Bệnh mạch vành ổn định với tổn thương nhiều nhánh ở người có bệnh thận mạn Khi nào nên can thiệp
Bạn đang xem bản rút gọn của tài liệu. Xem và tải ngay bản đầy đủ của tài liệu tại đây (2.62 MB, 34 trang )
Stable CKD: when do we need PCI?
G )contilia
i
Heart and Vascular Center
Christoph K. Naber
Contilia Heart and Vascular
Conflicts of Interest
Nothing to declare
Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany
Stages of CKD
Sarnak et al. Circulation 2003
Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany
C.,)contilia
i Heart
CKD and Mortality
and Vascular Center
Cardiovascularmortalityin the general population(NCHS) and
in
kidneyfailuretreated
by dialysisor transplant(USRDS)
-+-GP
---
-
Male
GP Fermle
----..- GP Black
·-
_.
---0---
GP White
Dialysis Male
-o-Dialysis Fermle
c
-tr-
Dialysis Black
u
c:
---&-
Dialysis White
~
----*- Transplant
c:
<(
25-34
35-44
45-54
55-64
65-74
75-84
>85
Age {years)
Sarnak et al. Circulation 2003
Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany
CKD and Cardiovascular
Disease
Sarnak et al. Circulation 2003
Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany
CKD and MACE
N=16.958
Di Angelantonio et al.
BMJ 2010
Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany
How 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
How 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?
Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany
&)contilia
Serum phosphorus and cardiac injury
0.25
y=0.037x-0.026
y=132.1x-98.4
600
R2=0.189 p=0.00
0.20
•
E o.rs
.§
--
en
en
c:
R2=0.348 p=0.00
R2=0.16 p=0.00
c:
>-
-u
:E
0.05
0.00
8
-
2
3
20000
:z
0...
cc
200
0
0
~
0
400
C>
1--
30000
0
..s
;::::: 0.10
4
Heart and Vascular Center
y=467Sx-4684
40000
=E
•
r)
0
2
3
•
10000
0
0
-
e
4
0
2
3
4
n
300
y=38.3x+67.4
R2=0.16 p=0.00
•
.;.
E
-9
-:E
::;
••
~
200
R2=0.006 p=0.19
80
R2=0.095 p=0.01
•
80
u....
y=1.78x+ 1.96
0
100
250
N
100
y=-8.7x+75.7
=3 60
0
cc
::;
•
LU
150
60
~
40
::
20
::.::
100
•
..
\...J
40
so
0
0
0
•
•
0
•
0
0.5
1.0
1.5
2.0
2.5
3.0
0.5
1.0
1.5
2.0
2.5
3.0
0
2
3
4
Serum phosphorus (mmol/L)
Wang et al.
Med Sci Mon 2014
Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany
Phosphate and CMC Apoptosis
Wang et al.
Med Sci Mon 2014
Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany
Troponin 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
How 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
Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany
How 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
CKD and Coronary Angiography
N=3.637 patents
Table: GFR < 60 ml/min/1.73 m2
Na et al.
J Korean Med Sci 2009
Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany
Platelet activation in CKD
306 patents with diabetes mellitus on DAPT
Angiolillo et al.
JACC 2010
Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany
GFR and outcome after PCI
13.307 patents from 5 TIMI trials with NSTEMI-ACS
Gibson et al. EHJ 2004
Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany
NSTEMI ACS & early angio in CKD
Charytan et al. Clin J Am Soc Nephrol 2009
Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany
How 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
Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany
Need for revascularizaton?
Symptomatic indication:
is the patient already on optimal medical therapy?
COURAGE: Boden et al. NEJM 2007
Contilia Heart- and Vascular
Center, Elisabeth Krankenhaus Essen, Germany
Need for revascularizaton?
Prognostic indication:
ischemic burden > 10%?
COURAGE NUCLEAR SUBSTUDY:
Shaw et al. Circulation 2008
Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany
CKD 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
C.,)contilia
i Heart and Vascular Center
CABG vs. PCI in HD patients
Table 6. Comparison of CABG and PCI in HD Patients
Freedom From
In-Hospital
Mortality (%)
n
Study (Ref.)
