Chronic Kidney Disease and Coronary Artery Disease

Sarnak MJ, Amann K, Bangalore S, et al.
Chronic Kidney Disease and Coronary Artery Disease: JACC State-of-the-Art Review. J Am Coll Cardiol 2019;74:1823-1838.

The following are key points to remember from this JACC state-of-the-art review on chronic kidney disease (CKD) and coronary artery disease (CAD):

  1. CKD is a major risk factor for CAD. In addition to the high prevalence of traditional CAD risk factors, such as diabetes and hypertension, persons with CKD are also exposed to other nontraditional, uremia-related cardiovascular disease risk factors, including inflammation, oxidative stress, and abnormal calcium-phosphorus metabolism.
  2. CKD and end-stage kidney disease (ESKD) not only increase the risk of CAD, but they also modify its clinical presentation and cardinal symptoms.
  3. In the absence of evidence that pre-emptive coronary revascularization is effective in reducing death or myocardial infarction risk in asymptomatic patients, screening for underlying anatomic CAD lacks either a rationale or evidence even in at-risk asymptomatic patients.
  4. Coronary artery calcium score or computed tomography angiography (CTA) may offer significant advantages over functional imaging modalities in the setting of CKD. In a comparison of coronary artery calcium score, CTA, exercise, or pharmacologic stress single-photon emission computed tomography (SPECT) in which stenosis >50% was detected by quantitative coronary angiography in 138 transplant candidates, coronary artery calcium score and SPECT had only modest specificity (67% and 53%) and sensitivity (77% and 82%), and CTA had a high sensitivity (93%), but poor specificity (63%).
  5. However, risks of acute kidney injury (AKI) need to be considered with CTA, particularly in late-stage CKD.
  6. Management of CAD is complicated in CKD patients, due to their likelihood of comorbid conditions and potential for side effects during interventions.
  7. Although medical therapy is the cornerstone of CAD treatment, challenges exist in CKD for a number of reasons since the proportional contribution of atherosclerosis to events in those with advanced CKD and especially ESKD is low and patients with CKD (especially advanced CKD and/or ESKD) are under-represented in clinical trials, and as such, the evidence to support recommendations is limited.
  8. The choice of medical therapy alone or revascularization (percutaneous coronary intervention or coronary artery bypass grafting) in symptomatic patients with CKD and/or ESKD is controversial.
  9. The frailty and comorbidity burden of patients with CKD makes it critical to use patient-centric decision making that takes into consideration the relative short- and long-term risks and/or benefits of intervention, overall CKD-related prognosis, and patient preference.
  10. Additional prospective studies focusing on diagnosis, prevention, and treatment of CAD are needed in patients with CKD.

Clinical Topics: Cardiac Surgery, Diabetes and Cardiometabolic Disease, Geriatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Aortic Surgery, Cardiac Surgery and Arrhythmias, Interventions and Imaging, Angiography, Computed Tomography, Nuclear Imaging, Hypertension

Keywords: Acute Kidney Injury, Atherosclerosis, Constriction, Pathologic, Coronary Angiography, Coronary Artery Bypass, Diabetes Mellitus, Frail Elderly, Hypertension, Kidney Failure, Chronic, Metabolic Syndrome X, Myocardial Infarction, Myocardial Ischemia, Myocardial Revascularization, Percutaneous Coronary Intervention, Primary Prevention, Risk Factors, Tomography, Tomography, Emission-Computed, Single-Photon, Uremia

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