Caring for Australians with Renal Impairment

CARI: Revascularisation

H Pilmore

Caring for Australians with Renal Impairment

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.6

Mor

talit

y pe

r yea

r

20 40 60 80 100Age (years)

Dialysis Population

vs. general populationDialysis mortality

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Mor

talit

y pe

r yea

r

20 40 60 80Age (years)

Transplant Population

vs. general populationTransplant mortality

ANZDATA 2008

> 40 % CVS Death

Aims• Examine:

– Revascularisation compared with medical therapy: stable or asymptomatic CAD

– Revascularisation compared with medical therapy: unstable CAD– Revascularisation: coronary artery surgery compared with

percutaneous intervention– Revascularisation: stenting compared with angioplasty– Revascularisation: bare metal compared with drug eluting stents

• Revascularisation in the following populations:– CKD– Dialysis– Transplant

General Population Guidelines

• Indications for Revascularisation in Stable or Silent IHD

Eur Heart J 2010; 20; 2501

Renal Failure

• Manske Lancet 1992• RCT in 26 patients with CKD

– Diabetic– 13 Revascularisation; 13 Medical Therapy– Powered for 162 patients to detect a 10% improvement

with revascularisation– 10/13 in medical group compared to 2/13 in

revascularisation group reached cardiac endpoint– Study discontinued as too difficult to enroll– Sub-optimal medical therapy

Revascularisation compared with medical therapy: stable or asymptomatic CAD

McFalls NEJM 2004

• No Recommendation for Revascularisation in stable CAD

Revascularisation compared with medical therapy: unstable CAD

Fox JACC 2010; 55: 2435

FRISC II Investigators. Lancet 1999; 354: 708-15

Tertiles of creatinine clearance< 69ml/min69 – 90ml/min> 90 ml/min

842 patients with creatinine clearance less than 69ml/min (1/3 of total population) Cockcroft and Gault

Johnston Am Heart J 2006; 152: 1052

TACTICS-TIMI 18 Trial

• Patients with Non STEMI treated with heparin, tirofiban and aspirin• Randomised to:

– Early invasive treatment– Invasive treatment only if unstable or failed myocardial stress test– Excluded patients with creatinine > 2.5mg/dL

Januzzi. AM Coll Cardiol 2002; 90: 1246

Guidelines

• In patients with CKD 2 and 3, with increasing angina, angina at rest or who have a suspicion of a MI in the previous 48 hours: with >70% Coronary artery stenoses, acute revascularisation with CABG or PCI results in a reduction in the incidence of MI and Death compared with conservative treatment (Level II)

• RCT but sub-analyses and inadequately powered

– Revascularisation: coronary artery surgery compared with percutaneous intervention

– NO RCT– Revascularisation: stenting compared with

angioplasty– No RCT– Revascularisation: bare metal compared with

drug eluting stents– One RCT

Stenting• Normal Population

– Drug eluting stents result in• Less repeat revascularisation• Less re-stenosis

• CKD Population– TAXUS IV Trial– Randomised patients to paclitaxel-eluting stent or bare

metal stent– Exclusion creatinine < 200mg/dL– 50% Renal Impairment on Cockcroft Gault

• 410 : CKD Stage 2• 223: CKD Stage 3 or less

1 year Target Vessel Revascularisation

Meta-analysis of Stents in ESRF

Guideline

• The use of drug eluting stents is associated with a lower re-stenosis rate that the use of bare metal stents in patients with CKD (Level II)– Probably should change to suggestion for clinical

care– Could add ESRF

Suggestions for Clinical Care• Revascularisation of coronary arteries with CABG and PCI is

associated with greater mortality in patients with CKD and those on dialysis compared to the general population.

• Revascularisation of coronary arteries in renal transplant recipients is associated with a low risk of returning to dialysis.

• In patients with coronary artery disease, CABG is associated with improved all cause and cardiac survival compared with angioplasty in dialysis patients

• In patients with CAD and renal transplants, CABG with internal mammary artery grafting is associated with a reduced risk of cardiac death or MI compared to PCI.

Questions• Should we make any guidelines at all or should they

all be suggestions?– Suggestions for Clinical Care

• What about just using General population guidelines?– Make a statement saying that due to a current lack of

evidence we suggest adhering to guidelines for the general population

• Are post hoc analyses sufficient for a guideline?– No???

• What about the new CARI levels of evidence?– Probably doesn’t matter as little in way or RCT

Additional Slides for Discussion if required

Revascularisation associated with high mortality in ESRF

Herzog: Circulation 2002

Herzog et al. Circulation 2004; 109: 2866