Chronic kidney disease negatively impacts coronary revascularization outcomes: JACC Study

A new study finds that the presence of comorbid chronic kidney disease (CKD) has a negative impact on the optimal coronary revascularization strategy in patients with stable ischemic heart disease (SIHD) who have type 2 diabetes (T2DM).

In the study, published in the Journal of the American College of Cardiology, the authors found that among SIHD patients with T2DM and no CKD, CABG (coronary artery bypass graft) + OMT (optimal medical therapy) significantly reduced MACCE compared with PCI (percutaneous coronary intervention) + OMT. In subjects with CKD, there was a nonsignificant trend toward a better MACCE outcome with CABG and a significant reduction in subsequent revascularization.

Michael E. Farkouh, the University of Toronto, and colleagues sought to compare outcomes 3 large, federally-funded randomized trials in SIHD patients with T2DM and CKD. The trials included (COURAGE [Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation], BARI 2D [Bypass Angioplasty Revascularization Investigation 2 Diabetes], and FREEDOM [Future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multi-vessel Disease]). In total, 1,058 (21.4 percent) of the 4,953 patients had CKD.

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Key Findings:

• CKD patients were more likely to be older, be female, and have a history of heart failure.


• During a median 4.5 years of follow-up, CKD participants were more likely to experience a major adverse cardiovascular or cerebrovascular event.


• MACCE was predicted by both mild (estimated glomerular filtration rate [eGFR] 45 to 60 mL/min/1.73 m²) and moderate to severe (eGFR <45 mL/min/1.73 m²) CKD (adjusted HRs, 1.25 and 2.26, respectively).


• CABG plus optimal medical therapy (OMT) was associated with lower MACCE rates versus PCI plus OMT (adjusted HR, 0.69) among patients without CKD.


• For patients with CKD, there was only a statistically significant difference between CABG and PCI in subsequent revascularization rates (HR, 0.25), but not in MACCE rates.

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"In patients with stable ischemic heart disease and T2DM and normal renal function, CABG is associated with lower rates of major adverse cardiovascular events compared with PCI, but the difference in outcomes is lost in those with CKD," concluded the authors.

For further reference log on to 10.1016/j.jacc.2018.11.044