Coronary revascularization in patients with coronary artery disease and chronic kidney disease

There is a remarkable lack of randomized trial data on optimal management of coronary artery disease (CAD) in patients with chronic kidney disease (CKD). In fact, patients with CKD are often excluded from randomized trials that compare different treatment strategies for CAD. Because the most common cause of death in CKD patients is cardiovascular disease, it is crucial that studies are designed to determine the best therapy for CAD in this high-risk group. This article discusses the available data on coronary revascularization outcomes in CKD patients.     

Risk of bleeding and restenosis among chronic kidney disease patients undergoing percutaneous coronary intervention

BACKGROUND: Bleeding risk is increased in renal failure due to impaired platelet adhesiveness. Patients who undergo percutaneous coronary intervention (PCI) are given multiple antiplatelet agents that increase that risk. We retrospectively tested the hypothesis that chronic kidney disease (CKD) patients who undergo PCI are at higher risk of bleeding and restenosis (due to chronic inflammation) compared to patients with normal renal function. METHODS: Patients who had PCI for non-ST elevation myocardial infarction or unstable angina between July 2001 and June 2003 (1,184 patients) were included in the study. All the patients were given periprocedural clopidogrel, aspirin and glycoprotein IIb/IIIa inhibitor if indicated, and then continued on clopidogrel and aspirin daily for 12 months. The patients were classified into 5 groups according to the CKD stage and followed-up for 12 months for development of major or minor bleeding, restenosis, length of hospital stay and survival. RESULTS: The incidence of major bleeding within the first month (3.4% in normal kidney function patients (Gp 1), 4.8% for CKD Stages 1 and 2 patients (Gp2), 5.2% for CKD Stage 3 patients (Gp3), 6.1% for CKD Stage 4 patients (Gp4) and 9.3% for CKD Stage 5 patients (Gp5), p = 0.001) and for minor bleeding (5.7% in Gp1, 6.5% for Gp2, 7.4% for Gp3, 9.2% for Gp4 and 11.3% for Gp5, p = 0.001) and the incidence of restenosis at one month (4.6% in Gp1, 5.3% for Gp2, 6.8% for Gp3, 7.3% for Gp4 and 9.6% for Gp5, p = 0.001) and 6 months (11.2% in Gp1, 13.5% for Gp2, 15.7% for Gp3, 16.4% for Gp4 and 19.7% for Gp5, p = 0.001) were higher with worsening CKD. Survival at one year was worse with worsening of the kidney function. CONCLUSION: Worsening of CKD is associated with progressively increased risk of minor and major bleeding, restenosis and death during and after PCI.     

合并甲状腺功能低下病人的冠状动脉旁路移植术

目的 探讨冠心病(CAD)合并甲状腺功能低下(甲低)病人的冠状动脉旁路移植术(CABG)围术期外科处理的临床效果.方法 2002年9月至2009年6月,1347例CABG中21例(A组)合并甲低需要甲状腺激素替代治疗,男6例,女15例;平均(60.4±14.2)岁.体外循环下手术4例(包括心脏停跳手术1例),非体外循环下CABG 17例.术前均口服左旋甲状腺素,FT3、FT4、TSH、TT3、TT4明显改善后手术.同期对照20例甲状腺功能正常CABG者(B组),其中4例体外循环下CABG.观察两组术前、术中、术后甲状腺功能指标以及近端吻合时血流动力学指标.结果 围术期应用放射免疫法甲状腺激素水平检测,非体外循环下手术者,A组17例FT3术前及术中水平为[(1.39±0.36)pg/ml对(1.29±0.32)pg/ml]、B组16例为[(2.28±0.36)pg/ml对(2.19±0.34)pg/ml];体外循环下手术者,A组4例FT3术前及术中水平为[(1.53±0.51)pg/ml对(0.85±0.40)pg/ml]、B组4例为[(2.08±0.24)pg/ml对(1.96±0.26)pg/ml].A、B两组术中心排指数[(2.7±1.4)L·min-1·m-2对(2.8±1.5)L·min-1·m-2,P=0.53].A组1例重度甲低病人体外循环下心脏停跳手术后因心脏复跳困难死亡,20例生存者均为心脏不停跳方式手术者,其中17例为非体外循环手术,术后随访2～30个月均有心功能改善,射血分数(EF)由术前0.48±0.17增加至术后0.55±0.21.B组均生存.两组间术中血流动力学、手术预后、住院时间[(12.2±4.7)天对(10.1±3.9)天]、呼吸机辅助[(17.6±9.1)h对(15.1±13.7)h],差异无统计学意义.结论 冠心病合并甲低病人,术前准备充分,采用心脏不停跳手术方式较安全,非体外循环下手术对病人FT3激素水平影响较小;围术期甲状腺素治疗是关键;重度甲低病人体外循环下手术风险大.     

