Abstract 13804: Differential Outcome of Medical Therapy Compared With Percutaneous and Surgical Coronary Revascularization in Individuals With Chronic Kidney Disease at Low, Medium, or High Cardiovascular Risk
Introduction: Comparisons of medical therapy (MT) and percutaneous (PCI) or surgical coronary revascularization (CABG) for the treatment of coronary artery disease (CAD) in the setting of chronic kidney disease (CKD) have suggested that MT is inferior, but may be confounded by failure to adequately account for baseline cardiovascular disease (CVD) risk and by the nihilistic definition of MT as absence of revascularization rather than active titration of MT.
Hypothesis: MT is superior to revascularization in CKD pts at low CV risk but PCI and CABG are superior to MT when CV risk is high.
Methods: The 20% Medicare sample was used to identify pts in 2007-2012 with CKD, assess outcomes, and define risk groups: Low risk: angiography or stress testing in the absence of prior CVD; Medium risk: stress test or angiography with prior CVD history; High risk: admission for acute coronary syndrome (ACS). PCI and CABG were defined on the basis of procedures within 60 days of risk group entry. MT included non-PCI/CABG pts with addition of new CV medication during the same time frame. Results: For low risk pts 1000 had PCI, 571 CABG, and 6848 MT. For medium risk 1751 PCI, 718 CABG and 9670 MT pts. For high risk 4542 PCI, 1481 CABG and 8287 MT pts. All-cause mortality rates increased across risk groups, consistent with excellent performance of our classification metric. Mortality rates per hundred pt years were lowest with MT in the low risk group—PCI 9.1, CABG 8.9, MT 8.1--and medium risk groups—PCI 13.5, CABG 14.6, MT 13.2. In contrast, survival was markedly better with CABG or PCI in high risk pts—PCI 18.4, CABG 13.1, MT 33.5 (Table).
Conclusions: The relative benefits of MT and coronary revascularization in the setting of CKD vary according to pre-treatment CV risk. For pts at low or moderate risk, MT, PCI, and CABG have similar survival. In contrast, revascularization, particularly CABG, is associated with markedly improved survival (and higher ESRD rate) compared to MT after ACS.
Author Disclosures: C.A. Herzog: Research Grant; Significant; Amgen, Zoll. Honoraria; Modest; UpToDate. Ownership Interest; Modest; Boston Scientific, GE, Johnson & Johnson, Merck. Consultant/Advisory Board; Modest; AbbVie, BMS, Davita Clinical Research, Relypsa, ZS Pharma. Consultant/Advisory Board; Significant; FibroGen. S. Li: None. T. Natwick: None. C. Solid: None. D.M. Charytan: Employment; Significant; Brigham & Women’s Hospital. Research Grant; Significant; Janssen, Medtronic. Expert Witness; Modest; Fresenius. Consultant/Advisory Board; Modest; Lilly/Boehringer Ingelheim, Medtronic.
- © 2016 by American Heart Association, Inc.