The risk for death or nonfatal myocardial infarction among patients with chronic coronary disease increases with declining kidney function, according to a recent study.

In addition, the study demonstrated that invasive management of chronic coronary disease was significantly associated with an increased risk for stroke and procedural myocardial infarction as well as improved angina-related quality of life (QOL).

The findings are from a study of 5956 participants in the International Study of Comparative Health Effectiveness With Medical and Invasive Approaches (ISCHEMIA) and ISCHEMIA-Chronic Kidney Disease (CKD) trials. The primary clinical outcome was a composite of death or nonfatal myocardial infarction. The primary QoL outcome was the Seattle Angina Questionnaire (SAQ)-7 summary score. The median follow-up duration was 3.1 years.

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The 3-year cumulative incidence of the primary clinical outcome were 9.5%, 10.7%, 18.2%, 34.2%, and 38.0% for patients with CKD stage 1, 2, 3, 4, and 5, respectively, Sripal Bangalore, MD, MHA, of the New York University Grossman School of Medicine in New York City, and colleagues reported in JAMA Cardiology.

Overall, the 3-year cumulative incidence of stroke was 2.2% with invasive management compared with 1.2% with conservative management, according to the investigators. The 3-year cumulative incidence of stroke was significantly higher among patients with stage 4 CKD (5.7% vs 0.7%) and stage 5 CKD or dialysis (6.8% vs 2.1%). 

Results also showed that the 3-year cumulative incidence of procedural myocardial infarction was significantly higher with intensive vs conservative management (2.6% vs 1.0%), but the 3-year cumulative incidence of non-procedural myocardial infarction was significantly lower with intensive management (5.5% vs 8.0%).

The increased risks of stroke and procedural myocardial infarction associated with invasive management were consistent across CKD stages, according to investigators.

Invasive management was significantly associated with improved angina-related QOL in patients with CKD stages 1-3, but not in those with CKD stages 4-5. Among patients with stages 1, 2, and 3 CKD, the SAQ-7 QOL summary scores were 79.8, 80.1, and 81.1, respectively, in the intensive management group and 76.0, 76.8, 76.4 in the conservative treatment group, Dr Bangalore’s team reported.

“The study reinforces the evidence that cardiovascular rather than end-stage kidney disease is the leading cause of death in this high-risk population,” the authors wrote. “This finding challenges the practice of excluding patients with CKD from cardiovascular clinical trials owing to a misconception that most deaths will likely be noncardiovascular and hence nonmodifiable with cardiovascular therapies.”


Bangalore S, Hochman JS, Stgevens SR, et al. Clinical and quality-of-life outcomes following invasive vs conservative treatment of patients with chronic coronary disease across the spectrum of kidney function. JAMA Cardiol. Published online June 29, 2022. doi:10.1001/jamacardio.2022.1763