cari: revascularisation h pilmore · • revascularisation of coronary arteries in renal transplant...
TRANSCRIPT
![Page 1: CARI: Revascularisation H Pilmore · • Revascularisation of coronary arteries in renal transplant recipients is associated with a low risk of returning to dialysis. • In patients](https://reader034.vdocuments.us/reader034/viewer/2022050417/5f8cfaa3c346240a7f474fc1/html5/thumbnails/1.jpg)
Caring for Australians with Renal Impairment
CARI: Revascularisation
H Pilmore
![Page 2: CARI: Revascularisation H Pilmore · • Revascularisation of coronary arteries in renal transplant recipients is associated with a low risk of returning to dialysis. • In patients](https://reader034.vdocuments.us/reader034/viewer/2022050417/5f8cfaa3c346240a7f474fc1/html5/thumbnails/2.jpg)
Caring for Australians with Renal Impairment
.001
.01
.1
.2
.4
.6
Mor
talit
y pe
r yea
r
20 40 60 80 100Age (years)
Dialysis Population
vs. general populationDialysis mortality
.001
.01
.1
.2
Mor
talit
y pe
r yea
r
20 40 60 80Age (years)
Transplant Population
vs. general populationTransplant mortality
ANZDATA 2008
> 40 % CVS Death
![Page 3: CARI: Revascularisation H Pilmore · • Revascularisation of coronary arteries in renal transplant recipients is associated with a low risk of returning to dialysis. • In patients](https://reader034.vdocuments.us/reader034/viewer/2022050417/5f8cfaa3c346240a7f474fc1/html5/thumbnails/3.jpg)
Aims• Examine:
– Revascularisation compared with medical therapy: stable or asymptomatic CAD
– Revascularisation compared with medical therapy: unstable CAD– Revascularisation: coronary artery surgery compared with
percutaneous intervention– Revascularisation: stenting compared with angioplasty– Revascularisation: bare metal compared with drug eluting stents
• Revascularisation in the following populations:– CKD– Dialysis– Transplant
![Page 4: CARI: Revascularisation H Pilmore · • Revascularisation of coronary arteries in renal transplant recipients is associated with a low risk of returning to dialysis. • In patients](https://reader034.vdocuments.us/reader034/viewer/2022050417/5f8cfaa3c346240a7f474fc1/html5/thumbnails/4.jpg)
General Population Guidelines
• Indications for Revascularisation in Stable or Silent IHD
Eur Heart J 2010; 20; 2501
![Page 5: CARI: Revascularisation H Pilmore · • Revascularisation of coronary arteries in renal transplant recipients is associated with a low risk of returning to dialysis. • In patients](https://reader034.vdocuments.us/reader034/viewer/2022050417/5f8cfaa3c346240a7f474fc1/html5/thumbnails/5.jpg)
Renal Failure
• Manske Lancet 1992• RCT in 26 patients with CKD
– Diabetic– 13 Revascularisation; 13 Medical Therapy– Powered for 162 patients to detect a 10% improvement
with revascularisation– 10/13 in medical group compared to 2/13 in
revascularisation group reached cardiac endpoint– Study discontinued as too difficult to enroll– Sub-optimal medical therapy
![Page 6: CARI: Revascularisation H Pilmore · • Revascularisation of coronary arteries in renal transplant recipients is associated with a low risk of returning to dialysis. • In patients](https://reader034.vdocuments.us/reader034/viewer/2022050417/5f8cfaa3c346240a7f474fc1/html5/thumbnails/6.jpg)
Revascularisation compared with medical therapy: stable or asymptomatic CAD
McFalls NEJM 2004
![Page 7: CARI: Revascularisation H Pilmore · • Revascularisation of coronary arteries in renal transplant recipients is associated with a low risk of returning to dialysis. • In patients](https://reader034.vdocuments.us/reader034/viewer/2022050417/5f8cfaa3c346240a7f474fc1/html5/thumbnails/7.jpg)
• No Recommendation for Revascularisation in stable CAD
![Page 8: CARI: Revascularisation H Pilmore · • Revascularisation of coronary arteries in renal transplant recipients is associated with a low risk of returning to dialysis. • In patients](https://reader034.vdocuments.us/reader034/viewer/2022050417/5f8cfaa3c346240a7f474fc1/html5/thumbnails/8.jpg)