Impact of haemoglobin concentration and chronic kidney disease in patients with coronary heart disease undergoing percutaneous coronary interventions.

BACKGROUND: A few recent studies suggested that anaemia has a marked impact on the survival of patients with coronary heart disease (CHD). However, all of these analyses did not take into consideration that chronic kidney disease (CKD) plays an important role in erythropoiesis and anaemia. Therefore, we assessed in this study whether anaemia is an independent predictor of mortality or if its impact was confounded by CKD, which is known to have itself a marked impact on outcomes of patients with CHD. METHODS: In a retrospective cohort study, we analysed 709 patients with symptomatic and significant CHD who underwent percutaneous coronary interventions. Patients were classified as anaemic using the WHO definition; renal function was classified by the estimated glomerular filtration rate (eGFR). RESULTS: In comparison with non-anaemic patients, anaemic patients had a significantly higher in-hospital mortality (4.9 vs 0.5%, P<0.001). Moreover, 1-year mortality rates of anaemic patients were significantly higher regardless of whether they had a normal eGFR (22 vs 2.8%, P=0.029), an eGFR of 60-89 ml/min (14 vs 4.2%, P<0.001), an eGFR of 30-59 ml/min (21 vs 3.7%, P<0.001) or an eGFR<30 ml/min (26 vs 0%, NS). When cumulative mortality was analysed by haemoglobin concentrations in steps of 1 g/dl from <11.0 g/dl to >16.9 g/dl, 1-year mortality rates were 28, 18, 15, 5.5, 3.8, 5.7, 1.5 and 0%, respectively (P<0.001, log rank). Even after adjustment for comorbidities by multivariable Cox regression models, haemoglobin remained a significant predictor of long-term mortality (hazard rate ratio 0.77, 95% confidence interval (CI): 0.62-0.82, P<0.001) while eGFR was not (hazard rate ratio 1.0, 95% CI: 0.99-1.01). CONCLUSIONS: Anaemia was found to be a strong and independent predictor of acute and long-term mortality in patients with symptomatic CHD, regardless of the presence of CKD.     

Percutaneous coronary intervention in chronic kidney disease patients

Cardiovascular disease (CVD) is the major cause of morbidity and mortality in patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD). The increased prevalence of CVD in patients with renal dysfunction has been attributed to lack of effective prevention and low utilization of effective therapy. The optimal treatment of ischemic heart disease in ESRD patients before renal transplantation is controversial. Although no meta-analysis or pooled analysis of the data from small trials exists, it appears that percutaneous coronary intervention (PCI) provides excellent angiographic success but is associated with increased restenosis and the need for revascularization and that coronary artery bypass grafting (CABG), while associated with higher in-hospital morbidity and mortality, provides better overall long-term results and freedom from angina. Despite suboptimal results for percutaneous interventions in comparison with bypass surgery, PCI remains a viable option, especially for patients who are not candidates for surgery and those with disabling angina despite anti-anginal therapy. Regardless of the revascularization strategy used, outcomes of CABG or PCI in these patients are significantly worse than outcomes in the general population. The long-term benefit after revascularization and adjunctive medical therapy should be an area of intense future research. Studies should also be conducted to investigate the benefit and safety of therapies such as the long-term use of beta-blockers, statins, and renin-angiotensin-aldosterone axis inhibition in patients with CKD.     