CABG
PCI
CABG
Rinehart et al. (95)
60
24
Koyanagi et al. (109)
23
20
Event-Free
Survival (%)
Angina(%)
PCI
CABG
PCI
77
60
CABG
66
(6 mo)
0
PCI
51
(2 yrs)
0
18
70
(5 yrs)
Simsir et al. (110)
19
22
4.5
5.3
87
40
67
(1.5 yr)
Herzog et al. (111)
7,419
6,887
12.5
69
(1.5 yr)
5.4
71
62
(2 yrs)
Agirbasli et al. (112)
130
122
6.9
1.6
27
23
(1 yr)
Ivens et al. (113)
65
40
4.8
0
90
29
86
(2 yrs)
Herzog et al. (114)
6,668
4,836
t/1
(4,280)
8.6
6.4
t/1
82
(2 yrs)
48
56
t/1 (48) (2
(4.1%)
yrs)
Ix et al. (115)*
290
t/1
(all)
72.7t
71.5
(3 yrs)
"Arterial Revascularization Therapies Study substudy; tend point was combined incidence of death, myocardial infarction, or stroke.
t/J = stents; PCI = percutaneous coronary intervention. Other abbreviations as in Table 5.
Gupta et al.
JACC 2004
Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany
C.,)contilia
i
PCI vs. CABG in CKD: all events
Table 6:
Comparison of cumulative events between ESRD patients who underwent
CABG
Study or subgroup
Total
Agirbasli et al. (2000) [9]
51
130
Aoki et al. {2003) (15]
26
55
Ashrith et al. (2010) (1
OJ
23
Chertow et al. {2000) (20]
14
Hemmelgarn et al. (2004) (49]
93
153
Herzog et al. (1999) [6]
20
65
Koyanagi et al. (1996) [7]
34
8
Simsir et al. {1998) (19]
9
29
Szczech et al. {2001) (50]
Total {95% Cl)
events
10876
6961
17194
49.4
0.78 {0.73-0.84) Ivens
0.06 {0.01-0.32)
18
13
0.10 {0.02-0.44)
0.3
0.2
2.04 {0.71-5.90)
24
16
244
I
0.08 {0.03-0.22)
10
75
0.55 {0.21-1.40)
0.59 {0.54-0.64)
42.3
0.4
92
22
0.3
9116
0.9
60
0.74 {0.30-1.79)
1.45 {0.92-2.29)
6887
20
27
92
15 156
6668
74
34
6
5823
28
47
Rinehart et al. (1995) (18]
Sunagawa et al. {2010) [22]
7419
18
3
42
0.9
0.3
2.93 {1.57-5.47)
0.3
46
Odds ratio
M-H, Random {95% Cl)
0.04 {0.01-0.14)
33
322
M-H, Random {95% Cl)
0.57 (0.34-0.93)
0.9
14
29
40
23
Manabe et al. {2009) [14]
Ohmoto et al. {1999) [17]
70
22
147
4774
1.2
54
29
5662
Herzog et al. {2002)[13]
et al. {2001) (21]
67
Weight{%)
Total
122
65
130
76
Odds ratio
Events
19
Charytan et al. {2006) (16]
CABG or PCI
PCI
Events
Heart and Vascular Center
0.2
19
0.4
75
100.0
1.11
0.3
{0.43-2.87)
0.13 {0.03-0.58)
0.46 {0.17-1.28)
163
1.7
0.71 {0.47-1.06)
0.1
10
Favours CABG
0.01
Favours PCI
100
0.69 {0.65-0.73) Total
13 324
Zheng et al.
EJCTS 2012
Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany
PCI vs. CABG in CKD: repeat revascularization
Zheng et al.
EJCTS 2012
Contilia Heart-
and Vascular Center, Elisabeth Krankenhaus Essen, Germany
PCI vs. CABG in CKD: myocardial infarction
Zheng et al.
EJCTS 2012
Contilia Heart-
and Vascular Center,
Elisabeth Krankenhaus Essen, Germany