Revascularisation compared with medical therapy: unstable CAD
Fox JACC 2010; 55: 2435
![Page 9: CARI: Revascularisation H Pilmore · • Revascularisation of coronary arteries in renal transplant recipients is associated with a low risk of returning to dialysis. • In patients](https://reader034.vdocuments.us/reader034/viewer/2022050417/5f8cfaa3c346240a7f474fc1/html5/thumbnails/9.jpg)
FRISC II Investigators. Lancet 1999; 354: 708-15
Tertiles of creatinine clearance< 69ml/min69 – 90ml/min> 90 ml/min
842 patients with creatinine clearance less than 69ml/min (1/3 of total population) Cockcroft and Gault
Johnston Am Heart J 2006; 152: 1052
![Page 10: CARI: Revascularisation H Pilmore · • Revascularisation of coronary arteries in renal transplant recipients is associated with a low risk of returning to dialysis. • In patients](https://reader034.vdocuments.us/reader034/viewer/2022050417/5f8cfaa3c346240a7f474fc1/html5/thumbnails/10.jpg)
![Page 11: CARI: Revascularisation H Pilmore · • Revascularisation of coronary arteries in renal transplant recipients is associated with a low risk of returning to dialysis. • In patients](https://reader034.vdocuments.us/reader034/viewer/2022050417/5f8cfaa3c346240a7f474fc1/html5/thumbnails/11.jpg)
TACTICS-TIMI 18 Trial
• Patients with Non STEMI treated with heparin, tirofiban and aspirin• Randomised to:
– Early invasive treatment– Invasive treatment only if unstable or failed myocardial stress test– Excluded patients with creatinine > 2.5mg/dL
Januzzi. AM Coll Cardiol 2002; 90: 1246
![Page 12: CARI: Revascularisation H Pilmore · • Revascularisation of coronary arteries in renal transplant recipients is associated with a low risk of returning to dialysis. • In patients](https://reader034.vdocuments.us/reader034/viewer/2022050417/5f8cfaa3c346240a7f474fc1/html5/thumbnails/12.jpg)
Guidelines
• In patients with CKD 2 and 3, with increasing angina, angina at rest or who have a suspicion of a MI in the previous 48 hours: with >70% Coronary artery stenoses, acute revascularisation with CABG or PCI results in a reduction in the incidence of MI and Death compared with conservative treatment (Level II)
• RCT but sub-analyses and inadequately powered
![Page 13: CARI: Revascularisation H Pilmore · • Revascularisation of coronary arteries in renal transplant recipients is associated with a low risk of returning to dialysis. • In patients](https://reader034.vdocuments.us/reader034/viewer/2022050417/5f8cfaa3c346240a7f474fc1/html5/thumbnails/13.jpg)
– Revascularisation: coronary artery surgery compared with percutaneous intervention
– NO RCT– Revascularisation: stenting compared with
angioplasty– No RCT– Revascularisation: bare metal compared with
drug eluting stents– One RCT
![Page 14: CARI: Revascularisation H Pilmore · • Revascularisation of coronary arteries in renal transplant recipients is associated with a low risk of returning to dialysis. • In patients](https://reader034.vdocuments.us/reader034/viewer/2022050417/5f8cfaa3c346240a7f474fc1/html5/thumbnails/14.jpg)
Stenting• Normal Population
– Drug eluting stents result in• Less repeat revascularisation• Less re-stenosis
• CKD Population– TAXUS IV Trial– Randomised patients to paclitaxel-eluting stent or bare
metal stent– Exclusion creatinine < 200mg/dL– 50% Renal Impairment on Cockcroft Gault
• 410 : CKD Stage 2• 223: CKD Stage 3 or less
![Page 15: CARI: Revascularisation H Pilmore · • Revascularisation of coronary arteries in renal transplant recipients is associated with a low risk of returning to dialysis. • In patients](https://reader034.vdocuments.us/reader034/viewer/2022050417/5f8cfaa3c346240a7f474fc1/html5/thumbnails/15.jpg)
1 year Target Vessel Revascularisation
