Reduced risk of myocardial infarct and revascularization following coronary artery bypass grafting compared with percutaneous coronary intervention in patients with chronic kidney disease.
Coronary atherosclerotic disease is highly prevalent in chronic kidney disease (CKD). Although revascularization improves outcomes, procedural risks are increased in CKD, and unbiased data comparing coronary artery bypass grafting (CABG) and percutaneous intervention (PCI) in CKD are sparse. To compare outcomes of CABG and PCI in stage 3 to 5 CKD, we identified randomized trials comparing these procedures. Investigators were contacted to obtain individual, patient-level data. Ten of 27 trials meeting inclusion criteria provided data. These trials enrolled 3993 patients encompassing 526 patients with stage 3 to 5 CKD of whom 137 were stage 3b-5 CKD. Among individuals with stage 3 to 5 CKD, mortality through 5 years was not different after CABG compared with PCI (hazard ratio [HR] 0.99, 95% confidence interval [CI] 0.67-1.46) or stage 3b-5 CKD (HR 1.29, CI 0.68-2.46). However, CKD modified the impact on survival free of myocardial infarction: it was not different between CABG and PCI for individuals with preserved kidney function (HR 0.97, CI 0.80-1.17), but was significantly lower after CABG in stage 3-5 CKD (HR 0.49, CI 0.29-0.82) and stage 3b-5 CKD (HR 0.23, CI 0.09-0.58). Repeat revascularization was reduced after CABG compared with PCI regardless, of baseline kidney function. Results were limited by unavailability of data from several trials and paucity of enrolled patients with stage 4-5 CKD. Thus, our patient-level meta-analysis of individuals with CKD randomized to CABG versus PCI suggests that CABG significantly reduces the risk of subsequent myocardial infarction and revascularization without affecting survival in these patients.
Departments of Medicine, Brigham & Women's Hospital, Boston, Massachusetts, USA. Electronic address: dcharytan@partners.org.
David M
DM
Charytan
Stanford University School of Medicine, Palo Alto, California, USA.
Manisha
M
Desai
Stanford University School of Medicine, Palo Alto, California, USA.
Maya
M
Mathur
Departments of Medicine, Brigham & Women's Hospital, Boston, Massachusetts, USA.
Noam M
NM
Stern
University of Pittsburgh, Graduate School of Public Health, Pittsburgh, Pennsylvania, USA.
Maria M
MM
Brooks
Department of Cardiac Anesthesiology and Intensive Care Medicine, Medical University of Silesia, Katowice, Poland.
Lukasz J
LJ
Krzych
Heart Center, University of Leipzig, Leipzig, Germany.
Gerhard C
GC
Schuler
Department of Cardiology, Klinikum Herford, Herford, Germany.
Jan
J
Kaehler
Research Department, Centro de Estudios en Cardiologia Intervencionista, Buenos Aires, Argentina.
Alfredo M
AM
Rodriguez-Granillo
Heart Institute (InCor), University of Sao Paulo, Sao Paulo, Brazil.
Whady
W
Hueb
Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, United Kingdom.
Barnaby C
BC
Reeves
University Heart Center Luebeck and German Heart Research Center (DZHK), Luebeck, Germany.
Holger
H
Thiele
Cardiac Unit, Otamendi Hospital, Buenos Aires School of Medicine, Buenos Aires, Argentina.
Alfredo E
AE
Rodriguez
Silesian Center for Heart Diseases, Zabrze, Poland; American Heart of Poland, Katowice, Poland.
Piotr P
PP
Buszman
American Heart of Poland, Katowice, Poland.
Paweł E
PE
Buszman
Departments of Medicine, Brigham & Women's Hospital, Boston, Massachusetts, USA.
Rie
R
Maurer
Department of Medicine, Baylor College of Medicine, Houston, Texas, USA.
Wolfgang C
WC
Winkelmayer
D001026:Coronary Artery Bypass / Q000706:statistics & numerical data*; D003324:Coronary Artery Disease / Q000150:complications / Q000401:mortality* / Q000601:surgery; D006801:Humans; D015994:Incidence; D009203:Myocardial Infarction / Q000401:mortality* / Q000517:prevention & control; D062645:Percutaneous Coronary Intervention / Q000706:statistics & numerical data*; D016016:Proportional Hazards Models; D016032:Randomized Controlled Trials as Topic; D051436:Renal Insufficiency, Chronic / Q000150:complications*; D016019:Survival Analysis
chronic kidney disease; coronary artery disease; coronary revascularization; myocardial infarction