Stable CKD: when we need PCI? G )contilia i Heart and Vascular Center Christoph K Naber Contilia Heart and Vascular Conflicts of Interest Nothing to declare Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany Stages of CKD Sarnak et al Circulation 2003 Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany C.,)contilia i Heart CKD and Mortality and Vascular Center Cardiovascularmortalityin the general population(NCHS) and in kidneyfailuretreated by dialysisor transplant(USRDS) -+-GP - - Male GP Fermle - GP Black ·- _ -0 - GP White Dialysis Male -o-Dialysis Fermle c -tr- Dialysis Black u c: -&- Dialysis White ~ *- Transplant c: 85 Age {years) Sarnak et al Circulation 2003 Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany CKD and Cardiovascular Disease Sarnak et al Circulation 2003 Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany CKD and MACE N=16.958 Di Angelantonio et al BMJ 2010 Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany How should I treat? 67 year old patient on hemodialysis Symptoms: progressive over months (CCS II, NYHA III) Echo: hypokinesia of inferior wall, EF 45% Laboratory: mildly elevated Troponin T (0.2 µg/l) ECG: SR 70 and RBB Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany How should I treat? 67 year old patient on hemodialysis Symptoms: progressive over months (CCS II, NYHA III) Echo: hypokinesia of inferior wall, EF 45% Laboratory: mildly elevated Troponin T (0.2 µg/l) ECG: SR 70 and RBB Stable or instable patient? Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany &)contilia Serum phosphorus and cardiac injury 0.25 y=0.037x-0.026 y=132.1x-98.4 600 R2=0.189 p=0.00 0.20 • E o.rs § en en c: R2=0.348 p=0.00 R2=0.16 p=0.00 c: >- -u :E 0.05 0.00 - 20000 :z cc 200 0 ~ 400 C> 30000 s ;::::: 0.10 Heart and Vascular Center y=467Sx-4684 40000 =E • r) • 10000 0 - e 4 n 300 y=38.3x+67.4 R2=0.16 p=0.00 • ; E -9 -:E ::; •• ~ 200 R2=0.006 p=0.19 80 R2=0.095 p=0.01 • 80 u y=1.78x+ 1.96 100 250 N 100 y=-8.7x+75.7 =3 60 cc ::; • LU 150 60 ~ 40 :: 20 ::.:: 100 • \ J 40 so 0 • • • 0.5 1.0 1.5 2.0 2.5 3.0 0.5 1.0 1.5 2.0 2.5 3.0 Serum phosphorus (mmol/L) Wang et al Med Sci Mon 2014 Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany Phosphate and CMC Apoptosis Wang et al Med Sci Mon 2014 Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany Need for revascularizaton? Prognostic indication: ischemic burden > 10%? COURAGE NUCLEAR SUBSTUDY: Shaw et al Circulation 2008 Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany CKD in randomized trials* on CAD Trials where CKD is exclusion criterion Trials reporting CKD as baseline condition *(86 trials randomizing 411 653 patients) Charytan et al Kidney Int 2006 Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany C.,)contilia i Heart and Vascular Center CABG vs PCI in HD patients Table Comparison of CABG and PCI in HD Patients Freedom From In-Hospital Mortality (%) n Study (Ref.) CABG PCI CABG Rinehart et al (95) 60 24 Koyanagi et al (109) 23 20 Event-Free Survival (%) Angina(%) PCI CABG PCI 77 60 CABG 66 (6 mo) PCI 51 (2 yrs) 18 70 (5 yrs) Simsir et al (110) 19 22 4.5 5.3 87 40 67 (1.5 yr) Herzog et al (111) 7,419 6,887 12.5 69 (1.5 yr) 5.4 71 62 (2 yrs) Agirbasli et al (112) 130 122 6.9 1.6 27 23 (1 