Elsevier

American Heart Journal

Volume 243, January 2022, Pages 187-200
American Heart Journal

Clinical Investigations
Predictors of outcome in the ISCHEMIA-CKD trial: Anatomy versus ischemia

https://doi.org/10.1016/j.ahj.2021.09.008Get rights and content

Background

The ISCHEMIA-CKD (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches–Chronic Kidney Disease) trial found no advantage to an invasive strategy compared to conservative management in reducing all-cause death or myocardial infarction (D/MI). However, the prognostic influence of angiographic coronary artery disease (CAD) burden and ischemia severity remains unknown in this population. We compared the relative impact of CAD extent and severity of myocardial ischemia on D/MI in patients with advanced chronic kidney disease (CKD).

Methods

Participants randomized to invasive management with available data on coronary angiography and stress testing were included. Extent of CAD was defined by the number of major epicardial vessels with ≥50% diameter stenosis by quantitative coronary angiography. Ischemia severity was assessed by site investigators as moderate or severe using trial definitions. The primary endpoint was D/MI.

Results

Of the 388 participants, 307 (79.1%) had complete coronary angiography and stress testing data. D/MI occurred in 104/307 participants (33.9%). Extent of CAD was associated with an increased risk of D/MI (P < .001), while ischemia severity was not (P = .249). These relationships persisted following multivariable adjustment. Using 0-vessel disease (VD) as reference, the adjusted hazard ratio (HR) for 1VD was 1.86, 95% confidence interval (CI) 0.94 to 3.68, P = .073; 2VD: HR 2.13, 95% CI 1.10 to 4.12, P = .025; 3VD: HR 4.00, 95% CI 2.06 to 7.76, P < .001. Using moderate ischemia as the reference, the HR for severe ischemia was 0.84, 95% CI 0.54 to 1.30, P = .427.

Conclusion

Among ISCHEMIA-CKD participants randomized to the invasive strategy, extent of CAD predicted D/MI whereas severity of ischemia did not.

Section snippets

Methods

Detailed descriptions of the ISCHEMIA-CKD trial design, protocol, baseline and procedural characteristics, and initial results have been previously published.8,16 In brief, a total of 777 CCD patients with advanced CKD (defined as estimated glomerular filtration rate [eGFR] <30 mL/min/1.73 m2 or on dialysis) and site-assessed moderate or severe myocardial ischemia on stress testing were enrolled between April 29, 2014 and January 31, 2018. Patients were randomly assigned to either an initial

Results

A total of 307 participants met the available criteria for analysis, representing 79.1% of the 388 randomized to the invasive arm. The remaining 81 subjects were excluded for the following reasons: 5 subjects had limited data for ischemia severity, and 78 subjects did not have complete CAD information (with 2 subjects having missing data for both ischemia severity and CAD extent). Baseline characteristics for the invasive arm of the ISCHEMIA-CKD trial, comparing the participants included in the

Discussion

Among the invasively managed participants in the ISCHEMIA-CKD trial, extent of CAD as demonstrated on the baseline coronary angiogram was strongly associated with D/MI (and its individual components) both in unadjusted and adjusted models, whereas myocardial ischemia severity was not.

To our knowledge, this is the first study examining the association of angiographic coronary anatomy versus severity of myocardial ischemia with outcomes in advanced CKD. Importantly, the Hachamovitch study

Conclusion

In a subgroup analysis of invasively treated patients from the ISCHEMIA-CKD trial with site-assessed moderate or severe myocardial ischemia, anatomic coronary artery disease burden predicted death or MI, while ischemia severity did not.

What is Known

  • The ISCHEMIA-CKD trial demonstrated no advantage to an invasive strategy compared to conservative management (all-cause death or myocardial infarction) in patients with advanced chronic kidney disease (CKD) and moderate or severe myocardial ischemia.

  • How to risk stratify patients with advanced CKD and moderate or severe ischemia is not well established.

What the Study Adds

  • In participants managed invasively in the ISCHEMIA-CKD trial, extent of coronary artery disease (CAD) by coronary angiography was associated with greater risk of all-cause death or myocardial infarction, whereas ischemia severity on stress testing was not.

  • Knowing the number of diseased coronary arteries helps predict the risk of death or myocardial infarction in patients with advanced CKD.

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  • This paper was handled by Guest Editor (Dhaval Kolte, MD, PhD. Clin. Inv.)

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