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CABG no better than PCI in CKD
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The presence of chronic kidney disease in patients with diabetes appears to attenuate the benefits of CABG over PCI, although researchers found a nonsignificant trend toward better outcomes with CABG in this patient population, according to new data published in the Journal of the American College of Cardiology.
In a patient-level pooled analysis, Michael Farkouh, MD, MSc, clinical epidemiologist at Mount Sinai New York and the Peter Munk Chair in Multinational Clinical Trials at the Peter Munk Cardiac Center in Toronto, and colleagues compared outcomes from the randomized COURAGE, BARI 2D and FREEDOM trials.
Of 4,953 patients with stable ischemic heart disease and type 2 diabetes for whom estimated glomerular filtration rate was available at baseline, 21.4% had chronic kidney disease (CKD). Patients were randomly assigned PCI plus optimal medical therapy, CABG plus optimal medical therapy or optimal medical therapy alone. The median follow-up was 4.53 years. MACCE, including all-cause death, MI or stroke, served as the primary endpoint.
CKD as a risk predictor
Overall, 5-year mortality rates were greater for patients with CKD vs. without CKD (22.3% vs. 9.8%; P = .0001), as were rates of MACCE (adjusted HR = 1.48; 95% CI, 1.28-1.71) and death (aHR = 1.69; 95% CI, 1.4-2.05). When compared with patients without CKD, the MACCE rate remained elevated in both those with mild CKD (aHR = 1.25; 95% CI, 1.05-1.47) and moderate to severe CKD (aHR = 2.26; 95% CI, 1.83-2.8). Mortality was also higher among those with mild CKD (aHR = 1.45; 95% CI, 1.16-1.8) and moderate to severe CKD (aHR = 2.44; 95% CI, 1.86-3.2) vs. patients without CKD.
Subsequent revascularization rates, however, were comparable among all patients, regardless of CKD status.
CABG vs. PCI
Among patients without CKD, the risk for MACCE did not differ significantly for those who underwent CABG vs. those who received optimal medical therapy only (aHR = 0.85; 95% CI, 0.66-1.09). For patients who underwent PCI, though, the risk for MACCE was higher than those who received optimal medical therapy only (aHR = 1.23; 95% CI, 1.01-1.5). When comparing the two revascularization strategies, patients who underwent CABG were at a lower risk for MACCE than those who underwent PCI (aHR = 0.69; 95% CI, 0.55-0.86).
Similarly, although there were no differences in all-cause mortality between patients who underwent CABG or PCI vs. optimal medical therapy alone, the risk for death was significantly lower among those who underwent CABG compared with PCI (aHR = 0.65; 95% CI, 0.47-0.89).
The risk for subsequent revascularization was lower for both CABG and PCI, as compared with medical therapy, but was substantially lower with CABG compared with PCI (aHR = 0.38; 95% CI, 0.3-0.48).
Among patients with CKD, however, there were no overall differences in MACCE rates with any of the three treatment strategies, with the exception of a lower risk for subsequent revascularization with CABG vs. PCI (aHR = 0.25; 95% CI, 0.15-0.41).
For patients with mild CKD, the risk for MACCE did not differ significantly among patients receiving CABG, PCI or medical therapy alone, although patients who underwent CABG again had a lower risk for subsequent revascularization.
For patients with moderate to severe CKD, there were no significant differences among treatment groups, although the researchers noted a trend toward a lower risk for MACCE in patients who underwent CABG, as compared with medical therapy alone (aHR = 0.69; 95% CI, 0.33-1.46) or with PCI (aHR = 0.68; 95% CI, 0.39-1.19). Subsequent revascularization rates were also lower with CABG when compared with optimal medical therapy alone (aHR = 0.12; 95% CI, 0.04-0.38) or PCI (aHR = 0.17; 95% CI, 0.06-0.44).
Findings in context
In light of these findings, the researchers recommended that patients with type 2 diabetes and CKD should receive evidence-based secondary prevention and intensive lifestyle interventions and periodic risk assessments to determine whether revascularization is necessary.
The trend toward a benefit of CABG over PCI in patients with moderate to severe CKD, though, should prompt further investigation to understand the impact of revascularization in this patient population, they noted.
In an accompanying editorial, Cardiology Today’s Intervention Editorial Board Member David Faxon, MD, and Natalia C. Berry, MD, both from Brigham and Women’s Hospital and Harvard Medical School, highlighted the importance of studying patients with CKD, particularly as this population grows. However, there has not been a randomized trial of coronary revascularization and medical therapy in patients with CKD and most of the data derive from substudies of larger randomized trials, Faxon and Berry noted.
“As demonstrated by this study and multiple prior reports, patients with CKD and coronary artery disease have poorer outcomes than patients with preserved kidney function. Although CABG was not clearly superior to PCI as a revascularization strategy in the current study, as might be expected and as was seen in the substudy of SYNTAX, there was a preserved numerical trend toward improved outcomes with CABG,” they wrote. “Ultimately, further and more robust study is needed for a better understanding of to what degree CKD affects outcomes in revascularization.”
The ongoing, randomized ISCHEMIA-CKD trial comparing PCI with CABG in advanced CKD or end-stage renal disease will be integral to providing some answers, according to Faxon and Berry. – by Melissa Foster
Disclosures: This study was sponsored by Gilead Sciences. The authors report no relevant financial disclosures. Faxon and Berry report no relevant financial disclosures.
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