PCI στους νεφροπαθείς - PDF

PCI στους νεφροπαθείς ΓΡΑΪΔΗΣ ΧΡΗΣΤΟΣ Επεμβατικός Καρδιολόγος, FSCAI Euromedica-Κυανούς Σταυρός Θεσσαλονίκη CKD clearly represents a major public heath problem Current estimates from the U.S. show that

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PCI στους νεφροπαθείς ΓΡΑΪΔΗΣ ΧΡΗΣΤΟΣ Επεμβατικός Καρδιολόγος, FSCAI Euromedica-Κυανούς Σταυρός Θεσσαλονίκη CKD clearly represents a major public heath problem Current estimates from the U.S. show that 13% of the population has CKD, with 341,000 on chronic dialysis and 140,000 with kidney transplants World-wide, 5-10% of the world s population may also have CKD, a staggering million people It causes a huge economic burden worldwide. Health costs of treating people with CKD are nearly 3-fold higher than those for people without CKD, and the cost of treating ESRD is 10- fold higher Chronic Kidney Disease (CKD): A silent epidemic Earlier stage CKD CKD is under-diagnosed and under-treated The adverse outcomes of CKD can be prevented or delayed through interventions during earlier stages of CKD Estimates of GFR are the best overall indices of the level of kidney function The serum creatinine concentration alone should not be used to assess the level of kidney function Why Estimate GFR From SCr, Instead of Using SCrfor Kidney Function? Age Gender Race SCr (mg/dl) egfr (ml/min/1.73 m 2 ) CKD Stage 20 M B* M W M W F W F B F W Heart and Kidneys : a complicated love story The multiple connections that exist between the cardiovascular system and the kidney lead to a complex cardiovascular and renal medicine relationship. Bidirectional nature of heart-kidney interactions primary disorders of one organ causing secondary dysfunction or injury to the other Acute Renal Failure and Death in the Cardiac Patient Myocardial Infarction, Heart Failure, Arrhythmias, and Cardiac Death in the Renal Patient The multiple connections that exist between the cardiovascular system and the kidney lead to a complex cardiovascular and renal medicine relationship. ACC/AHA and National Kidney Foundation recommend that CKD should be considered as equivalent of CAD The prevalence of CVD in the CKD population ranges between 7 and 85% according to the CKD stage and type The prevalence of CKD is even higher among patients with cardiovascular disease 14.5% to 42.9% of patients with NSTEMI have moderate to severe CKD 20% of patients undergoing coronary angiography have stage 3 CKD Cardiovascular disease remains the leading cause of mortality in patients with chronic kidney disease (CKD) and dialysis-dependent renal disease. Death from cardiac causes is times more common in chronic kidney disease (CKD) patients than in age-and gender-matched population. In a large US community study involving over one million people, an independent, graded relationship was observed between estimated glomerularfiltration rate (egfr) and rates of death, cardiovascular events and hospitalization Although patients on dialysis are at greatest risk, the increased risk also extends to those with milder forms of CKD Adjusted Hazard Ratio for Cardiovascular Events among adults according to estimated glomerularfiltration rate (egfr). Adapted from Go et al.5 Rates Sudden Cardiac Death by GFR Sudden cardiac death (SCD) constitutes 62% of the CV mortality in ESRD and 25% of all-cause mortality. The annual rate of SCD in ESRD patients on dialysis is 7% Kidney International 2009; 76: In chronic kidney disease patients who are not hemodialysis dependent, the risk of dying of cardiovascular disease is greater than the risk of developing ESRD. Outcomes of 27,998 patients with evidence of CKD That the 5-year mortality rates for CKD stages 2, 3, and 4 were 19.5, 24.3, and 45.7% respectively; while the percentages of patients with these stages who progressed to ESRD were much lower at 1.1%, 1.3%, and 19.9%. Arch Intern Med. 2004;164: Causes of cardiovascular diseases in CKD: A puzzle with many pieces Unique Cardiac Risk Factors in CKD Standard cardiovascular risk factors are common in CKD, but do not fully explain the high incidence of cardiovascular events or increased mortality rates This disproportionate impact of cardiovascular events on patients with renal disease is due to the exceptionally atherogenicenvironment created by a combination of classical risk factors with other, novel factors Arteriosclerosis and Atherosclerosis The vascular complications in CKD are attributable to two different but associated mechanisms, namely atherosclerosis and arteriosclerosis. Atherosclerosis is an intimaldisease that (in the general population) is characterized by fibroatheromatous plaques and occlusive disease. The other characteristic feature in CKD is thickening and calcification of the medial arterial layer known as arteriosclerosis. Coronary Calcification in Chronic Kidney Disease CAC is frequently seen in patients with all stages of CKD CT of a patient with chronic renal failure under haemodialysis ClinJ Am Soc Nephrol 4: , 2009 In the non-ckd setting, CAC deposition is