Meta-analysis of clinical studies comparing coronary artery bypass grafting with percutaneous coronary intervention in patients with end-stage renal disease

ArticleinEuropean journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery 43(3) · July 2012with11 Reads
DOI: 10.1093/ejcts/ezs360 · Source: PubMed
Abstract
End-stage renal disease (ESRD) patients are at high risk for coronary artery disease (CAD). The optimal revascularization strategy remains unknown. We performed a meta-analysis of retrospective observational trials to compare coronary artery bypass grafting (CABG) with percutaneous coronary intervention (PCI) for ESRD patients with CAD. A search of published reports was conducted to identify clinical studies comparing CABG with PCI in ESRD patients with CAD with a minimal follow-up of 12 months. Sixteen studies included 32 350 ESRD patients with revascularization. Compared with PCI, CABG was associated with a lower risk for late mortality [relative risk (RR) 0.90, 95% confidence interval (CI) 0.87-0.93], myocardial infarction event (RR 0.64, 95% CI: 0.61-0.68), repeat revascularization event (RR 0.22, 95% CI: 0.16-0.31) and cumulative events (RR 0.69, 95% CI: 0.65-0.73), despite having a higher risk for early mortality (RR 1.98, 95% CI: 1.51-2.60). In conclusion, the long-term results of PCI in ESRD patients are dismal, and CABG is significantly superior to PCI in this subset of patients.
    • "The minimally invasive nature and the low risk of immediate adverse events are strong arguments in favor of PCI. However, the current durability of PCI is most likely inferior to that of CABG, particularly in patients with multivessel disease [1, 2], diabetes [2, 3] and renal failure [4]. Contrary to PCI, advancements in coronary surgery during the last decade have been slow and limited to improvements in perfusion and anesthesiological methods. "
    [Show abstract] [Hide abstract] ABSTRACT: Clinical evidence in coronary surgery is usually derived from retrospective, single institutional series. This may introduce significant biases in the analysis of critical issues in the treatment of these patients. In order to avoid such methodological limitations, we planned a European multicenter, prospective study on coronary artery bypass grafting, the E-CABG registry. The E-CABG registry is a multicenter study and its data are prospectively collected from 13 centers of cardiac surgery in university and community hospitals located in six European countries (England, Italy, Finland, France, Germany, Sweden). Data on major and minor immediate postoperative adverse events will be collected. Data on late all-cause mortality, stroke, myocardial infarction and repeat revascularization will be collected during a 10-year follow-up period. These investigators provided a score from 0 to 10 for any major postoperative adverse events and their rounded medians were used to stratify the severity of these complications in four grades. The sum of these scores for each complication/intervention occurring after coronary artery bypass grafting will be used as an additive score for further stratification of the prognostic importance of these events. The E-CABG registry is expected to provide valuable data for identification of risk factors and treatment strategies associated with suboptimal outcome. These information may improve the safety and durability of coronary artery bypass grafting. The proposed classification of postoperative complications may become a valuable research tool to stratify the impact of such complications on the outcome of these patients and evaluate the burden of resources needed for their treatment. NCT02319083.
    Full-text · Article · Jun 2015
    • "However, in a 5-year retrospective analysis from the US Renal Data System database, Herzog et al showed that dialysis patients with diabetes had better survival rates after CABG than PTCA [35]. A meta-analysis in 2012 showed that dialysis patients had lower long-term mortality rate and a lower rate of cardiac events after CABG than patients with PTCA, but large, randomized cohort studies are still needed [39]. In short, the optimal therapy for coronary revascularization in dialysis patients could depend on the severity of CAD in an individual patient and the skill of the surgeon. "
    [Show abstract] [Hide abstract] ABSTRACT: Coronary artery disease (CAD) carries a high risk of mortality in dialysis patients. End-stage renal disease is considered to increase the vulnerability of patients with atherosclerosis superimposed on artery calcification. Recently, an increasing prevalence of CAD in dialysis patients has been attributed to a lack of effective prevention and treatment. Further studies have shown that optimal therapies for CAD in dialysis patients remain neglected and unclarified. These therapies include correction of anemia, control of blood pressure, and antiplatelet therapy. Because of bleeding tendencies in dialysis patients, the benefits of antiplatelet therapy and platelet glycoprotein IIb/IIIa inhibitors for treating CAD require more research. In addition, a meta-analysis of retrospective studies in 2012 showed that dialysis patients with CAD receiving coronary artery bypass surgery had a lower long-term mortality rate and fewer postoperative cardiac complications than those receiving percutaneous coronary angioplasty. A large randomized, long-term cohort study is necessary to confirm these issues.
    Full-text · Article · Jun 2013
  • [Show abstract] [Hide abstract] ABSTRACT: Background: Renal function is usually evaluated by detecting the serum creatinine level. Serum creatinine level is a significant prognostic factor in patients with coronary heart disease, however, a normal range of serum creatinine can mask the established renal insufficiency. Therefore, patients with normal serum creatinine level and reduced estimated glomerular filtration rate (eGFR) are more likely to be ignored before coronary revascularization, similarly, the prognosis of these groups is easily neglected and still indeterminate. Methods: In this study, a total number of 5173 consecutive patients with normal serum creatinine were selected and grouped by eGFR to follow-up and analyze prognosis after coronary revascularization. The serum creatinine ≤1.2 mg/dl was defined normal. eGFR (ml/min/1.73m2) is divided into 3 stages (≥90, 60-89, <60). We compared the groups in respect of the primary outcome of all-cause death, and the secondary outcome of main adverse cardiac and cerebral vascular events (MACCE) - cardiac death, non-cardiac death, nonfatal myocardial infarction (MI), nonfatal stroke and repeat revascularization, at a median follow-up of 549 days. Results: The mean serum creatinine was 0.97±0.32 [0.2, 6.5] mg/dl, with 5256 (87.5%) patients were within the normal limits. Among them, 5173 patients were suitable for our study; 2265(43.8%) patients' eGFR were ≥90 ml/min/1.73m2, with the remaining 2713(52.4%) being 60-89 ml/min/1.73m2, 195(3.8%) was 30-59 ml/min/1.73m2, and none (0%) was <30 ml/min/1.73m2. During hospitalization, there were statistical significant differences in in-hospital all-cause mortality (p=0.006) and no differences in MACCE (p=0.320) among different groups distinguished by eGFR. During follow-up, there were still statistical significant differences in follow-up all-cause mortality (p=0.002) and no differences in MACCE (p=0.240). In Cox regression analysis, the independent risk factors of all-cause death after coronary revascularization were identified, they were age, body mass index (BMI), left ventricular ejection fraction (LVEF), history of diabetes mellitus, indication for revascularization, number of diseased cononary artery and failed revascularization; While, only LVEF, number of diseased cononary artery and failed revascularization for MACCE. Conclusions: Normal serum creatinine and reduced eGFR are common among patients who have received coronary revascularization; patients with normal serum creatinine and mild or moderate renal insufficiency are more likely to associated with adverse clinical outcomes. In each group, gender and mode of revascularization may also lead to significant differences in prognosis. Therefore, it is important to estimate eGFR of patients even if their serum creatinine is within normal limits.
    Article · Jan 2014 · Tzu Chi Medical Journal
    H. MiaoH. MiaoS. NieS. NieZ. ZhangZ. Zhang+1more author...[...]
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