Renal outcomes associated with invasive versus conservative management of acute coronary syndrome: propensity matched cohort study

James, Matthew T.; Ghali, William A.; Knudtson, Merril L.; Faris, Peter; Manns, Braden; Pannu, Neesh; Galbraith, P. Diane; Hemmelgarn, Brenda R.

doi:10.1136/bmj.f4151

Cited by 33 publications

(38 citation statements)

References 35 publications

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“…135 It is less clear whether this apparently favorable risk-to-benefit ratio applies to dialysis patients or would persist if revascularization were more liberally used in CKD patients. On the other hand, even among patients undergoing coronary revascularization, postprocedural use of potentially cardioprotective medications is lower in CKD patients than in those with normal kidney function, 136 suggesting that closer attention to medical regimens may improve outcomes.…”

Section: Current Management and Therapeutic Gaps Coronary Artery Diseasementioning

confidence: 99%

Epidemiology and Mechanisms of Uremia-Related Cardiovascular Disease

2016

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Abstract-Patients with chronic kidney disease and end-stage renal disease are at 5-to 10-fold higher risk for developing cardiovascular disease (CVD) than age-matched controls. Clinically, CVD in this population manifests as coronary artery disease, arrhythmias, stroke, or congestive heart failure. Beyond the traditional risk factors (eg, diabetes mellitus and hypertension), uremia-specific factors that arise from accumulating toxins also contribute to the pathogenesis of CVD.In this review, we summarize the literature on the epidemiology of both traditional and uremia-related CVD and focus on postulated mechanisms of the latter. P. Jousset, MD, 1 describing common causes of death among patients with Bright disease C hronic kidney disease (CKD) is an increasingly urgent public health concern that is projected to grow worldwide at a rate of 8% annually, with the fastest growth expected in developing nations.2,3 It has long been known that patients with kidney failure are predisposed to cardiovascular disease (CVD) that manifests clinically in various forms, including coronary artery disease, atrial or ventricular arrhythmias, myocardial infarction, stroke, or congestive heart failure. Over the last 30 years, it has become clear that the risk of CVD increases early in the course of progressive kidney disease and that the epidemiology, pathophysiology, prevention, and treatment of CVD and CKD are closely related and interdependent. 4 In this review, we initially describe the epidemiology of CVD among people with CKD, noting the limitations of available research. We then discuss common risk factors for CVD (traditional and nontraditional) and key shared aspects of its pathophysiology with CKD. Next we describe emerging diagnostic tools and novel therapies that may help to delay or prevent end-stage renal disease (ESRD) and to curtail the escalating burden of cardiorenal disease. In the final section, we discuss the health services and health policy challenges that CKD and its inextricably linked CVD morbidities pose worldwide, particularly for low-and middle-income countries (LMICs). Phenotypes and Epidemiology of CVD in Patients With CKDPatients with CKD and some forms of CVD share a number of risk factors and underlying pathophysiological mechanisms that, by virtue of their similarities, offer opportunities to improve their management. The epidemiology of 4 of the commonest clinical phenotypes of CVD associated with CKD is discussed below. Coronary Artery DiseaseCoronary artery disease (CAD) is a leading cause of death among people with advanced CKD. Clinical syndromes compatible with CAD (including angina and myocardial infarction) are exceedingly common in patients with nondialysis-dependent CKD, and the incidence of myocardial

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Section: Current Management and Therapeutic Gaps Coronary Artery Diseasementioning

confidence: 99%

Epidemiology and Mechanisms of Uremia-Related Cardiovascular Disease

2016

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“…The concept of CI-AKI arose from observation and assumed causality, and despite a lack of rigorous hypothesis testing, has driven clinical practice for more than five decades. While a randomized controlled trial has not been conducted, there is now substantial evidence suggesting that CM contributes minimally, if at all, to the development of AKI [6,7,9,11,13,[15][16][17]. Despite the existence of such evidence, a pervasive preoccupation with what should be referred to as contrast-associated AKI (CA-AKI) persists in clinical practice, medical texts, and even among clinical researchers.…”

Section: Resultsmentioning

confidence: 99%

“…Further, a study performed in a large inpatient sample that controlled for comorbidity and acuity of illness found that patients with acute coronary syndromes (n = 1,251,812) who received CM experienced an unexpectedly lower rate of AKI as compared to patients who were not exposed to contrast (6.4% versus 17.4%) [10]. Finally, a propensity-matched cohort study of patients with non-STEMI reported one additional episode of AKI for every 62 participants treated with an early invasive approach instead of a conservative approach, with similar risks of dialysis or long-term risk of end-stage renal disease, but better long-term survival with the invasive approach [6] and in a propensitymatched cohort study of patients with STEMI, the risk of AKI was similar with and without CM exposure [7].…”

Section: Contrast Media and Acute Kidney Injury In Patients Undergoinmentioning

confidence: 99%

“…1). Indeed, multiple retrospective controlled studies in patients undergoing PCI were unable to show a meaningful adverse effect of CM exposure [6,7,10]. Further, a study performed in a large inpatient sample that controlled for comorbidity and acuity of illness found that patients with acute coronary syndromes (n = 1,251,812) who received CM experienced an unexpectedly lower rate of AKI as compared to patients who were not exposed to contrast (6.4% versus 17.4%) [10].…”

Section: Contrast Media and Acute Kidney Injury In Patients Undergoinmentioning

confidence: 99%

“…The prevailing belief that CM plays a central role in AKI has had major impacts over several decades, including promotion of potentially suboptimal clinical care at the patient level and subversion of a research agenda at the scientific level. Withholding CM on the basis of overestimated risk deprives individual patients of diagnostic studies and therapeutic interventions, many of which convey substantial proven benefit [6,7]. There are scenarios in which CM administration is unavoidable, however, and the perceived risk of CM administration associated with such scenarios has driven intense interest in preventive measures for CI-AKI.…”

Section: Clinical Importancementioning

confidence: 99%

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