yr) Ivens et al (113) 65 40 4.8 90 29 86 (2 yrs) Herzog et al (114) 6,668 4,836 t/1 (4,280) 8.6 6.4 t/1 82 (2 yrs) 48 56 t/1 (48) (2 (4.1%) yrs) Ix et al (115)* 290 t/1 (all) 72.7t 71.5 (3 yrs) "Arterial Revascularization Therapies Study substudy; tend point was combined incidence of death, myocardial infarction, or stroke t/J = stents; PCI = percutaneous coronary intervention Other abbreviations as in Table Gupta et al JACC 2004 Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany C.,)contilia i PCI vs CABG in CKD: all events Table 6: Comparison of cumulative events between ESRD patients who underwent CABG Study or subgroup Total Agirbasli et al (2000) [9] 51 130 Aoki et al {2003) (15] 26 55 Ashrith et al (2010) (1 OJ 23 Chertow et al {2000) (20] 14 Hemmelgarn et al (2004) (49] 93 153 Herzog et al (1999) [6] 20 65 Koyanagi et al (1996) [7] 34 Simsir et al {1998) (19] 29 Szczech et al {2001) (50] Total {95% Cl) events 10876 6961 17194 49.4 0.78 {0.73-0.84) Ivens 0.06 {0.01-0.32) 18 13 0.10 {0.02-0.44) 0.3 0.2 2.04 {0.71-5.90) 24 16 244 I 0.08 {0.03-0.22) 10 75 0.55 {0.21-1.40) 0.59 {0.54-0.64) 42.3 0.4 92 22 0.3 9116 0.9 60 0.74 {0.30-1.79) 1.45 {0.92-2.29) 6887 20 27 92 15 156 6668 74 34 5823 28 47 Rinehart et al (1995) (18] Sunagawa et al {2010) [22] 7419 18 42 0.9 0.3 2.93 {1.57-5.47) 0.3 46 Odds ratio M-H, Random {95% Cl) 0.04 {0.01-0.14) 33 322 M-H, Random {95% Cl) 0.57 (0.34-0.93) 0.9 14 29 40 23 Manabe et al {2009) [14] Ohmoto et al {1999) [17] 70 22 147 4774 1.2 54 29 5662 Herzog et al {2002)[13] et al {2001) (21] 67 Weight{%) Total 122 65 130 76 Odds ratio Events 19 Charytan et al {2006) (16] CABG or PCI PCI Events Heart and Vascular Center 0.2 19 0.4 75 100.0 1.11 0.3 {0.43-2.87) 0.13 {0.03-0.58) 0.46 {0.17-1.28) 163 1.7 0.71 {0.47-1.06) 0.1 10 Favours CABG 0.01 Favours PCI 100 0.69 {0.65-0.73) Total 13 324 Zheng et al EJCTS 2012 Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany PCI vs CABG in CKD: repeat revascularization Zheng et al EJCTS 2012 Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany PCI vs CABG in CKD: myocardial infarction Zheng et al EJCTS 2012 Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany PCI vs CABG in CKD: late mortality Table3: Comparison Study or subgroup of late mortality between ESRD patients CABG C ,)contilia Heart and Vascular i who underwent CABG or PCI PCI Events Total Events Total Weight Risk ratio Risk ratio M-H, Random (95% Cl) M-H, Random (95% Cl) et al (1995) [18] 32 60 24 0.2% 1.07 (0.67-1.70) Koyanagi et al (1996) [7] Si msir et al 23 20 0.0 1.74 {0.36-8.51) (1998) [19] Herzog et al (1999) [6] Ohmoto 22 19 0.1% 1.01 (0.41-2.48) Rinehart et al (1999) [17] Agirbasli et al (2000) 3197 12 7419 324 688 36.7% 0.92 (0.88-0.95) [9] Chertow et al (2000) [20] Ivens et al 16 47 0.3% 0.89 (0.56- 1.44) (2001) [21] Szczech et al (2001) [SO] 35 130 35 92 0.3% 1.17 (0.76-1.81) 29 28 122 0.2% 0.68 (0.36- 1.27) 65 21 46 0.1% 0.79 (0.32-1.96) 92 244 4201 6668 14 55 93 Herzog et al (2002) [13] Aoki et al (2003) [15] Hemmelgarn et al (2004) [49] Manabe et al (2009) [14] Ashrith et al (2010) [l OJ Sunagawa et al (2010) [22] Total (95% Cl) Total events 40 1.0% 0.82 (0.65-1.03) 75 163 59.8% 0.89 (0.87-0.91) 6475 9116 0.2% 0.94 (0.52-1.70) 153 19 70 0.8% 1.18 (0.96-1.44) 28 76 147 0.0% 0.43 (0.08-2.32) 16 54 18 0.2% 0.75 (0.42-1.36) 29 13 33 0.1% 0.54 (0.23- 1.28) 24 75 15 026 7732 Center 16872 100.0% 0.90 (0.88-0.92) 10037 0.10.2 0.5 Favours CABG 10 Favours PCI Zheng et al EJCTS 2012 Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany C.,)contilia PCI vs CABG in CKD: early mortality Table 2: Comparison of early mortality Study or subgroup between ESRD patients receiving [18] Total Events 60 Simsir et al (1998) [19] Herzog et al (1999) [6] 23 Koyanagi et al (1996) [7] Total 92 1.6 13.70 (1.74-108.11) 122 3.0 4.22 (0.93-19.16) 46 5.9 0.99 (0.36-2.74) 40 0.8 4.35 (0.23-82.05) 9116 33.1 1.61 (1.43-1.81) 70 2.8 1.27 (0.27-6.06) 22 322 14.5 2.59 (1.50-4.48) 18 47 130 Herzog et al (2002) [13] Aoki et al (2003) [15] 29 57 6668 55 Charytan et al (2006) [16] Manabe et al (2009) [14] Ashrith et al (2010) [1 23 Sunagawa et al (2010) [22] 28 54 3 1560 ' • 33 1.4 1.83 (0.20-16.90) 75 1.4 0.86 (0.09-7.95) 100.0 • • • - ' 16884 - Not estimable 29 14 759 Total (95% Cl) Total events 130 OJ 486 (95% Cl) ' Not estimable 2.33 (2.07-2.61) Random 0.80 (0.08-8.42) 0.86 (0.06-12.89) 65 M-H, 1.0 M-H, Random (95% Cl) 33.1 371 Risk ratio 19 22 741 Ohmoto et al (1999) [17] Ivens et al (2001) [21] Risk ratio 6887 93 Chertow et al (2000) [20] 1.3 20 Agirbasli et al (2000) [9] Weight(%) 24 Heart and Vascular Center CABG or PCI PCI CABG Events Rinehart et al (1995) i 1.98 (1.51-2.60) 899 I I ' 0.10.2 Favours CABG • I ' 0.5 10 Favours PCI Zheng et al EJCTS 2012 Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany ' MV-PCI vs CABG in CKD 21,981 CKD patients (US Renal Data System 1997-2009) undergoing MV-revascularization Chang et al JASON 2012 Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany C.,)contilia i CKD in the FREEDOM trial and Vascular Center Heart FREEDOM Subjects (n=1900) _ _ _ ( _ l CKD Not Calculated (n=14) ) (Missing Serum Creatinine) r l ~ 1-~ Without CKD CKD (n=467) (n=1419) l I No Procedure I Performed (n=16) , L No Procedure Performed ( ~ n=27) L CABG Performed (n=226) PCI Performed CABG Performed PCI Performed (n=225) (n=668) (n=724) Baber et al EHJ 2016 Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany CKD in the FREEDOM trial Baber et al EHJ 2016 Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany Discussion in Heart Team 67 year old patient on hemodialysis Symptoms: progressive over months (CCS II, NYHA III) Echo: hypokinesia of inferior wall, EF 45% Laboratory: mildly elevated Troponin T (0.2 µg/l) remaining stable after and 12 hours ECG: SR 70 and RBB Patient refused by surgeons (porcelain aorta) Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany How did I treat RCA: 2xDES 3.0/18 mm LAD: DES 3.5/18 mm LCX: DES 3.0/18 mm Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany Summary Chronic kidney disease patients are at a high risk for having ischemic heart disease and its complications Troponin dynamics rather than a single Tropnin measurement may be useful to diagnose ACS in patients Indications for revascularization are assumed to the the same as in other patients Despite randomized trials are lacking, available data indicate that CABG may be preferrable in therse Contilia Herz- und Gefäßzentrum, Elisabeth Krankenhaus Essen these be f