title: Percutaneous Coronary Intervention Versus Optimal Medical Therapy for Stable Angina in Advanced CKD: A Decision Analysis.
abstract: BACKGROUND
  Percutaneous coronary intervention (PCI) use is low in the setting of stable symptomatic angina in individuals with advanced chronic kidney disease (CKD) despite high cardiovascular risk in this population, and PCI is frequently deferred out of concern for precipitating dialysis therapy. Whether this is appropriate is uncertain, and patient-centered data comparing the relative risks and benefits of continued medical therapy versus PCI in patients with advanced CKD and stable angina are scarce.
  
  
  METHODS
  Decision analysis.
  
  
  METHODS
  Hypothetical cohort of individuals with advanced CKD (stages 4-5 with estimated glomerular filtration rates ≤ 20mL/min/1.73m2) and stable angina.
  A Markov model with a Monte Carlo simulation through 12 cycles, that is, 3 years of 3-month intervals, with 10,000 microsimulations predicted mean quality-adjusted life-years.
  
  
  METHODS
  PCI first, medical management, or dialysis (hemodialysis [HD]) followed by PCI.
  
  
  RESULTS
  Outcomes modeled were progression to HD therapy (for those not assigned to the preemptive HD strategy), catheter infection, and death.
  
  
  RESULTS
  Our analysis showed mean quality-adjusted life-years of 1.103 ± 0.69 for PCI first, 1.088±0.70 for medical management, and 0.670±0.58 for HD followed by PCI. Probabilistic sensitivity analysis found PCI as the preferred strategy > 60% of the time.
  
  
  CONCLUSIONS
  Values for probabilities and utilities were estimated and/or derived from multiple sources that were not uniform in their populations in terms of age, comorbid condition burden, and degree of kidney failure, and several simplifying assumptions were made.
  
  
  CONCLUSIONS
  Our analysis demonstrates that quality-adjusted life expectancy is similar for the PCI first and medical management strategies in patients with advanced CKD with stable angina and that the decision depends on patient preferences other than those incorporated in our model. Both strategies are superior to preemptive dialysis.
authors.affiliation: Renal Division, Brigham and Women's Hospital, Boston, MA.
authors.forename: Aisha
authors.initials: A
authors.lastname: Khattak
authors.affiliation: Renal Division, Brigham and Women's Hospital, Boston, MA; Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA.
authors.forename: Ernest I
authors.initials: EI
authors.lastname: Mandel
authors.affiliation: Department of Cardiovascular Medicine, Lahey Hospital & Medical Center, Burlington, MA; Harvard Clinical Research Institute, Boston, MA.
authors.forename: Matthew R
authors.initials: MR
authors.lastname: Reynolds
authors.affiliation: Renal Division, Brigham and Women's Hospital, Boston, MA. Electronic address: dcharytan@partners.org.
authors.forename: David M
authors.initials: DM
authors.lastname: Charytan
mesh_terms: D060050:Angina, Stable / Q000209:etiology* / Q000628:therapy*; D003661:Decision Support Techniques; D006801:Humans; D062645:Percutaneous Coronary Intervention; D006435:Renal Dialysis; D051436:Renal Insufficiency, Chronic / Q000150:complications* / Q000628:therapy; D012720:Severity of Illness Index
keywords: Percutaneous coronary intervention (PCI); advanced renal failure; cardiovascular intervention; catheter infection; chronic kidney disease (CKD); contrast nephropathy; contrast-induced nephropathy (CIN); death; decision model; hemodialysis; medical management; mortality; quality of life; quality-adjusted life-year (QALY); stable angina; therapeutic nihilism