title: Potential role of differential medication use in explaining excess risk of cardiovascular events and death associated with chronic kidney disease: a cohort study.
abstract: BACKGROUND
  Patients with chronic kidney disease (CKD) are less likely to receive cardiovascular medications. It is unclear whether differential cardiovascular drug use explains, in part, the excess risk of cardiovascular events and death in patients with CKD and coronary heart disease (CHD).
  
  
  METHODS
  The ADVANCE Study enrolled patients with new onset CHD (2001-2003) who did (N = 159) or did not have (N = 1088) CKD at entry. The MDRD equation was used to estimate glomerular filtration rate (eGFR) using calibrated serum creatinine measurements. Patient characteristics, medication use, cardiovascular events and death were ascertained from self-report and health plan electronic databases through December 2008.
  
  
  RESULTS
  Post-CHD event ACE inhibitor use was lower (medication possession ratio 0.50 vs. 0.58, P = 0.03) and calcium channel blocker use higher (0.47 vs. 0.38, P = 0.06) in CKD vs. non-CKD patients, respectively. Incidence of cardiovascular events and death was higher in CKD vs. non-CKD patients (13.9 vs. 11.5 per 100 person-years, P < 0.001, respectively). After adjustment for patient characteristics, the rate of cardiovascular events and death was increased for eGFR 45-59 ml/min/1.73 m2 (hazard ratio [HR] 1.47, 95% CI: 1.10 to 2.02) and eGFR < 45 ml/min/1.73 m2 (HR 1.58, 95% CI: 1.00 to 2.50). After further adjustment for statins, β-blocker, calcium channel blocker, ACE inhibitor/ARB use, the association was no longer significant for eGFR 45-59 ml/min/1.73 m2 (HR 0.82, 95% CI: 0.25 to 2.66) or for eGFR < 45 ml/min/1.73 m2 (HR 1.19, 95% CI: 0.25 to 5.58).
  
  
  CONCLUSIONS
  In adults with CHD, differential use of cardiovascular medications may contribute to the higher risk of cardiovascular events and death in patients with CKD.
authors.affiliation: Department of Medicine, University of California-San Francisco, CA, USA. nisha.bansal@ucsf.edu
authors.forename: Nisha
authors.initials: N
authors.lastname: Bansal
authors.forename: Chi-yuan
authors.initials: CY
authors.lastname: Hsu
authors.forename: Malini
authors.initials: M
authors.lastname: Chandra
authors.forename: Carlos
authors.initials: C
authors.lastname: Iribarren
authors.forename: Stephen P
authors.initials: SP
authors.lastname: Fortmann
authors.forename: Mark A
authors.initials: MA
authors.lastname: Hlatky
authors.forename: Alan S
authors.initials: AS
authors.lastname: Go
mesh_terms: D000368:Aged; D002317:Cardiovascular Agents / Q000009:adverse effects / Q000627:therapeutic use*; D002318:Cardiovascular Diseases / Q000139:chemically induced / Q000188:drug therapy* / Q000401:mortality*; D015331:Cohort Studies; D005260:Female; D006801:Humans; D007676:Kidney Failure, Chronic / Q000188:drug therapy* / Q000401:mortality*; D008297:Male; D008875:Middle Aged; D012307:Risk Factors
chemical_list: D002317:Cardiovascular Agents