Everolimus-Eluting Stents vs. CABG for Chronic Kidney Disease
What are the outcomes of percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG) in patients with chronic kidney disease (CKD)?
Patients were identified using the New York State Percutaneous Coronary Intervention Reporting System (PCIRS) and Cardiac Surgery Reporting System (CSRS) registries. Patients with CKD who underwent PCI using everolimus-eluting stents (EES) were propensity score-matched to patients who underwent isolated CABG for multivessel coronary disease in New York. The primary outcome was all-cause mortality. Secondary outcomes were myocardial infarction (MI), stroke, and repeat revascularization.
Among 11,305 patients with CKD, 5,920 patients were propensity score-matched. At short term, PCI was associated with a lower risk of death (hazard ratio [HR], 0.55; 95% confidence interval [CI], 0.35-0.87), stroke (HR, 0.22; 95% CI, 0.12-0.42), and repeat revascularization (HR, 0.48; 95% CI, 0.23-0.98) compared with CABG. At longer term, PCI was associated with a similar risk of death (HR, 1.07; 95% CI, 0.92-1.24), higher risk of MI (HR, 1.76; 95% CI, 1.40-2.23), lower risk of stroke (HR, 0.56; 95% CI, 0.41-0.76), and higher risk of repeat revascularization (HR, 2.42; 95% CI, 2.05-2.85). In the subgroup with complete revascularization with PCI, the increased risk of MI was no longer statistically significant (HR, 1.18; 95% CI, 0.67-2.09). In the 243 pairs of patients with end-stage renal disease on hemodialysis, PCI was associated with a significantly higher risk of death (HR, 2.02; 95% CI, 1.40-.93) and repeat revascularization (HR, 2.44; 95% CI, 1.50-3.96) compared with CABG.
The authors concluded that among subjects with CKD, CABG is associated with higher short-term risk of death, stroke, and repeat revascularization, whereas PCI with EES is associated with higher long-term risk of repeat revascularization and perhaps MI, with no long-term mortality difference.
This registry analysis reports that PCI using the latest-generation stents (EES) was associated with lower short-term risk (death, stroke, and repeat revascularization), similar long-term risk of death, higher risk of MI (in those with incomplete revascularization), and a lower risk of stroke, but a higher risk of repeat revascularization when compared with CABG. However, in patients on dialysis, the results favored CABG over PCI. Given the analysis does not control for unmeasured confounders, a prospective randomized trial would be needed to guide optimal strategy for patients with CKD undergoing myocardial revascularization. For now, a multidisciplinary team approach to decision making is indicated for these high-risk patients.
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