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 EC
Trang 1Stable CKD: when do we need PCI?
Christoph K Naber
Contilia Heart and Vascular Center
Trang 2Conflicts of Interest
Nothing to declare
Trang 3Stages of CKD
Sarnak et al Circulation 2003
Trang 4CKD and Mortality
Sarnak et al Circulation 2003
Trang 5CKD and Cardiovascular Disease
Sarnak et al Circulation 2003
Trang 6CKD and MACE
Di Angelantonio et al BMJ 2010
N=16.958
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
Trang 867 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
How should I treat?
Stable or instable patient?
Trang 9Serum phosphorus and cardiac injury
Wang et al Med Sci Mon 2014
Trang 10Phosphate and CMC Apoptosis
Wang et al Med Sci Mon 2014
Trang 11Troponin and prognosis in CKD
Michos et al AHRQ Publication No 14-EHC030-EF 2014
Metaanalysis of 124 trials adjusting for age and CAD
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?
Trang 14CKD and Coronary Angiography
Na et al
J Korean Med Sci 2009
Table: GFR < 60 ml/min/1.73 m2
N=3.637 patients
Trang 15Platelet activation in CKD
Angiolillo et al JACC 2010
306 patients with diabetes mellitus on DAPT
Trang 16GFR and outcome after PCI
Gibson et al EHJ 2004
13.307 patients from 5 TIMI trials with NSTEMI-ACS
Trang 17NSTEMI ACS & early angio in CKD
Charytan et al Clin J Am Soc Nephrol 2009
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 revascularization?
Symptomatic indication:
is the patient already on optimal medical therapy?
COURAGE: Boden et al NEJM 2007
Trang 20Prognostic indication:
ischemic burden > 10%?
COURAGE NUCLEAR SUBSTUDY:
Shaw et al Circulation 2008
Need for revascularization?
Trang 21CKD in randomized trials* on CAD
Charytan et al Kidney Int 2006 Trials where CKD is exclusion criterion Trials reporting CKD as baseline condition
*(86 trials randomizing 411 653 patients)
Trang 22CABG vs PCI in HD patients
Gupta et al JACC 2004
Trang 23PCI vs CABG in CKD: all events
Zheng et al EJCTS 2012
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
Zheng et al EJCTS 2012
Trang 27PCI vs CABG in CKD: early mortality
Zheng et al EJCTS 2012
Trang 28MV-PCI vs CABG in CKD
Chang et al JASON 2012 21,981 CKD patients (US Renal Data System 1997-2009) undergoing MV-revascularization
Trang 29CKD in the FREEDOM trial
Baber et al EHJ 2016
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)
Trang 32How did I treat
RCA: 2xDES 3.0/18 mm
LAD: DES 3.5/18 mm LCX: DES 3.0/18 mm
Trang 33Summary
1 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 these patients
3 Indications for revascularization are assumed to be the the same as in other patients
4 Despite randomized trials are lacking, available data indicate that CABG may be preferrable in therse
patients