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Background Few published data describe long-term survival of dialysis patients undergoing surgical versus percutaneous coronary revascularization in the era of drug-eluting stents (DES). Methods and Results Using United States Renal Data System data, we identified 23,033 dialysis patients who underwent coronary revascularization (6178 coronary artery bypass grafting [CABG], 5011 bare-metal stent [BMS], 11,844 DES), 2004–2009. Revascularization procedures decreased from 4347 in 2004 to 3344 in 2009. DES use decreased by 41% and BMS use increased by 85% 2006–2007. Long-term survival was estimated by the Kaplan-Meier method and independent predictors of mortality examined in a comorbidity-adjusted Cox model. In-hospital mortality for CABG patients was 8.2%; all-cause survival at 1, 2, and 5 years was 70%, 57%, and 28% respectively. In-hospital mortality for DES patients was 2.7%; 1, 2, and 5 year survival was 71%, 53%, and 24% respectively. Independent predictors of mortality were similar in both cohorts: age >65 years, white race, dialysis duration, peritoneal dialysis, and congestive heart failure, but not diabetes. Survival was significantly higher for CABG patients who received internal mammary grafts (IMG) (HR 0.83, P<0.0001). Probability of repeat revascularization accounting for the competing risk of death was 18% with BMS, 19% with DES, and 6% with CABG at 1 year. Conclusions Among dialysis patients undergoing coronary revascularization, in-hospital mortality was higher after CABG but long-term survival was superior with IMGs. In-hospital mortality was lower for DES patients, but probability of repeat revascularization was higher and comparable to BMS patients. Revascularization decisions for dialysis patients should be individualized.

The conference agenda, discussion questions, and plenary session presentations are available on the KDIGO website: https://kdigo.org/ conferences/controversies-conference-on-coronary-artery-valvulardisease/. 18 THM and MJS are primary co-authors.

Background Patients with chronic kidney disease (CKD) experience poor outcomes after acute myocardial infarction (AMI). We sought to compare clinical characteristics of advanced CKD, dialysis, and non-CKD patients hospitalized with AMI. Methods This observational study used record-linked data from the US Renal Data System and Third National Registry of Myocardial Infarction to identify 2390 dialysis patients with AMI hospitalizations between April 1998 and June 2000. Advanced CKD patients (n = 29,319) were identified by baseline creatinine ≥ 2.5 mg/dL. Clinical characteristics of CKD, dialysis, and non-CKD patients (n = 274,777) were compared using the χ2 test. Results Clinically significant differences among advanced CKD (dialysis, non-CKD, respectively) patients on admission were chest pain, 40.4% (41.1%, 61.6%); diagnosis other than acute coronary syndrome, 44% (47.7%, 25.8%); and ST elevation, 15.9% (17.6%, 32.5%). Inhospital adverse outcomes were mortality, 23% (21.7%, 12.6%); unexpected cardiac arrest, 8.9% (12.3%, 6%); congestive heart failure, 41% (25.8%, 21.1%); and major bleeding, 4.9% (4.4%, 3%). P < 0.001 for all comparisons. In a logistic regression model, the adjusted odds ratio for inhospital mortality for CKD (vs. non-CKD) patients was 1.44 (95% confidence interval 1.39–1.49). Conclusions The clinical characteristics of nondialysis-dependent, advanced CKD patients with AMI are similar to characteristics of dialysis patients, and likely contribute to poor outcomes. Intensive efforts for timely, accurate recognition of AMI in advanced CKD patients are warranted.

