Renal Artery Revascularization Improves Heart Failure Control in Patients with Atherosclerotic Renal Artery Stenosis

Abstract

about the value of raising HDL-C. There is therefore also a need to reliably characterize the relationship between HDL-C and vascular risk, especially at the high HDL-C levels (N Engl J Med 2007;357:2109-22). Given uncertainties of the relationship between LDL-C and HDL-C levels and the various manifestations of vascular disease, as well as the uncertainties of the roll of proatherogenic lipoproteins in various types of vascular disease, the authors sought to produce reliable estimates of the association of major lipids and apolipoproteins with respect to risk for ischemic stroke and coronary heart disease (CHD). A total of 112 prospective studies of cardiovascular risk factors involving 1.2 million participants with shared individual medical records are in the Emerging Risk Factors Collaboration (ERFC). Sixty-eight studies involving 302,430 participants without any known history of CHD at initial examination also had complete information on baseline levels of total cholesterol, HDL-C, and triglyceride, and several conventional risk factors for vascular disease (diabetes, blood pressure, body mass index, smoking status, age, and sex). These patients had a total of 2.79 million person-years of follow-up. During follow-up, there were 8857 nonfatal myocardial infarctions, 2534 ischemic strokes, 3928 coronary heart disease deaths, 513 hemorrhagic strokes, and 2536 unclassified strokes. The lipid information and the outcome information was used to calculate hazard ratios adjusted for conventional variables. Rates of CHD per 1000 personyears in the bottom and top thirds of baseline lipid distributions, respectively, were 2.6 and 2.2 for triglycerides, 6.4 and 2.4 for HDL-C, and 2.3 and 6.7 for non-HDL-C. The adjusted hazard ratio for CHD was 0.99 (95% CI 0.94-1.04) for triglycerides, 0.78 (95% CI 0.74-0.82) for HDL-C, and 1.5 (95% CI, 1.39-1.61) for non-HDL-C. Hazard ratios were as strong in participants who did not fast as those did. A combination of 80 mg/dL lower non-HDL-C and 15 mg/dL high HDL-C resulted in a hazard ratio for CHD of 0.35 (95% CI, 0.3-0.42). For the subset with apolipoproteins or directly measured LDL-C, hazard ratios were 1.5 (95% CI, 1.38-1.62), with a ratio of non-HDL-C/HDL-C the hazard ratio was 1.49 (95% CI, 1.39-1.60), with a ratio of apo B/apo A1, the hazard ratio was 1.42 (95% CI, 1.06-1.91), and with a non-HDL-C the hazard ratio was 1.38 (95% CI, 1.09-1.73). With directly measured LDL-C, hazard ratios for ischemic stroke were 1.02 (95% CI, 0.94-1.11) with triglycerides, 0.93 (95% CI, 0.84-1.02) with HDL-C, and 1.12 (95% CI, 1.04-1.20) with non-HDL-C.Comment: The data are important but complicated as presented. Nevertheless, the implications of the findings can be simplified as follows: What to measure in vascular risk assessment depends more on practical considerations rather than major differences in strength of epidemiologic associations. In addition, hazard ratios for vascular disease with lipid levels are of similar magnitude in fasted and non-fasted patients. Hazard ratios are also sim...

ACCF/AHA 2011 Expert Consensus Document on Hypertension in the Elderly

“…Outcomes in HF and BP control were improved by revascularization compared with outcomes of patients who underwent medical management, but mortality was not affected. 663 Investigators from the ASPIRE II (renal Artery Stenting After Unsuccessful Balloon Angioplasty) study analyzed safety and durability of renal stenting after suboptimal or failed renal artery BA in patients, average age 69Ϯ9.9 years. Stenting was immediately successful in 80.2% lesions treated, and at 9 months, the restenosis rate was 17.4%.…”

Efficacy of Renal Revascularization in a Patient With Fibromuscular Renal Artery Stenosis and Heart Failure

“…One study in 163 consecutive patients who underwent percutaneous transluminal renal angioplasty for atherosclerotic RAS, reported that heart failure was present in one-third of the patients, and renal revascularization had resulted in improved heart failure control and a reduction in hospitalizations. 16) In contrast, few reports have described the efficacy of renal revascularization in FMD patients with congestive heart failure. In the present case, successful surgical revascularization was achieved without major periprocedural complications; blood pressure was well controlled during the 33 months of follow-up with improved BNP serum concentration and LV diastolic function.…”

Effect of renal artery revascularization upon cardiac structure and function in atherosclerotic renal artery stenosis: cardiac magnetic resonance sub-study of the ASTRAL trial

“…Heart failure, either flash pulmonary edema (FPE) or CHF, is a well-recognized clinical presentation for ARVD. Although the hearts of patients with FPE have not been subject to systematic study, Kane et al did examine the hearts of ARVD patients being referred for renal revascularization at the Mayo clinic (7), dividing patients into those with and without clinical heart failure; mean LVM was greater in those with CHF (LVM index 130±34 vs. 112±31 g/m 2 ). Randomized controlled trials comparing the addition of percutaneous renal artery revascularization to optimal medical therapy in ARVD have, at best, shown only minor and inconsistent benefits in blood pressure control (8)(9)(10).…”