CAD in advanced kidney disease: invasive does not best conservative management

  • Bangalore S & al.
  • N Engl J Med
  • 23 Apr 2020

  • curated by Emily Willingham, PhD
  • Clinical Essentials
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Takeaway

  • For stable coronary artery disease (CAD) in advanced kidney disease, initial surgical vs conservative management does not differ for mortality or nonfatal myocardial infarction (MI) risk.
  • Stroke incidence was higher with an initial invasive approach.
  • Results are from the ISCHEMIA-CKD trial.

Why this matters

  • A trial from the early 1990s found a benefit of revascularization in this patient population, but much has changed in the ensuing decades, say these authors.

Key results

  • Estimated 3-year event rates for the primary composite outcome of death/nonfatal MI:
    • 36.4% invasive vs 36.7% conservative.
    • Difference, −0.4% (95% CI, −8.5 to 7.8).
    • Adjusted HR: 1.01 (95% CI, 0.79-1.29).
  • Estimated 3-year event rates for the secondary composite outcome (death/nonfatal MI or hospitalization for unstable angina, heart failure, resuscitated cardiac arrest):
    • 38.5% invasive vs 39.7% conservative.
    • HR, 1.01 (95% CI, 0.79-1.29).
  • Stroke incidence was higher with invasive strategy: HR, 3.76 (95% CI, 1.52-9.32).
    • Most strokes were nonprocedural.

Study design

  • Multinational (30 countries, 118 sites) study of 777 patients with advanced kidney disease who were randomly allocated to initial invasive or conservative management strategy for moderate-severe ischemia.
  • Funding: US National Heart, Lung, and Blood Institute.

Limitations

  • Highly selected participant population, so generalization not clear.