Impact of Chronic Kidney Disease on Outcomes of Myocardial Revascularization in Patients With Diabetes

• Published in: Journal of the American College of Cardiology Vol. 73; no. 4; pp. 400 - 411
• Main Authors: Farkouh, Michael E., Sidhu, Mandeep S., Brooks, Maria M., Vlachos, Helen, Boden, William E., Frye, Robert L., Hartigan, Pamela, Siami, F.S., Bittner, Vera A., Chaitman, Bernard R., Mancini, G.B. John, Fuster, Valentin
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 05.02.2019; Elsevier Limited
• Subjects: Aged; Angioplasty; CABG; CAD; Cardiology; Cardiovascular; Cardiovascular disease; Cerebral infarction; CKD; Clinical outcomes; Clinical trials; Coronary artery; Coronary Artery Bypass; Coronary artery disease; Diabetes; Diabetes mellitus; Diabetes mellitus (non-insulin dependent); Diabetes Mellitus, Type 2 - complications; Epidermal growth factor receptors; Female; Glomerular filtration rate; Heart attacks; Heart diseases; Heart surgery; Humans; Ischemia; Kidney diseases; Male; Middle Aged; Myocardial infarction; Myocardial Ischemia - complications; Myocardial Ischemia - surgery; Patients; PCI; Percutaneous Coronary Intervention; Randomized Controlled Trials as Topic; Renal Insufficiency, Chronic - complications; Statistical analysis; Stroke; eGFR; T2DM; SIHD; CAD; PCI; HR; MACCE; CABG; MI; CKD; diabetes; coronary artery disease; chronic kidney disease; estimated glomerular filtration rate; major adverse cardiac and cerebrovascular events; myocardial infarction; stable ischemic heart disease; percutaneous coronary intervention; hazard ratio; type 2 diabetes mellitus; coronary artery bypass grafting
• ISSN: 0735-1097; 1558-3597; 1558-3597
• DOI: 10.1016/j.jacc.2018.11.044

The optimal coronary revascularization strategy in patients with stable ischemic heart disease (SIHD) who have type 2 diabetes (T2DM) and chronic kidney disease (CKD) remains unclear. This patient-level pooled analysis sought to compare outcomes of 3 large, federally-funded randomized trials in SIHD patients with T2DM and CKD (COURAGE [Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation], BARI 2D [Bypass Angioplasty Revascularization Investigation 2 Diabetes], and FREEDOM [Future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multi-vessel Disease]). The primary endpoint was the composite of major adverse cardiovascular or cerebrovascular events (MACCE) including all-cause death, myocardial infarction (MI), or stroke adjusted for trial and randomization strategy. Of the 4,953 patients with available estimated glomerular filtration rate (eGFR) at baseline, 1,058 had CKD (21.4%). CKD patients were more likely to be older, be female, and have a history of heart failure. CKD subjects were more likely to experience a MACCE (adjusted hazard ratio [HR]: 1.48; 95% confidence interval [CI]: 1.28 to 1.71; p = 0.0001) during a median 4.5-year follow-up. Both mild (eGFR 45 to 60 ml/min/1.73 m2) and moderate to severe (eGFR <45 ml/min/1.73 m2) CKD predicted MACCE (adjusted HRs: 1.25 and 2.26, respectively). For patients without CKD, coronary artery bypass graft (CABG) surgery combined with optimal medical therapy (OMT) was associated with lower MACCE rates compared with percutaneous coronary intervention (PCI) + OMT (adjusted HR: 0.69; 95% CI: 0.55 to 0.86; p = 0.001). For the comparison of CABG + OMT versus PCI + OMT in the CKD group, there was only a statistically significant difference in subsequent revascularization rates (HR: 0.25; 95% CI: 0.15 to 0.41; p = 0.0001) but not in MACCE rates. Among SIHD patients with T2DM and no CKD, CABG + OMT significantly reduced MACCE compared with PCI + OMT. In subjects with CKD, there was a nonsignificant trend toward a better MACCE outcome with CABG and a significant reduction in subsequent revascularization. [Display omitted]