Clinical InvestigationsPredictors of outcome in the ISCHEMIA-CKD trial: Anatomy versus ischemia
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
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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.
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How to risk stratify patients with advanced CKD and moderate or severe ischemia is not well established.
What the Study Adds
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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.
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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.)