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Percutaneous Coronary Intervention Versus Optimal Medical Therapy for Stable Angina in Advanced CKD: A Decision
Aisha Khattak1, Ernest I Mandel2, Matthew R Reynolds3
1Renal Division, Brigham and Women's Hospital, Boston, MA.
Insights
For patients with advanced chronic kidney disease (CKD) and stable angina, percutaneous coronary intervention (PCI) offers similar quality-adjusted life expectancy to medical management. Preemptive dialysis is not recommended.
Area of Science:
- Nephrology
- Cardiology
- Health Economics
Background:
- Individuals with advanced chronic kidney disease (CKD) have high cardiovascular risk but low percutaneous coronary intervention (PCI) utilization for stable angina.
- PCI is often deferred due to concerns about precipitating dialysis, with limited patient-centered data comparing strategies.
Purpose of the Study:
- To compare the long-term effectiveness and risks of PCI versus medical management in patients with advanced CKD and stable angina.
- To evaluate the role of preemptive dialysis in this patient population.
Main Methods:
- A Markov decision analysis model with Monte Carlo simulation was used.
- A hypothetical cohort of patients with advanced CKD (stages 4-5) and stable angina was analyzed over 3 years.
- Outcomes included progression to hemodialysis (HD), catheter infection, and death.
Main Results:
- PCI first and medical management yielded similar mean quality-adjusted life-years (1.103 vs. 1.088).
- Preemptive hemodialysis followed by PCI resulted in significantly lower quality-adjusted life-years (0.670).
- Probabilistic sensitivity analysis indicated PCI as the preferred strategy in over 60% of simulations.
Conclusions:
- Quality-adjusted life expectancy is comparable between PCI first and medical management for advanced CKD patients with stable angina.
- The optimal strategy depends on patient preferences beyond those modeled.
- Both PCI and medical management are superior to preemptive dialysis.
Background:
Percutaneous coronary intervention (PCI) use is low in the setting of stable symptomatic angina in individuals with advanced chronic kidney disease (CKD) despite high cardiovascular risk in this population, and PCI is frequently deferred out of concern for precipitating dialysis therapy. Whether this is appropriate is uncertain, and patient-centered data comparing the relative risks and benefits of continued medical therapy versus PCI in patients with advanced CKD and stable angina are scarce.
Study Design:
Decision analysis.
Setting & Population:
Hypothetical cohort of individuals with advanced CKD (stages 4-5 with estimated glomerular filtration rates ≤ 20mL/min/1.73m2) and stable angina.
Model, Perspective, & Timeline:
A Markov model with a Monte Carlo simulation through 12 cycles, that is, 3 years of 3-month intervals, with 10,000 microsimulations predicted mean quality-adjusted life-years.
Intervention:
PCI first, medical management, or dialysis (hemodialysis [HD]) followed by PCI.
Outcomes:
Outcomes modeled were progression to HD therapy (for those not assigned to the preemptive HD strategy), catheter infection, and death.
Results:
Our analysis showed mean quality-adjusted life-years of 1.103 ± 0.69 for PCI first, 1.088±0.70 for medical management, and 0.670±0.58 for HD followed by PCI. Probabilistic sensitivity analysis found PCI as the preferred strategy > 60% of the time.
Limitations:
Values for probabilities and utilities were estimated and/or derived from multiple sources that were not uniform in their populations in terms of age, comorbid condition burden, and degree of kidney failure, and several simplifying assumptions were made.
Conclusions:
Our analysis demonstrates that quality-adjusted life expectancy is similar for the PCI first and medical management strategies in patients with advanced CKD with stable angina and that the decision depends on patient preferences other than those incorporated in our model. Both strategies are superior to preemptive dialysis.
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