冠心病介入患者基于自我超越理论的护理干预

目的 探讨基于自我超越理论的护理干预对冠心病介入患者希望水平、应对方式、自我管理行为及健康素养的影响。方法 将126例冠心病介入患者随机分为对照组与观察组各63例。对照组实施常规护理,观察组在此基础上基于自我超越理论进行护理干预。干预前及干预后2周比较两组希望水平、应对方式、自我管理行为及健康素养评分。结果 干预后观察组希望水平、积极应对方式、自我管理行为及健康素养评分显著高于对照组,消极应对方式得分显著低于对照组(均P<0.05)。结论 基于自我超越理论的护理干预可提高冠心病介入患者希望水平,增强积极应对及自我管理能力,提高健康素养。     

Percutaneous coronary intervention compared with coronary artery bypass graft in coronary artery disease patients with chronic kidney disease: a systematic review and meta-analysis

Previous reports of percutaneous coronary intervention versus coronary artery bypass graft outcomes in coronary artery disease patients with chronic kidney disease (CKD) were inconsistent. We evaluated the optimal revascularization strategy for CKD patients. We searched Pub Med, EMBASE, and the Cochrane Central Register of Controlled Trials and scanned the references of relevant articles and reviews. All studies that compared relevant clinical outcomes between percutaneous coronary intervention and coronary artery bypass graft in CKD patients were selected. We defined short-term and long-term all-cause mortality as primary outcome, and long-term incidences of myocardial infarction and revascularization as secondary outcomes. A total of 2235 citations were retrieved, and 31 studies involving 99,054 patients, with 55,383 receiving percutaneous coronary intervention and 43,671 receiving coronary artery bypass graft, were included. In subgroup analyses of dialysis patients receiving percutaneous coronary intervention with stents versus coronary artery bypass graft, CKD patients with multivessel coronary disease, and CKD patients receiving drug-eluting stent versus coronary artery bypass graft, the pooled outcomes revealed that percutaneous coronary intervention possessed lower short-term mortality, but higher late revascularization risk. No significant differences in long-term mortality were observed between the two strategies in these subgroup analyses. In conclusion, in some specific clinical circumstances, CKD patients receiving percutaneous coronary intervention possessed lower short-term all-cause mortality, but higher long-term revascularization risk, than coronary artery bypass graft; long-term all-cause mortality was not different between the two strategies.     

右美托咪定对经皮冠状动脉介入治疗患者氧化应激的影响

目的评价右美托咪定对经皮冠状动脉介入治疗(percutaneous coronary intervention,PCI)患者氧化应激的影响。方法选择急性心肌梗死需行急诊PCI患者50例,男39例,女11例,年龄47~79岁,体重45~83kg,ASAⅢ或Ⅳ级,采用随机数字表法将患者分为右美托咪定组(D组)和对照组(C组),每组25例。D组麻醉诱导前30min静脉泵注负荷剂量右美托咪定0.5μg/kg,泵注时间10min,随后持续静脉泵注右美托咪定0.2~1.0μg·kg~(-1)·h~(-1)至术毕;C组采用同样方法静脉泵注等量生理盐水。根据RASS镇静程度评估表,维持RASS评分-2~2分。于麻醉诱导前(T_0)、术毕(T_1)、术后6h(T_2)和24h(T_3)采集颈静脉血4ml,分别进行中性粒细胞(PMN)计数、血清丙二醛(MDA)浓度和超氧化物歧化酶(SOD)活性测定。记录术中低血压、心动过缓和低氧血症等不良反应的发生情况。结果与T_0时比较,T_1~T_3时两组血清PMN计数、MDA浓度均明显升高,血清SOD活性明显降低(P0.01或P0.05);T_1~T_3时D组PMN计数、MDA浓度均明显低于C组,血清SOD活性明显高于C组(P0.05)。两组患者术中低血压、心动过缓和低氧血症的发生率差异无统计学意义。结论持续静脉泵注右美托咪定0.5μg/kg,可以更好地抑制PCI患者的氧化应激反应,有助于减轻心肌缺血-再灌注损伤。     