limited almost entirely to the vessel intimain association with atherosclerosis. In CKD, calcification is thought to be both intimal and medial Medial calcification was present only in those with estimated GFR 30 ml/min per 1.73 m2 and hemodialysiscases, with incidence increased by the presence of uremic risk factors Medial calcification was present in coronary segments that often also contained intimalcalcification. REVASCULARIZATION for Coronary artery disease in CKD or ESRD In spite of those statistics, dialysis patients and patients with CKD that does not require dialysis are significantly less likely than patients with normal renal function to undergo coronary angiography and revascularization REVASCULARIZATION for Coronary artery disease in CKD or ESRD To treat or not to treat? REVASCULARIZATION for Coronary artery disease in CKD or ESRD LIMITATIONS Patients with CKD were excluded from 75% of published coronary artery disease trials Data are prinicipallybased on observational non randomized trials, registries, cohorts or meta-analyses Heterogeneous CKD population analyzed in many studies (pts on dialysis or severely impaired renal function are mixed with pts with moderate or mild renal dysfunction) Different acute kidney injury definitions REVASCULARIZATION for Coronary artery disease in CKD or ESRD Are patients with renal failure good candidates for percutaneouscoronary revascularization? REVASCULARIZATION for Coronary artery disease in CKD or ESRD To dilate or not to dilate? The literature has been very consistent in showing an increased risk of percutaneouscoronary interventions in patients with chronic kidney disease REVASCULARIZATIONfor Coronary artery disease in CKD or ESRD Older Clinical syndromes known to be associated with periprocedural complications: diabetes hypertension CKD pts. have an unfavorable profile lower left ventricular ejection fraction chronic obstructive pulmonary disease vascular disease Angiographic characteristics: small diffusely diseased vessels multivessel disease congestive heart failure cardiogenic shock multivessel disease history of prior CABG history of previous myocardial infarction extensive intimal and medial coronary calcification Rubenstein MH. Are patients with renal failure good candidates for percutaneous coronary revascularization in the new device era? Circulation. 2000;102: REVASCULARIZATION for Coronary artery disease in CKD or ESRD To dilate or not to dilate? Many studies performed in the pre-stent era reported unfavourable outcomes with balloon angioplasty in CKD. High rates of procedural complications (up to 10%) and restenosis(up to 80%) meant that percutaneouscoronary intervention (PCI) was thought to be ineffective in advanced renal disease The introduction of coronary artery stentingappears to have improved both early success rates and long-term outcomes Intracoronary stent placement is both safe and feasible and produces more favorable clinical outcomes in the management of coronary disease in hemodialysis patients Clear reduction in major cardiac events and mortality, from 71% to 30%, in patients in whom a stent was implanted PCI IN CKD-IN HOSPITAL OUTCOME (ACS and DES implantation more frequent in pts with preserved GFR) NY registry, n=474 dialysis, n= 6596 GFR 60, n=17948 GFR 60 Parikh et al, CCI 2012 (J Am Coll Cardiol Intv 2009;2:37 45) With decreasing CrCl, there was a stepwise increase in mortality across all groups During the index hospital stay, there was a step-wise increase in bleeding complications with decreasing CrCl (3.3%, 5.0%, 8.8%, and 14.3%; p for trend) Cumulative incidence for death (A), myocardial infarction (MI) J Am Coll Cardiol. 2011; 58(18): Increasing severity of CKD was associated with increasing rates of death and MI 121,446 patients with CKD Mortality rates were extremely high in patients with severe CKD, with 30-month mortality rates of 32.7% and peaked in patients on long-term dialysis at 51.9% Dialysis patients also had the highest adjusted rates of MI J Am Coll Cardiol. 2011; 58(18): Increasing severity of CKD was also associated with increasing rates of major bleeding 121,446 patients with CKD (GFR 60 ml/min/1.73 m2). Dialysis patients had the highest adjusted rates of major bleeding (adjusted HR: 2.27; 95% CI: 1.97 to 2.60) CKD and PCI: Reasons for higher bleeding rates Inappropriately high doses of antithrombotic agents (especially heparineand IIb-IIIa inhibitors) due to an underestimation of the severity of CKD on the basis of serum creatinine Alexander et al, CIRCULATION 2006 Nephrol Dial Transplant (2012) 27: Patients with CKD had a significantly higher incidence of peri-procedural myocardial injurycompared to those without (4.3 versus 20.9%, P ). Patients with chronic kidney disease undergoing primary angioplasty via the femoral route experience higher rates of major vascular complications. Patients with CKD and especially ESRD have higher in-stent restenosisrates with both bare-metal and drug eluting stents This has been attributed to: higher incidences of DM, higher