus 125 ± 17mmHg, LDL 79 ± 24 versus 78 ± 26mg/dL respectively p = NS). The primary composite end-point of COURAGE (death or MI) did not differ by treatment in patients with or without CKD. Rates of death, MI, CHF and angina-free survival at 36 months stratified by treatment status in patients with GFR>60 versus patients with GFR > 60 are shown in the table
.
Conclusion:
Patients with CKD and chronic stable angina when treated with OMT to aggressive blood pressure and lipid goals have marked and sustained improvement in angina similar to patients without CKD. Furthermore, patients with CKD can safely undergo PCI for improved angina control without excess death, MI or CHF when compared to patients treated by OMT alone.
Impact of Chronic Kidney Disease on In-Hospital and 3-Year Clinical Outcomes in Patients With Acute Myocardial Infarction Treated by Contemporary Percutaneous Coronary Intervention and Optimal Medical Therapy ― Insights From the J-MINUET Study ―
