Management of coronary disease in patients with advanced kidney disease
New England Journal of Medicine
© 2020 Massachusetts Medical Society. BACKGROUND Clinical trials that have assessed the effect of revascularization in patients with stable coronary disease have routinely excluded those with advanced chronic kidney disease. METHODS We randomly assigned 777 patients with advanced kidney disease and moderate or severe ischemia on stress testing to be treated with an initial invasive strategy consisting of coronary angiography and revascularization (if appropriate) added to medical therapy or an initial conservative strategy consisting of medical therapy alone and angiography reserved for those in whom medical therapy had failed. The primary outcome was a composite of death or nonfatal myocardial infarction. A key secondary outcome was a composite of death, nonfatal myocardial infarction, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest. RESULTS At a median follow-up of 2.2 years, a primary outcome event had occurred in 123 patients in the invasive-strategy group and in 129 patients in the conservative-strategy group (estimated 3-year event rate, 36.4% vs. 36.7%; adjusted hazard ratio, 1.01; 95% confidence interval [CI], 0.79 to 1.29; P=0.95). Results for the key secondary outcome were similar (38.5% vs. 39.7%; hazard ratio, 1.01; 95% CI, 0.79 to 1.29). The invasive strategy was associated with a higher incidence of stroke than the conservative strategy (hazard ratio, 3.76; 95% CI, 1.52 to 9.32; P=0.004) and with a higher incidence of death or initiation of dialysis (hazard ratio, 1.48; 95% CI, 1.04 to 2.11; P=0.03). CONCLUSIONS Among patients with stable coronary disease, advanced chronic kidney disease, and moderate or severe ischemia, we did not find evidence that an initial invasive strategy, as compared with an initial conservative strategy, reduced the risk of death or nonfatal myocardial infarction.
Bangalore, S., Maron, D., O'Brien, S., Fleg, J., Kretov, E., Briguori, C., Kaul, U., Reynolds, H., Mazurek, T., Sidhu, M., Berger, J., Mathew, R., Bockeria, O., Broderick, S., Pracon, R., Herzog, C., Huang, Z., Stone, G., Boden, W., Newman, J., Ali, Z., Mark, D., Spertus, J., Alexander, K., Chaitman, B., Chertow, G., & Hochman, J. (2020). Management of coronary disease in patients with advanced kidney disease. New England Journal of Medicine, 382 (17). http://dx.doi.org/10.1056/NEJMoa1915925