incidences diffuse atherosclerosis, higher incidences calcifications enhanced oxidative stress and granulocyte activation BMS vsdes in patients with CKD There is limited data and often conflicting results regarding the safety and efficacy of DES compared to BMS in patients with renal dysfunction normal renal function (12.2% vs. 14.7%, p 0.001), mild CKD (15.1% vs. 18.6%, p 0.001) moderate CKD (24.1% vs. 26.6%, p 0.001) severe CKD (33.7% vs. 33.7%, p 0.04) and patients on long-term dialysis (48.9% vs. 56.4%, p 0.001) Compared with BMS, DES treatment was associated with lower 30- month death rates This pattern was not observed in patients on long-term dialysis. The use of DES compared with BMS was also associated with lower adjusted 30-month MI rates in patients with normal renal function or mild, moderate, or severe CKD. Patients with mild, moderate, or severe CKD and patients on dialysis did not show significant differences in revascularization rates for DES compared with BMS. The effect of DES in reducing repeat revascularization appeared to be attenuated in these patients. 1-year adverse outcomes DES use in this patient population did not appear to be associated with an increased hazard of death or MI when compared to BMS. Given the trends observed, however, one cannot discount the possibility that with a larger sample size, a beneficial effect could be seen. Am J Kidney Dis Oct;62(4): Data from 26 comparative studies with 66,840 patients were included. Compared with BMSs, DESs were associated with significant reductions in: repeat revascularization (OR, 0.61; 95% CI, ;P 0.001) and myocardial infarction (OR, 0.85; 95% CI, ;P 0.001), mortality also was documented (OR, 0.77; 95% CI, ;P= 0.01). with no detectable difference in stent thrombosis (OR, 0.72; 95% CI, ;P= 0.1). These data support the use of DES in patients with CKD In summary, the use of stents and particularly drug eluting stents has decreased the rates of in-stent restenosis, but these rates remain higher than in patients with normal renal function. There does not appear to be any signal of harm in any CKD subgroup including dialysis patients.. For now, the clinical treatment of CKD patients undergoing PCI should be focused on adequate stent deployment with judicious useof antiplateletand antithrombotic management CABG PCI European Heart Journal (2005) 26, The event-free survival at 5 years was 50.7% in the stent group and 68.5% in the surgery group (P 0.04) The differences in mortality between coronary stentingand surgery did not reach statistically significant level. The occurrence of MACCE in the stent group was higher than in the CABG group, mainly driven by the higher incidence of repeat revascularization in the stent group. 23033 dialysis patients who underwent coronary revascularization Circulation. 2013;127: Long-term survival (5 years) was superior with CABG 28%, vs24% in DES pts and 19% in BMS pts In-hospital mortality was significantly higher in CABG pts CABG 8.2% DES 2.7% BMS 4.9% Types of repeat coronary revascularization procedures The probability of repeat revascularization was 18% with bare metal stents, 19% with DES, and 6% with coronary artery bypass grafting at 1 year. European Heart Journal (2010) 31, Revascularization in Patients With CKD Revascularisationof coronary arteries with CABG and PCI is associated with greater mortality in patients with CKD and those on dialysis compared to the general population. The more pertinent question is whether patients with CKD undergoing revascularization do better or worse than those treated with medical therapy alone. Patients with CKD Coronary revascularization Medical therapy PCI vscabg The data supporting the use of percutaneouscoronary interventions over medical therapy in patients with chronic kidney disease is extremely limited and fraught with confounding data in the absence of a RCT J Am Soc Nephrol Sep;14(9): patients included, 24% had CrCl 60 ml/min PCI was associated with a survival benefit compared with medical management among patients with mildly, and moderately impaired renal function but not among patients with severe CKD CABG was associated with a survival benefit among patients with with CKD compared with medical management. Revascularization decisions for CKD patients should be individualized (adopt a heart team approach) The decision to proceed with a conservative strategy with medical therapy versus a more aggressive strategy incorporating coronary revascularization requires consideration: of the patient s symptoms, the amount of myocardium at risk, the presence and severity of impaired left ventricular function (reduced ejection fraction), and the severity of coronary artery disease. We recommend that in patients with chronic kidney disease (CKD), end-stage renal failure (ESRF) and after kidney transplantation, that guidelines for revascularization of the general population be adhered to. PCI may be a reasonable consideration in CKD patients in whom CABG is not an appropriate option in the revascularization strategy because of the higher perioperativemortality and morbidity or whose overall life expectancy is judged to be limited. ACUTE CORONARY SYNDROMES IN CKD Overall, nearly one third of patients presenting with STEMI and 40% of patients presenting with NSTEMI Fox et al. Circulation. 