Invasive management of chronic coronary disease not tied to QoL benefit in patients with CKD
USA: Among patients with chronic coronary disease (CCD), quality of life (QoL) outcomes may not improve with invasive management in those with poorer kidney function, states research published in JAMA Cardiology.
"Event rates in people with CCD were inversely proportional to kidney function. Invasive management was tied to an increase in stroke and procedural myocardial infarction and a reduced risk of spontaneous MI," the researchers wrote in their study. "The effect was found to be similar across different stages of CKD with no difference in other outcomes including death."
Previous trials of invasive versus conservative management of chronic coronary disease did not enroll patients with severe chronic kidney disease (CKD). There is no proper characterization of the outcomes across kidney function. Considering this, Sripal Bangalore, New York University Grossman School of Medicine, New York, and colleagues aimed to evaluate clinical and quality-of-life outcomes across the spectrum of CKD following conservative and invasive treatment strategies.
For this purpose, the researchers categorized participants from the International Study of Comparative Health Effectiveness With Medical and Invasive Approaches (ISCHEMIA) and ISCHEMIA–Chronic Kidney Disease (CKD) trials by CKD stage. They were categorized as: stage 1 (estimated glomerular filtration rate [eGFR] 90 mL/min/1.73m2 or greater), stage 2 (eGFR 60-89 mL/min/1.73m2), stage 3 (eGFR 30-59 mL/min/1.73m2), stage 4 (eGFR 15-29 mL/min/1.73m2), or stage 5 (eGFR less than 15 mL/min/1.73m2 or receiving dialysis).
Enrollment took place from July 26, 2012, through January 31, 2018, with a median follow-up of 3.1 years. Data analysis was done from January 2020 to May 2021.
Initial invasive management of coronary angiography and revascularization with guideline-directed medical therapy (GDMT) vs initial conservative management of GDMT alone were the interventions.
A composite of death or nonfatal myocardial infarction (MI) was the primary clinical outcome. The primary QoL outcome was the Seattle Angina Questionnaire (SAQ) summary score.
Among the 5956 participants included in this analysis (mean age, 64 years; 24% were female and 76% were males, 32%, 43%, 12%, 5%, and 8% were respectively in CKD stages 1, 2, 3, 4, and 5.
The researchers found the following:
- By self-report, 18 participants (<1%) were American Indian or Alaska Native; 1676 (29%), Asian; 267 (5%), Black; 861 (16%), Hispanic or Latino; 18 (<1%), Native Hawaiian or Other Pacific Islander; 3884 (66%), White; and 13 (<1%), multiple races or ethnicities.
- There was a monotonic increase in the risk of the primary composite endpoint (3-year rates, 9.52%, 10.72%, 18.42%, 34.21%, and 38.01% respectively), death, cardiovascular death, MI, and stroke in individuals with higher CKD stages.
- Invasive management was associated with an increase in stroke (3-year event rate difference, 1%) and procedural MI (1.6%) and a decrease in spontaneous MI (−2.5%) with no difference in other outcomes; the effect was similar across CKD stages.
- There was heterogeneity of treatment effect for QoL outcomes such that invasive management was associated with an improvement in angina-related QoL in individuals with CKD stages 1 to 3 and not in those with CKD stages 4 to 5.
"A higher CKD stage was associated with a worse prognosis with a high risk of cardiovascular morbidity and mortality in patients with CCD and moderate or severe myocardial ischemia," the authors wrote in their study.
"Invasive management was associated with higher stroke and procedural MI rates but a lower risk of spontaneous MI with no difference in other clinical outcomes, including the primary outcome and death. Consistent associations were observed across CKD stages."
This led researchers to conclude that, "invasive management was associated with an improvement in angina-related QoL but not in those with poorer kidney function."
Reference:
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
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