In patients with advanced chronic kidney disease (CKD) who have stable coronary disease but moderate to severe ischemia, initial revascularization offers no survival advantage over medical therapy alone, according to new study findings published in the New England Journal of Medicine.
In ISCHEMIA-CKD (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches–Chronic Kidney Disease), investigators randomly assigned 777 patients with an estimated glomerular filtration rate (eGFR) of less than 30 mL/minute/1.73 m2, including half receiving dialysis, to medical therapy with or without angiography and revascularization (percutaneous coronary intervention [PCI] or coronary artery bypass grafting [CABG]). Previous trials routinely excluded patients with advanced CKD.
Over a median 2.2 years, 123 patients in the invasive-strategy group and 129 patients in the medical therapy-alone group (estimated 3-year event rate, 36.4% vs 36.7%) died or had a nonfatal myocardial infarction – a nonsignificant difference, Sripal Bangalore, MD, MHA, of New York University, and colleagues reported. Similar proportions (38.5% vs 39.7%, respectively), also experienced the secondary outcome, which was a composite of death, nonfatal myocardial infarction, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest.
The invasive strategy was associated with greater harm. PCI or CABG was significantly associated with approximately 3.8- and 1.5-fold increased risks for stroke (mostly unrelated to the procedure) and death or dialysis initiation, respectively.
Several strategies were employed to reduce the risk for acute kidney injury (AKI). Contrast-associated AKI occurred in 7.9% of the invasive-strategy group compared with 0% in the conservative-strategy group. Of patients who underwent CABG (approximately half of the invasive-strategy group), 12.5% vs 11.1%, respectively, initiated dialysis. Stent thrombosis occurred in just 0.9%.
Bangalore S, Maron DJ, O’Brien SM, et al. Management of coronary disease in patients with advanced kidney disease. N Engl J Med. 2020;382:1608-18. doi: 10.1056/NEJMoa1915925