2010;121: Presence of renal impairment influenced the clinical presentation for MI. J InternMed2010;268: More patients had heart failure and fewer presented with typical symptoms and ECG. Lack of chest pain and pre-existing left bundle branch block results in a lower suspicion of MI, and likely contributes to a worse outcome The present study also documented lower use of short-term therapies, in-hospital procedures, cardioprotectivemedications, and higher rates of medication overdosing among patients with CKD. Fox et al. Circulation. 2010;121: Overall, the risk of mortality increased with CKD stage Odds ratios for death being 4 to 8 times higher among those with stage 5 CKD than among patients without CKD Fox et al. Circulation. 2010;121: ) However, there was a greater relative increase in death for patients with STEMI with advancing CKD stage than was seen in NSTEMI A total of consecutive non ST-elevation myocardial infarction patients 80 years old Szummer et al Circulation. 2009;120: Those with lower egfr were less likely to undergo coronary angiography and to be revascularized within 14 days of admission European Heart Journal (2009) 30, Misperception of patient risk was the most commonly cited reason for not referring patients with renal dysfunction to coronary angiography. Should we manage patients presenting with non ST segment elevation myocardial infarction (NSTEMI) with an early invasive strategy? Invasive strategy conservative strategy Early Angiography in Patients with Chronic Kidney Disease: A Collaborative Systematic Review Death MI An early invasive strategy was associated with nonsignificantreductions in all-cause mortality, nonfatal MI, and a composite of death or nonfatal MI. ClinJ Am Soc Nephrol4: , 2009. Early Angiography in Patients with Chronic Kidney Disease: A Collaborative Systematic Review An invasive strategy could prevent up to 20 deaths for every 1000 patients compared with only six deaths prevented in patients without CKD. ClinJ Am Soc Nephrol4: , The invasive strategy significantly reduced rehospitalization. Among subjects with CKD in this study, the risk of death greatly outweighed the risk of further reduction in egfr or development of ESRD Among subjects with CKD, there was no increased risk of a long-term decrease in renal function following cath ±PCI. Nephrol Dial Transplant (2008) 23: In summary, more aggressive management of the increased cardiovascular risk in CKD patients is clearly needed and the presence of CKD should not preclude the use of potentially beneficial diagnostic and therapeutic interventions. Reperfusion in Patients with Renal Dysfunction after presentation With ST-Segment Elevation Renal impairment altered both the frequency and type of therapy given in patients presenting with a STEMI within 12 h of symptom onset. Despite the proven effectiveness of reperfusion therapy in the general population, significantly less is known about reperfusion therapy in patients with CKD or ESRD, because these patients have generally been excluded from randomized trials. The likelihood of receiving reperfusion therapy for STEMI was similar in patients with normal-to-moderate renal dysfunction, but decreased in severe renal dysfunction or renal failure. With decreasing renal function the use of reperfusion therapy declined from 77.3% (normal) to 49.4% (renal failure) J InternMed2010;268:40 49. With lower renal function more patients received fibrinolysis and fewer had primary PCI. Reperfusion therapy shifted from primary percutaneouscoronary intervention in 71% of patients with normal renal function to fibrinolysis in 58% of those with renal failure. J Am Coll Cardiol. 2013;61 This study suggests that patients with moderate, but not severe, CKD might benefit from primary PCI in an acute STEMI. Additionally, this study demonstrates less risk of complications of stroke with primary PCI in patients with moderate or severe CKD when compared with fibrinolytic therapy. J Am Coll Cardiol Intv 2009;2:26-33. Decisions on reperfusion in patients with STEMI have to be made before any assessment of renal function is available, but it is important to estimate the glomerularfiltration rate as soon as possible after admission. Ensuring proper hydration during and after primary PCI, and limiting the dose of contrast agents, are important in minimizing the risk of contrast-induced nephropathy. ACS patients with chronic kidney disease are frequently overdosed with antithrombotics, leading to increased bleeding risk. In patients with known or anticipated reduction of renal function, several antithrombotic agents should be either withheld or their doses reduced appropriately In patients with known or anticipated reduction of renal
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