Reperfusion injury may offset the optimal salvage of myocardium achieved during primary coronary angioplasty. Thus, coronary reperfusion must be combined with cardioprotective adjunctive therapies in order to optimize myocardial salvage and minimize infarct size. Forty-three patients with their first ST-elevation myocardial infarction were randomized to myocardial postconditioning or standard of care at the time of primary coronary angioplasty. Postconditioning was performed immediately upon crossing the lesion with the guide wire and consisted of four cycles of 30 s occlusion followed by 30 s of reperfusion. End-points included infarct size, myocardial perfusion grade (MPG), left-ventricular ejection fraction (LVEF), and long-term clinical events (death and heart failure). Despite similar ischemic times (≅4.5 h) (p = 0.9) a reduction in infarct size was observed among patients treated with the postconditioning protocol. Peak creatine phosphokinase (CPK), as well as its myocardial band (MB) fraction, was significantly lower in the postconditioning group when compared with the control group (CPK--control, 2,444 ± 1,928 IU/L vs. PC, 2,182 ± 1,717 IU/L; CPK-MB--control, 242 ± 40 IU/L vs. PC, 195 ± 33 IU/L; p = 0.64 and p < 0.01, respectively). EF in the postconditioning group was improved when compared with the control group (control, 43% ± 15 vs. PC, 52% ± 9; p = 0.05). After a mean follow-up of 3.4 years, a 6-point absolute difference in LVEF was still evident in the postconditioning group (p = 0.18). MPG was better among patients treated with the postconditioning protocol compared with control (2.5 ± 0.5 vs. 2.1 ± 0.6; p = 0.02). Due to the small sample size no significant differences in clinical events were detected (p value for death = 0.9; p value for heart failure = 0.2). A simple postconditioning protocol applied at the onset of mechanical reperfusion, resulted in reduction of infarct size, better epicardial and myocardial flow, and improvement in left ventricular function. The beneficial effects of postconditioning on cardiac function persist beyond 3 years.

Aortic stenosis with concomitant chronic kidney disease (CKD) represents a clinical challenge. Aortic stenosis is more prevalent and progresses more rapidly and unpredictably in CKD, and the presence of CKD is associated with worse short-term and long-term outcomes after aortic valve replacement. Because patients with advanced CKD and end-stage kidney disease have been excluded from randomized trials, clinicians need to make complex management decisions in this population that are based on retrospective and observational evidence. This statement summarizes the epidemiological and pathophysiological characteristics of aortic stenosis in the context of CKD, evaluates the nuances and prognostic information provided by noninvasive cardiovascular imaging with echocardiography and advanced imaging techniques, and outlines the special risks in this population. Furthermore, this statement provides a critical review of the existing literature pertaining to clinical outcomes of surgical versus transcatheter aortic valve replacement in this high-risk population to help guide clinical decision making in the choice of aortic valve replacement and specific prosthesis. Finally, this statement provides an approach to the perioperative management of these patients, with special attention to a multidisciplinary heart-kidney collaborative team-based approach.

Background--Atrial fibrillation (AF) and chronic kidney disease (CKD) are prevalent in the elderly and are independently associated with increased risk of death. We evaluated risk of incident AF with advancing CKD and examined the mortality rate associated with CKD after incident AF in elderly patients.

BackgroundWe evaluated temporal trends in ischemic stroke and warfarin use among demographic subsets of the US Medicare population that are not well represented in randomized trials of warfarin for stroke prevention in nonvalvular atrial fibrillation (AF).Methods and ResultsOne‐year cohorts of Medicare–primary payer patients (1992–2010) were created using the Medicare 5% sample. International Classification of Diseases, Ninth Revision, Clinical Modification codes were used to identify AF and ischemic and hemorrhagic stroke; ≥3 consecutive prothrombin time claims were used to identify warfarin use. Ischemic stroke rates (per 1000 patient‐years) decreased markedly from 1992 to 2010. Among women, rates decreased from 37.1 to 13.6 for ages 65 to 74 years, from 55.2 to 16.5 for ages 74 to 84, and from 66.9 to 22.9 for age ≥85; warfarin use increased 31% to 59%, 27% to 63%, and 15% to 49%, respectively. Among men, rates decreased from 33.8 to 11.7 for ages 65 to 74 years, from 49.2 to 13.8 for ages 75 to 84, and from 51.5 to 18.0 for age ≥ 85; warfarin use increased 34% to 63%, 28% to 66%, and 15% to 55%, respectively. Rates decreased from 47.0 to 14.8 for whites and 73.0 to 29.3 for blacks; warfarin use increased 27% to 61% and 19% to 52%, respectively. In all age categories, the thromboembolic risk (CHADS [congestive heart failure, hypertension, age ≥75 years, diabetes, stroke]) score was significantly higher among women (versus men) and blacks (versus whites).ConclusionsIschemic stroke rates among Medicare AF patients decreased significantly in all demographic subpopulations from 1992–2010, coincident with increasing warfarin use. Ischemic stroke rates remained higher and warfarin use rates remained lower for women and blacks with AF, groups whose baseline CHADS scores were higher.