Management of coronary disease in patients with advanced kidney disease
Open accessAbstract
BACKGROUND: Clinical trials that have assessed the effect of revascularization in patients with stable coronary disease have routinely excluded those with advanced chronic kidney disease. METHODS: We randomly assigned 777 patients with advanced kidney disease and moderate or severe ischemia on stress testing to be treated with an initial invasive strategy consisting of coronary angiography and revascularization (if appropriate) added to medical therapy or an initial conservative strategy consisting of medical therapy alone and angiography reserved for those in whom medical therapy had failed. The primary outcome was a composite of death or nonfatal myocardial infarction. A key secondary outcome was a composite of death, nonfatal myocardial infarction, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest. RESULTS: At a median follow-up of 2.2 years, a primary outcome event had occurred in 123 patients in the invasive-strategy group and in 129 patients in the conservative-strategy group (estimated 3-year event rate, 36.4% vs. 36.7%; adjusted hazard ratio, 1.01; 95% confidence interval [CI], 0.79 to 1.29; P = 0.95). Results for the key secondary outcome were similar (38.5% vs. 39.7%; hazard ratio, 1.01; 95% CI, 0.79 to 1.29). The invasive strategy was associated with a higher incidence of stroke than the conservative strategy (hazard ratio, 3.76; 95% CI, 1.52 to 9.32; P = 0.004) and with a higher incidence of death or initiation of dialysis (hazard ratio, 1.48; 95% CI, 1.04 to 2.11; P = 0.03). CONCLUSIONS: Among patients with stable coronary disease, advanced chronic kidney disease, and moderate or severe ischemia, we did not find evidence that an initial invasive strategy, as compared with an initial conservative strategy, reduced the risk of death or nonfatal myocardial infarction. (Funded by the National Heart, Lung, and Blood Institute and others; ISCHEMIA-CKD ClinicalTrials.gov number, NCT01985360.).
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Lowering phosphate, controlling parathyroid hormone, and maintaining normal calcium levels is common practice in nephrology despite a lack of definitive evidence that it modifies risk of CVD.
“Lowering phosphate, controlling parathyroid hormone, and maintaining normal calcium levels is common practice in nephrology despite a lack of definitive evidence that it modifies risk of CVD.691,741”
From 2023 ESC guidelines for the management of cardiovascular disease in patients with diabetes. (2023) · cites this paper as [741]
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Self-citation
- Authors
- Bangalore, S., Maron, D. J., O’Brien, S. M., Fleg, J. L., Kretov, E. I., Briguori, C., Kaul, U., Reynolds, H. R., Mazurek, T., Sidhu, M. S., Berger, J. S., Mathew, R. O., Bockeria, O., Broderick, S., Pracon, R., Herzog, C. A., Huang, Z., Stone, G. W., Boden, W. E., Newman, J. D., Ali, Z. A., Mark, D. B., Spertus, J. A., Alexander, K. P., Chaitman, B. R., Chertow, G. M., & Hochman, J. S.
- Affiliations
- Mount Sinai Hospital (US)
- From the New York University Grossman School of Medicine (S. Bangalore, H.R.R., J.S.B., J.D.N., J.S.H.), Mount Sinai Hospital (G.W.S.), the Cardiovascular Research Foundation (G.W.S., Z.A.A.), and Columbia University Irving Medical Center/New York Presbyterian Hospital (Z.A.A.), New York, Albany Medical College and Albany Medical Center, Albany (M.S.S.), and St. Francis Hospital, Roslyn (Z.A.A.) — all in New York; the Department of Medicine, Stanford University School of Medicine, Stanford, CA (D.J...
- University of Minnesota (US)
- Mount Sinai Hospital (CA)
- Boston University (US)
- ORCID
- Bangalore, Sripal
- Maron, David J.
- O’Brien, Sean M.
- Fleg, Jerome L.
- Kretov, Evgeny I.
- Briguori, Carlo
- Kaul, Upendra
- Reynolds, Harmony R.
- Mazurek, Tomasz
- Sidhu, Mandeep S.
- Berger, Jeffrey S.
- Mathew, Roy O.
- Bockeria, Olga
- Pracon, Radoslaw
- Huang, Zhen
- Stone, Gregg W.
- Boden, William E.
- Newman, Jonathan D.
- Ali, Ziad A.
- Mark, Daniel B.
- Spertus, John A.
- Alexander, Karen P.
- Chaitman, Bernard R.
- Chertow, Glenn M.
- Hochman, Judith S.
- Venue
- New England Journal of Medicine
- Publisher
- Massachusetts Medical Society
- Published
- 2020-04-23
- Volume
- 382
- Issue
- 17
- Pages
- 1608-1618
- ISSN
- 0028-4793 (ISSN-L)
- 1533-4406
- PMC
- PMC7274537
- OpenAlex
- W3013648138
- Cited by
- 499
- References
- 37
- Citations by year
- 2026: 51 · 2025: 56 · 2024: 58 · 2023: 79 · 2022: 89 · 2021: 98 · 2020: 66 · 2014: 1
- FWCI
- 76.08
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- New England Journal of Medicine (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Archivio istituzionale della ricerca (Alma Mater Studiorum Università di Bologna) (submittedVersion)
- Funders
- National Heart, Lung, and Blood Institute (U01HL117904, U01HL117905)
- Topics
- Health Sciences › Medicine › Surgery › Coronary Interventions and Diagnostics
- Health Sciences › Medicine › Radiology, Nuclear Medicine and Imaging › Cardiac Imaging and Diagnostics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Acute Myocardial Infarction Research
- Keywords
- stable coronary artery disease, advanced chronic kidney disease, coronary revascularization, coronary angiography, invasive strategy, conservative strategy, myocardial ischemia, myocardial infarction, stroke, dialysis initiation
- MeSH terms
- Adrenergic beta-Antagonists, Aged, Coronary Artery Bypass, Calcium Channel Blockers, Exercise Test, Female, Follow-Up Studies, Humans, Male, Middle Aged, Myocardial Infarction, Risk Factors, Coronary Angiography, Myocardial Ischemia, Renal Insufficiency, Chronic, Percutaneous Coronary Intervention
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