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Multivessel coronary artery bypass grafting versus percutaneous coronary intervention in ESRD
Tara I Chang1, David Shilane, Dhruv S Kazi
1Division of Nephrology, Department of Medicine, Stanford University, 780 Welch Road Suite 106, Palo Alto, CA 94304, USA. tichang@stanford.edu
Insights
Coronary artery bypass grafting (CABG) may be superior to percutaneous coronary intervention (PCI) for patients with end-stage renal disease (ESRD) on dialysis needing coronary revascularization. CABG was associated with significantly lower risks of death and myocardial infarction.
Area of Science:
- Cardiology
- Nephrology
- Health Services Research
Background:
- Coronary heart disease affects 30-60% of patients with end-stage renal disease (ESRD) on dialysis.
- Optimal coronary revascularization strategy for ESRD patients remains undetermined.
Purpose of the Study:
- To compare the effectiveness of coronary artery bypass grafting (CABG) versus percutaneous coronary intervention (PCI) for revascularization in dialysis patients with coronary heart disease.
Main Methods:
- Analysis of 21,981 ESRD patients on maintenance dialysis who underwent initial CABG or PCI between 1997-2009.
- Primary outcome: all-cause mortality. Secondary outcome: composite of death or myocardial infarction.
- Utilized multivariable-adjusted proportional hazards regression and propensity score-matched cohort analyses.
Main Results:
- Overall 5-year survival rates were poor (22-25%) regardless of revascularization strategy.
- CABG was associated with significantly lower risks of death (HR=0.87) and death or myocardial infarction (HR=0.88) compared to PCI.
- Findings were consistent in propensity score-matched analyses.
Conclusions:
- Coronary artery bypass grafting (CABG) may be preferred over percutaneous coronary intervention (PCI) for multivessel coronary revascularization in selected dialysis patients.
- Further data from randomized trials are needed to confirm these findings.
Abstract:
Thirty to sixty percent of patients with ESRD on dialysis have coronary heart disease, but the optimal strategy for coronary revascularization is unknown. We used data from the United States Renal Data System to define a cohort of 21,981 patients on maintenance dialysis who received initial coronary revascularization with either coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) between 1997 and 2009 and had at least 6 months of prior Medicare coverage as their primary payer. The primary outcome was death from any cause, and the secondary outcome was a composite of death or myocardial infarction. Overall survival rates were consistently poor during the study period, with unadjusted 5-year survival rates of 22%-25% irrespective of revascularization strategy. Using multivariable-adjusted proportional hazards regression, we found that CABG compared with PCI associated with significantly lower risks for both death (HR=0.87, 95% CI=0.84-0.90) and the composite of death or myocardial infarction (HR=0.88, 95% CI=0.86-0.91). Results were similar in analyses using a propensity score-matched cohort. In the absence of data from randomized trials, these results suggest that CABG may be preferred over PCI for multivessel coronary revascularization in appropriately selected patients on maintenance dialysis.
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