CABG and PCI Comparison in Community-Based CKD Population
CABG and PCI Comparison in Community-Based CKD Population
Background Randomized clinical trials comparing coronary artery bypass grafting (CABG) with percutaneous coronary intervention (PCI) have largely excluded patients with chronic kidney disease (CKD), leading to uncertainty about the optimal coronary revascularization strategy. We sought to test the hypothesis that an initial strategy of CABG would be associated with lower risks of long-term mortality and cardiovascular morbidity compared with PCI for the treatment of multivessel coronary heart disease in the setting of CKD.
Methods We created a propensity score–matched cohort of patients aged ≥30 years with no prior dialysis or renal transplant who received multivessel coronary revascularization between 1996 and 2008 within a large integrated health care delivery system in northern California. We used extended Cox regression to examine death from any cause, acute coronary syndrome, and repeat revascularization.
Results Coronary artery bypass grafting was associated with a significantly lower adjusted rate of death than PCI across all strata of estimated glomerular filtration rate (eGFR) (in mL/min per 1.73 m): the adjusted hazard ratio (HR) was 0.81, 95% CI 0.68 to 1.00 for patients with eGFR ≥60; HR 0.73 (CI 0.56–0.95) for eGFR of 45 to 59; and HR 0.87 (CI 0.67–1.14) for eGFR <45. Coronary artery bypass grafting was also associated with significantly lower rates of acute coronary syndrome and repeat revascularization at all levels of eGFR compared with PCI.
Conclusions Among adults with and without CKD, multivessel CABG was associated with lower risks of death and coronary events compared with multivessel PCI.
Cardiovascular disease is the leading cause of death among patients with chronic kidney disease (CKD). Up to two-thirds of patients with CKD have coronary heart disease (CHD), which usually involves multiple coronary arteries. Given the high burden of CHD in patients with CKD and associated poor prognosis, it is important to determine the optimal method of coronary revascularization for this high-risk patient population.
There are large knowledge gaps regarding the optimal coronary revascularization strategy in patients with CKD. Randomized trials of coronary artery bypass grafting (CABG) versus percutaneous coronary intervention (PCI) have largely excluded patients with CKD or have not reported outcomes by level of preprocedural kidney function, limiting the generalizability of the results to patients with CKD. Observational studies comparing CABG and PCI in patients with CKD have yielded conflicting results, with some reporting lower mortality associated with CABG and others reporting no significant differences. However, these studies were limited by relatively small sample sizes, varying definitions of CKD and limited spectra of CKD severity. Moreover, many of these studies included patients with both single and multivessel CHD, which, without confirmation of left main or proximal left anterior descending artery disease, may not necessarily represent fair comparison groups.
To address these issues, we compared the effectiveness of CABG with PCI for multivessel CHD within a large, diverse, contemporary cohort of real-world patients. We hypothesized that an initial strategy of CABG would be associated with lower risks of long-term mortality, acute coronary syndrome, and repeat revascularization compared with PCI for the treatment of multivessel CHD in the setting of CKD.
Abstract and Introduction
Abstract
Background Randomized clinical trials comparing coronary artery bypass grafting (CABG) with percutaneous coronary intervention (PCI) have largely excluded patients with chronic kidney disease (CKD), leading to uncertainty about the optimal coronary revascularization strategy. We sought to test the hypothesis that an initial strategy of CABG would be associated with lower risks of long-term mortality and cardiovascular morbidity compared with PCI for the treatment of multivessel coronary heart disease in the setting of CKD.
Methods We created a propensity score–matched cohort of patients aged ≥30 years with no prior dialysis or renal transplant who received multivessel coronary revascularization between 1996 and 2008 within a large integrated health care delivery system in northern California. We used extended Cox regression to examine death from any cause, acute coronary syndrome, and repeat revascularization.
Results Coronary artery bypass grafting was associated with a significantly lower adjusted rate of death than PCI across all strata of estimated glomerular filtration rate (eGFR) (in mL/min per 1.73 m): the adjusted hazard ratio (HR) was 0.81, 95% CI 0.68 to 1.00 for patients with eGFR ≥60; HR 0.73 (CI 0.56–0.95) for eGFR of 45 to 59; and HR 0.87 (CI 0.67–1.14) for eGFR <45. Coronary artery bypass grafting was also associated with significantly lower rates of acute coronary syndrome and repeat revascularization at all levels of eGFR compared with PCI.
Conclusions Among adults with and without CKD, multivessel CABG was associated with lower risks of death and coronary events compared with multivessel PCI.
Introduction
Cardiovascular disease is the leading cause of death among patients with chronic kidney disease (CKD). Up to two-thirds of patients with CKD have coronary heart disease (CHD), which usually involves multiple coronary arteries. Given the high burden of CHD in patients with CKD and associated poor prognosis, it is important to determine the optimal method of coronary revascularization for this high-risk patient population.
There are large knowledge gaps regarding the optimal coronary revascularization strategy in patients with CKD. Randomized trials of coronary artery bypass grafting (CABG) versus percutaneous coronary intervention (PCI) have largely excluded patients with CKD or have not reported outcomes by level of preprocedural kidney function, limiting the generalizability of the results to patients with CKD. Observational studies comparing CABG and PCI in patients with CKD have yielded conflicting results, with some reporting lower mortality associated with CABG and others reporting no significant differences. However, these studies were limited by relatively small sample sizes, varying definitions of CKD and limited spectra of CKD severity. Moreover, many of these studies included patients with both single and multivessel CHD, which, without confirmation of left main or proximal left anterior descending artery disease, may not necessarily represent fair comparison groups.
To address these issues, we compared the effectiveness of CABG with PCI for multivessel CHD within a large, diverse, contemporary cohort of real-world patients. We hypothesized that an initial strategy of CABG would be associated with lower risks of long-term mortality, acute coronary syndrome, and repeat revascularization compared with PCI for the treatment of multivessel CHD in the setting of CKD.
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