Comparative Efficacy of Coronary Revascularization Procedures for Multivessel Coronary Artery Disease in Patients With Chronic Kidney Disease.
Patients with chronic kidney disease (CKD) are at increased risk of cardiovascular disease and death, yet little data exist regarding the comparative efficacy of coronary revascularization procedures in CKD patients with multivessel disease. We created a cohort of 4,687 adults who underwent cardiac catheterization, had a serum creatinine value measured within 30 days, and had more than one vessel with ≥50% stenosis. We used Cox proportional hazard regression modeling weighted by the inverse probability of treatment to examine the association between 4 treatment strategies (medical management, percutaneous coronary intervention [PCI] with bare metal stent, PCI with drug-eluting stent, and coronary artery bypass grafting [CABG]) and mortality among patients across categories of estimated glomerular filtration rate; secondary outcome was a composite of mortality, myocardial infarction, or revascularization. Compared with medical management, CABG was associated with a reduced risk of death for patients of any nondialysis CKD severity (hazard ratio [HR] range 0.43 to 0.59). There were no significant mortality differences between CABG and PCI, except a decreased death risk in CABG-treated CKD patients (HR range 0.54 to 0.55). Compared with medical management and PCI, CABG was associated with a lower risk of death, myocardial infarction, or revascularization in nondialysis CKD patients (HR range 0.41 to 0.64). There were similar associations between decreased estimated glomerular filtration rate and increased mortality across all multivessel coronary artery disease patient treatment groups. When accounting for treatment propensity, surgical revascularization was associated with improved outcomes in patients of all CKD severities. A prospective randomized trial in CKD patients is required to confirm our findings.
Division of Nephrology, Duke University Medical Center, Durham, North Carolina; Duke University School of Medicine, Durham, North Carolina. Electronic address: john.roberts@dm.duke.edu.
John K
JK
Roberts
Duke University School of Medicine, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina.
Sunil V
SV
Rao
Duke University School of Medicine, Durham, North Carolina.
Linda K
LK
Shaw
Duke University School of Medicine, Durham, North Carolina.
Dianne S
DS
Gallup
Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
Oscar C
OC
Marroquin
Division of Nephrology, Duke University Medical Center, Durham, North Carolina; Duke University School of Medicine, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina.
Uptal D
UD
Patel
D000368:Aged; D000072700:Conservative Treatment; D001026:Coronary Artery Bypass / Q000379:methods*; D003324:Coronary Artery Disease / Q000150:complications / Q000601:surgery*; D054855:Drug-Eluting Stents; D005260:Female; D006801:Humans; D007676:Kidney Failure, Chronic / Q000150:complications / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D009026:Mortality; D009203:Myocardial Infarction / Q000453:epidemiology; D009204:Myocardial Revascularization / Q000706:statistics & numerical data; D062645:Percutaneous Coronary Intervention / Q000379:methods*; D011183:Postoperative Complications / Q000453:epidemiology; D016016:Proportional Hazards Models; D012042:Registries; D051436:Renal Insufficiency, Chronic / Q000150:complications; D015607:Stents; D016896:Treatment Outcome