By Dr. Jonathan Shurlock
The management of coronary artery disease in patients with chronic kidney disease (CKD) has not been explored in any depth, and thus the optimal approach is not well understood. Dr Bangalore and co-authors set out to explore this question through a secondary analysis of the International Study of Comparative Health Effectiveness With Medical and Invasive Approaches (ISCHEMIA).
The authors reviewed participants from ISCHEMIA and categorised them into stages of chronic kidney disease (Stage 1-5). There were 5,956 participants included in the study and available for final analysis. The mean [SD] age of participants was 64  years; and 1,410[24%] were female. Median follow up was 3.1 years. Participants either received invasive management with coronary angiography and revascularization in addition to guideline directed medical therapy (GDMT) or a conservative approach with GDMT only. Outcome measures included a composite of death or non-fatal MI and a qualitative quality of life score, the Seattle Angina Questionnaire (SAQ).
Unsurprisingly, there was an increase in risk of the composite end point of death and non-fatal MI in those with worse renal function (represented as higher CKD scores).
Invasive management was associated with an increased risk of stroke (3-year event rate difference, 1%; 95% CI, 0.3 to 1.7) and procedural MI with a decrease in spontaneous MI (−2.5%; 95% CI, −3.9 to −1.1). There were no other differences in outcome and these group differences were similar across all stages of CKD. An improvement in self-reported angina-related quality of life measures with invasive management was reported, though this was only seen in those with CKD stage 1-3.
The role of functioning kidneys in the axis of cardiovascular disease cannot be overstated, and the findings in this study demonstrate the role of kidney disease in increasing cardiovascular events. Invasive management was shown to be associated with increased adverse outcomes across all CKD groups.
This work demonstrates the need to carefully consider the best treatment strategy for patients with concurrent coronary artery and kidney disease, and that an invasive strategy may not be appropriate. These findings should be considered with each patient presenting with these combination pathologies, rather than dictating treatment strategies for all such patients.
Bangalore S, Hochman JS, Stevens SR, et al. Clinical and Quality-of-Life Outcomes Following Invasive vs Conservative Treatment of Patients With Chronic Coronary Disease Across the Spectrum of Kidney Function. JAMA Cardiol. Published online June 29, 2022. doi:10.1001/jamacardio.2022.1763