![Page 16: CARI: Revascularisation H Pilmore · • Revascularisation of coronary arteries in renal transplant recipients is associated with a low risk of returning to dialysis. • In patients](https://reader034.vdocuments.us/reader034/viewer/2022050417/5f8cfaa3c346240a7f474fc1/html5/thumbnails/16.jpg)
Meta-analysis of Stents in ESRF
![Page 17: CARI: Revascularisation H Pilmore · • Revascularisation of coronary arteries in renal transplant recipients is associated with a low risk of returning to dialysis. • In patients](https://reader034.vdocuments.us/reader034/viewer/2022050417/5f8cfaa3c346240a7f474fc1/html5/thumbnails/17.jpg)
Guideline
• The use of drug eluting stents is associated with a lower re-stenosis rate that the use of bare metal stents in patients with CKD (Level II)– Probably should change to suggestion for clinical
care– Could add ESRF
![Page 18: CARI: Revascularisation H Pilmore · • Revascularisation of coronary arteries in renal transplant recipients is associated with a low risk of returning to dialysis. • In patients](https://reader034.vdocuments.us/reader034/viewer/2022050417/5f8cfaa3c346240a7f474fc1/html5/thumbnails/18.jpg)
Suggestions for Clinical Care• Revascularisation of coronary arteries with CABG and PCI is
associated with greater mortality in patients with CKD and those on dialysis compared to the general population.
• Revascularisation of coronary arteries in renal transplant recipients is associated with a low risk of returning to dialysis.
• In patients with coronary artery disease, CABG is associated with improved all cause and cardiac survival compared with angioplasty in dialysis patients
• In patients with CAD and renal transplants, CABG with internal mammary artery grafting is associated with a reduced risk of cardiac death or MI compared to PCI.
![Page 19: CARI: Revascularisation H Pilmore · • Revascularisation of coronary arteries in renal transplant recipients is associated with a low risk of returning to dialysis. • In patients](https://reader034.vdocuments.us/reader034/viewer/2022050417/5f8cfaa3c346240a7f474fc1/html5/thumbnails/19.jpg)
Questions• Should we make any guidelines at all or should they
all be suggestions?– Suggestions for Clinical Care
• What about just using General population guidelines?– Make a statement saying that due to a current lack of
evidence we suggest adhering to guidelines for the general population
• Are post hoc analyses sufficient for a guideline?– No???
• What about the new CARI levels of evidence?– Probably doesn’t matter as little in way or RCT
![Page 20: CARI: Revascularisation H Pilmore · • Revascularisation of coronary arteries in renal transplant recipients is associated with a low risk of returning to dialysis. • In patients](https://reader034.vdocuments.us/reader034/viewer/2022050417/5f8cfaa3c346240a7f474fc1/html5/thumbnails/20.jpg)
Additional Slides for Discussion if required
![Page 21: CARI: Revascularisation H Pilmore · • Revascularisation of coronary arteries in renal transplant recipients is associated with a low risk of returning to dialysis. • In patients](https://reader034.vdocuments.us/reader034/viewer/2022050417/5f8cfaa3c346240a7f474fc1/html5/thumbnails/21.jpg)
Revascularisation associated with high mortality in ESRF
Herzog: Circulation 2002
![Page 22: CARI: Revascularisation H Pilmore · • Revascularisation of coronary arteries in renal transplant recipients is associated with a low risk of returning to dialysis. • In patients](https://reader034.vdocuments.us/reader034/viewer/2022050417/5f8cfaa3c346240a7f474fc1/html5/thumbnails/22.jpg)
![Page 23: CARI: Revascularisation H Pilmore · • Revascularisation of coronary arteries in renal transplant recipients is associated with a low risk of returning to dialysis. • In patients](https://reader034.vdocuments.us/reader034/viewer/2022050417/5f8cfaa3c346240a7f474fc1/html5/thumbnails/23.jpg)
Herzog et al. Circulation 2004; 109: 2866