Bệnh mạch vành ổn định với tổn thương nhiều nhánh ở người có bệnh thận mạn khi nào nên can thiệp

Stable CKD: when do we need PCI?
Christoph K. Naber
Contilia Heart and Vascular Center
Elisabeth Krankenhaus Essen
Germany


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


CKD and Mortality

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


Serum phosphorus and cardiac injury

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 adjusting 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 patients

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 patients 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 patients 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 revascularization?
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 revascularization?
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


CABG vs. PCI in HD patients

Gupta et al.
JACC 2004
Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany


PCI vs. CABG in CKD: all events

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