Circulation 2003 Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany... Circulation 2003 Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany..
Trang 1Stable CKD: when do we need PCI?
Germany
Trang 2Conflicts of Interest
Nothing to declare
Trang 3Stages of CKD
Sarnak et al Circulation 2003
Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany
Trang 4CKD and Mortality
C.,) contil i a
i H eart and Vascular Center
Cardiovascularmortalityin the general population(NCHS) and
-o-Dialysis Fermle-tr- Dialysis Black -&- Dialysis White *- Transplant
Trang 5CKD and Cardiovascular Disease
Sarnak et al Circulation 2003
Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany
Trang 6CKD and MACE
N=16.958
Di Angelantonio et al BMJ 2010
Trang 7How should I treat?
67 year old patient on hemodialysis
Symptoms: progressive over 3 months (CCS II, NYHA III) Echo: hypokinesia of inferior wall, EF 45%
Laboratory: mildly elevated Troponin T (0.2 µg/l)
ECG: SR 70 and RBB
Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany
Trang 8How should I treat?
67 year old patient on hemodialysis
Symptoms: progressive over 3 months (CCS II, NYHA III) Echo: hypokinesia of inferior wall, EF 45%
Laboratory: mildly elevated Troponin T (0.2 µg/l)
ECG: SR 70 and RBB
Stable or instable patient?
Trang 9Serum phosphorus and cardiac injury &) r contilia ) Heart and Vascular Center
6000.20
sC>
100
80250
Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany
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Trang 10Phosphate and CMC Apoptosis
Wang et al Med Sci Mon 2014
Trang 11Troponin and prognosis in CKD
Metaanalysis of 124 trials adjustng for age and CAD
Michos et al AHRQ Publication No 14-EHC030-EF 2014
Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany
Trang 12How should I treat?
67 year old patient on hemodialysis
Symptoms: progressive over 3 months (CCS II, NYHA III) Echo: hypokinesia of inferior wall, EF 45%
Laboratory: mildly elevated Troponin T (0.2 µg/l)
remaining stable after 3 and 12 hours
ECG: SR 70 and RBB
Trang 13How should I treat?
67 year old patient on hemodialysis
Symptoms: progressive over 3 months (CCS II, NYHA III) Echo: hypokinesia of inferior wall, EF 45%
Laboratory: mildly elevated Troponin T (0.2 µg/l)
remaining stable after 3 and 12 hours
ECG: SR 70 and RBB
Coronary angiography indicated?
Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany
Trang 14CKD and Coronary Angiography
Trang 15Platelet activation in CKD
306 patents with diabetes mellitus on DAPT
Angiolillo et al JACC 2010
Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany
Trang 16GFR and outcome after PCI
13.307 patents from 5 TIMI trials with NSTEMI-ACS
Gibson et al EHJ 2004
Trang 17NSTEMI ACS & early angio in CKD
Charytan et al Clin J Am Soc Nephrol 2009
Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany
Trang 18How should I treat?
67 year old patient on hemodialysis
Symptoms: progressive over 3 months (CCS II, NYHA III) Echo: hypokinesia of inferior wall, EF 45%
Laboratory: mildly elevated Troponin T (0.2 µg/l)
remaining stable after 3 and 12 hours
ECG: SR 70 and RBB
Trang 19Need for revascularizaton?
Symptomatic indication:
is the patient already on optimal medical therapy?
COURAGE: Boden et al NEJM 2007
Trang 20Need for revascularizaton?
Prognostic indication:
ischemic burden > 10%?
COURAGE NUCLEAR SUBSTUDY:
Shaw et al Circulation 2008
Trang 21CKD in randomized trials* on CAD
Trials where CKD is exclusion criterion Trials reporting CKD as baseline condition
*(86 trials randomizing 411 653 patients)
Charytan et al Kidney Int 2006
Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany
Trang 22CABG vs PCI in HD patients
C.,) contil i a
i H eart and V asc ul a r Center
Table 6 Comparison of CABG and PCI in HD Patients
" Art e rial R ev asc ulariza ti n Th e api es Stud y s u s tud y; te nd poi n t w as co mb in e d ci d e n ce of d e t h , my oc ardial infar c ti , s tr ok e
t/J = s t e n t s ; PCI = p e ut an e o s co ro n ary int erv e nti o Oth e r a b br e v iati o s as in T ab le 5
Gupta et al JACC 2004
Trang 23PCI vs CABG in CKD: all events
C.,) contil i a
i H eart and V asc ul a Center
Table 6 : Comparison of cumul ative events between ESRD pat i ents who underwent CABGor PC I
Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany
Trang 24PCI vs CABG in CKD: repeat revascularization
Zheng et al EJCTS 2012
Trang 25PCI vs CABG in CKD: myocardial infarction
Zheng et al EJCTS 2012
Trang 26PCI vs CABG in CKD: late mortality C
i .,)contiliaH eart and V asc ul a r Center
3 97 16 3 9 9 92 4201 14 93 2 16 5
60 23 2
74 1
47 130 29 6 244 6668 55 153 28 54 29
1
2 6 324
1
35 28 2 7 75 64
1
76 3 13 24
24 20 19 688 7 92 122 46
4
163 9116 7 147 18 33 75
Trang 27PCI vs CABG in CKD: early mortality C.,) i contilH eart and i aV asc ul a r Center
0
7 9 5 3 57 3 3 23 0 3
60 23 22 7 9 47 130 29 65 6668 55 130 28 5 29
1 0 1 371
2
20
1
6887 92 122 46 40 9116
7
322
1
33 75
0.80 (0 08 - 8.42)
0.86 (0 06 - 12 89) 2.33 (2 07 - 2 61)
13 70 ( 1 74 - 108 11 )
4 22 (0 93-19 16) 0.99 (0.36 - 2 74 )
8 0 486 3 22 0
..
1 4 1.4
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I I
Trang 28MV-PCI vs CABG in CKD
21,981 CKD patients (US Renal Data System 1997-2009) undergoing MV-revascularization
Chang et al JASON 2012
Trang 29CKD in the FREEDOM trial
Baber et al EHJ 2016
Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany
C AB G P erformed (n = 668)
PCI Perfo r med
( n = 7 24)
P C I Pe rf or m e ( n = 225)
I
L
W ithou t CKD ( n = 1 9)
n = 27 )
F R EE DOM Su bjects (n = 1 00 )
l ( Missing S erum C reatinin e )
_
_
Trang 30CKD in the FREEDOM trial
Baber et al EHJ 2016
Trang 31Discussion in Heart Team
67 year old patient on hemodialysis
Symptoms: progressive over 3 months (CCS II, NYHA III)
Echo: hypokinesia of inferior wall, EF 45%
Laboratory: mildly elevated Troponin T (0.2 µg/l)
remaining stable after 3 and 12 hours
ECG: SR 70 and RBB
Patient refused by surgeons (porcelain aorta)
Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany
Trang 32How did I treat
RCA: 2xDES 3.0/18 mm
LAD: DES 3.5/18 mm LCX: DES 3.0/18 mm
Trang 331 Chronic kidney disease patients are at a high risk for
having ischemic heart disease and its complications.
2 Troponin dynamics rather than a single Tropnin
measurement may be useful to diagnose ACS in
patients.
these
3 Indications for revascularization are assumed to
the the same as in other patients.
be
4 Despite randomized trials are lacking, available data
indicate that CABG may be preferrable in therse
patients
Contilia Herz- und Gefäßzentrum, Elisabeth Krankenhaus Essen
Trang 34f