Invasive Management of Coronary Artery Disease in Advanced Renal Disease

Abstract

Coronary artery disease (CAD) is highly prevalent in chronic kidney disease (CKD). CKD modifies the effects of traditional risk factors on atherosclerosis, with CKD-specific mechanisms, such as inflammation and altered mineral metabolism, playing a dominant pathophysiological role as kidney function declines. Traditional risk models and cardiovascular screening tests perform relatively poorly in the CKD population, and medical treatments including lipid-lowering therapies have reduced efficacy. Clinical presentation of cardiac ischemia in CKD is atypical, whereas invasive therapies are associated with higher rates of complications than in with patients with normal or near normal kidney function. The main focus of the present review is on the invasive approach to management of CAD in late-stage CKD, with an in-depth discussion of the findings of the International Study of Comparative Health Effectiveness With Medical and Invasive Approaches (ISCHEMIA)-CKD trial, and their implications for therapeutic approach and future research in this area. We also briefly discuss the existing evidence in the epidemiology, pathogenesis, diagnosis, and medical management of CAD in late-stage CKD, end-stage kidney disease (ESKD), and kidney transplant recipients. We enumerate the evidence gap left by the frequent exclusion of patients with CKD from randomized controlled trials and highlight the priority areas for future research in the CKD population.

Association of abnormalities in electrocardiography and ultrasonic echocardiography with the occurrence of cardiovascular disease in patients with advanced chronic kidney disease

“…Low LVEF seen with resting UCG has been shown to be an important risk factor for mortality in CAD, HF, and CKD [ 28 , 29 ]. However, it has been proposed that routine UCG at rest is inappropriate to use to detect CAD in the absence of typical angina symptoms and other clinical findings [ 25 , 30 , 31 ]. Additionally, considering characteristics of patients with CKD, such as a high prevalence of asymptomatic myocardial ischemia, background CVD progression due to cardio-renal involvement, and remarkable hemodynamic changes, particularly in advanced CKD and end stage kidney disease (ESKD), UCG evaluation alone may also be warranted in these populations.…”

“…The ECG is a simple and useful non-invasive test for evaluating underlying cardiac conditions and is widely utilized in routine clinical practice. However, as a resting 12-lead ECG often shows normal findings in patients with stable angina pectoris [23] and ECG findings related to CAD are atypical, particularly in patients with CKD [24][25][26], its utility is limited when used alone to evaluate cardiac conditions. In addition to ECG, UCG is often performed in clinical settings.…”

Risk Factors of Cardiac Death for Elderly Patients with Severe Chronic Kidney Disease after Percutaneous Coronary Intervention

“…CKD alters the traditional risk factors for atherosclerosis, and CKD has some unique mechanisms, such as inflammation and changes in mineral metabolism, playing a major pathophysiological role in the decline of renal function. 26 Therefore, it is of great significance for clinical work to understand the prognostic risk factors for patients with severe CKD complicated with CAD.…”

The Controversies of Coronary Artery Disease in End-Stage Kidney Disease Patients: A Narrative Review

“…Refined intravascular imaging techniques including intravascular ultrasound (IVUS) and optical coherence tomography (OCT) have provided valuable information about plaque composition and calcium burden over and above conventional coronary angiography. Coronary angiography can be performed with ultra-low volumes of contrast by using only angiographic views, confirming catheter engagement with intracoronary saline injections, and then using either IVUS or invasive functional testing to determine the haemodynamic significance of any lesions [ 256 ]. Invasive functional assessments using fractional flow reserve (FFR) and instantaneous wave free ratios (iFRs) have become standard of care regarding treatment decisions for coronary artery disease but are largely unvalidated in the ESKD population.…”