CAD in Chronic Kidney Disease Kuang-Te Wang
InIntroduction What I am going to talk about: CKD and its clinical impact on CAD Diagnosis of CAD in CKD PCI / Revasc Outcomes in CKD
CKD PCI CAD
Ohtake T, Kobayashi S, Moriya H et al. High prevalence of occult coronary artery stenosis in patients Incidence and severity of CAD increases as GFR decrea Nakano T, Ninomiya T, Sumiyoshi S et al. Association of kidney function with coronary atherosclerosis calcification in autopsy samples from Japanese elders: the Hisayama study. Am J Kidney Dis 2010; 5 Chonchol M, Whittle J, Desbien A et al. Chronic kidney disease is associated with angiographic coron artery disease. Am J Nephrol 2008; 28: 354 360. Diffuse multivessel involvement with calcification Ix JH, Shlipak MG, Liu HH et al. Association between renal insufficiency and inducible ischemia in pat with coronary artery disease: the heart and soul study. J Am Soc Nephrol 2003; 14: 3233 3238. Among pts with CAD, presence of CKD portends a wors CV prognosis Joki N, Hase H, Nakamura R et al. Onset of coronary artery disease prior to initiation of haemodialysis patients with end-stage renal disease. Nephrol Dial Transplant 1997; 12: 718 723.
n a series of consecutive incident dialysis patients who underwent cardiac atheterization, more than 60% of patients ad significant CAD (defined as more than 5% narrowing of a major coronary artery), ith an average of 3.3 lesions per patient.
Standard CVRFs are common in CKD + CAD setting Longenecker JC, Coresh J, Powe NR et al. Traditional cardiovascular disease risk factors in dialysis p compared with the general population: the CHOICE Study. J Am Soc Nephrol 2002; 13: 1918 1927. Weiner DE, Tighiouart H, Elsayed EF et al. The Framingham predictive instrument in chronic kidney d Am Coll Cardiol 2007; 50:217 224. Oxidative stress & inflammation linked to pathogenesis of plaque formation and rupture, as is mineralocorticoid excess defilippi C, Wasserman S, Rosanio S et al. Cardiac troponin T and C-reactive protein for predicting pr coronary atherosclerosis, and cardiomyopathy in patients undergoing long-term hemodialysis. JAMA 2 290: 353 359 Weiner DE, Tighiouart H, Elsayed EF et al. Inflammation and cardiovascular events in individuals with without chronic kidney disease. Kidney Int 2008; 73: 1406 1412 Menon V, Greene T, Wang X et al. C-reactive protein and albumin as predictors of all-cause and cardiovascular mortality in chronic kidney disease. Kidney Int 2005; 68: 766 772
Ooi et al., approximately 29% of patients ithout overt acute coronary disease had an levated level of troponin T. [13] Furthermore, ly about 11% of patients had concentrations less than 0.01 g/l.
Disordered mineral and bone metabolism accelerates C burden Giovannucci E, Liu Y, Hollis BW et al. 25-Hydroxyvitamin D and risk of myocardial infarction in men: a prospective study. Arch Intern Med 2008; 168: 1174 1180. Kovesdy CP, Ahmadzadeh S, Anderson JE et al. Association of activated vitamin D treatment and mo chronic kidney disease. Arch Intern Med 2008; 168: 397 403. Gutierrez OM, Mannstadt M, Isakova T et al. Fibroblast growth factor 23 and mortality among patients undergoing hemodialysis. N Engl J Med 2008; 359: 584 592. CKD pts with clinical IHD symptoms may not have significant epicardial CAD Rostand SG, Kirk KA, Rutsky EA. Dialysis-associated ischemic heart disease: insights from coronary angiography. Kidney Int. 1984;25: 653 659.
Diagnosis of CAD in CKD
SCREENING AND DIAGNOSIS Who should be screened?
SCREENING AND DIAGNOSIS (K/DOQI guidelines) All patients upon initiation of renal replacement therapy, independent of symptoms. Kidney transplant wait list patients should be re-evaluated at intervals ranging from every year to every three years. Change in symptoms and signs, including recurrent hypotension, heart failure that is unresponsive to changes in dry weight,
SCREENING AND DIAGNOSIS Base line ECG and ECHO for all patients. Exercise or pharmacologic stress Echo: the K/DOQI guidelines state that dobutamine Echo was more sensitive in diagnosing obstructive coronary artery disease in the dialysis population. nuclear imaging-based stress testing Angiography: should be considered in dialysis patients who are candidates for coronary interventions and have positive
ST elevation, the most striking electrical sign of ischemia in patients with an MI, is 50% less frequent in those on dialysis versus the nondialysis population
compared with the general population, echocardiographic and nuclear imaging-based stress testing do appear to rform relatively well as prognostic tools and have at least moderate sensitivity for the detection of advanced obstructive CAD in dialysis patients.
Contrast enhanced cardiac magnetic resonance imaging allows for very sensitive detection of focal myocardial necrosis or fibrosis,
computed tomography angiography may also allow for noninvasive detection of obstructive coronary disease. However, neither computed tomography angiography nor cardiac magnetic resonance imaging have emerged as standard clinical tools
PCI in ACS + CKD
Coronary artery disease contributes to 40% to 50% of deaths among patients who receive dialysis. Approximately 10%-20% of these deaths are due to acute myocardial infarction (AMI) which tends to occur shortly after the initiation of dialysis with 29% within 1 year and 52% within 2 years
5 yrs mortality about 70-90%
Br J Cardio 2013;2
PCI in Stable CAD + CKD
3 yrs mortality 30-40
PCI in Stable CAD + CKD
Survival Curve Reference Group No Dialysis CKD Dialysis CKD
Stable CAD CKD Tex Heart Inst J 2010;37(1
PCI = CABG
Questions, questions CKD vs ESRD is there a difference for those already on dialysis? PCI vs CABG; DES vs BMS Multivessel / LM CAD; CTO management New PCI devices (rotablation, 3 rd /4 th Gen DES) and antithrombotics (ticagrelor, prasugrel) STE ACS vs NSTE ACS vs Stable CAD The anemia conundrum strategies (bivalirudin vs heparin DAPT duration, transfusion / Hb target, femoral vs radial)
CKD PCI CAD
The End