1031例冠脉造影患者慢性肾脏病流行情况调查

目的 调查疑似冠心病行冠脉造影患者的慢性肾脏病（CKD）流行情况。 方法 2008年12月至2009年10月,于东南大学附属中大医院心内科住院行选择性冠脉造影的1031例患者为对象,观察其CKD的患病率及其危险因素。CKD的定义为eGFR <60 ml?min-1?(1.73 m2)-1和(或)蛋白尿,eGFR以简化MDRD公式计算。冠心病定义为至少1支冠脉狭窄≥50%。 结果 患者平均年龄(64.37±11.02）岁,其中男性543例,女性488例;冠心病551例,CKD 134例（13%）。冠心病组CKD的患病率显著高于非冠心病组（18.33%比6.88%,P < 0.01）。随冠脉病变支数增加（0、1、2、3支）,eGFR逐渐下降[（84.24±19.00）、（81.61±23.92）、（75.16±20.99）、（73.92±20.66） ml?min-1?(1.73 m2)-1,P < 0.01];蛋白尿患者比例逐渐增加（0.42%、0.82%、1.96%、3.25%,P = 0.006）;CKD患病率逐渐增高（6.88%、13.11%、21.57%、23.38%,P < 0.01）。Logistic回归提示年龄增长（OR=1.094,95%CI 1.068~1.120）、冠脉病变支数增加（OR=1.288,95%CI 1.074~1.543）、高血压（OR=1.974,95%CI 1.082~3.603）、心脏收缩功能不全（OR=3.183,95%CI 1.696~5.972）、高尿酸血症（OR=5.366,95%CI 3.224~8.931）是CKD的重要危险因素。 结果 冠脉造影证实的冠心病患者中,CKD患病率显著高于非冠心病者,且随冠脉病变支数增加而显著增加。年龄增长、冠脉病变支数增加、高血压、心脏收缩功能不全、高尿酸血症为CKD的危险因素。     

慢性肾衰竭患者经皮冠状动脉介入治疗后血管并发症的临床研究

探讨慢性肾衰竭(CRF)合并冠心病患者经皮冠状动脉介入治疗(PCI)后穿刺部位血管并发症的影响因素.方法 在2 977例接受PCI治疗的冠心病患者中,其中CRF患者53例,肾功能正常患者2924例,比较2组穿刺部位血管并发症的发生率.在CRF患者中,按有、无穿刺部位血管并发症分为2组,比较2组性别、年龄、体质量指数、穿...     

川崎病冠状动脉病变及搭桥手术

目的 探讨川崎病后严重冠状动脉病变及搭桥手术（ＣＡＢＧ）后的近期及远期效果。方法随访发现,６例川崎病后严重冠状动脉病变的病儿均有左冠状动脉前降支（ＬＡＤ）病变,右冠状动脉（ＲＣＡ）病变５例,左冠状动脉回旋支（ＬＣＸ）病变３例,左冠状动脉主干（ＬＭＴ）病变２例,心肌梗死３例。共行１５支ＣＡＢＧ;单支２例,３支３例,４支１例;左胸廓内动脉（ＬＩＴＡ）至ＬＡＤ６例;右胸廓内动脉（ＲＩＴＡ）至ＬＡＤ１例。     

升主动脉粥样硬化患者的冠状动脉旁路移植

目的 总结冠状动脉粥样硬化性心脏病合并升主动脉粥样硬化患者冠状动脉旁路移植手术的特点。方法 22例患者中,13例采用非体外循环、心脏不停跳下冠状动脉旁路移植术(59％);9例采用低温体外循环(41％),其中5例在深低温、低流量并间断停循环条件下不阻断升主动脉行旁路-升主动脉近端吻合。结果 20例康复出院,术后早期死亡2例;并发症有肺部感染、心绞痛、室颤、急性心肌梗死和血胸,无神经系统并发症。结论 减少术中升主动脉操作是防止升主动脉损伤和减少并发症的关键。应用带蒂动脉旁路、旁路远端序贯吻合和近端Y形吻合可避免或减少旁路-升主动脉吻合;低温体外循环加左心室引流时,可不阻断升主动脉行旁路远端吻合;深低温、低流量并间断停循环下行旁路-升主动脉吻合,可避免阻断和部分阻断升主动脉,利于控制并发症。     

Coronary endarterectomy for diffuse extensive coronary artery disease

Introduction Atherosclerotic coronary artery disease is in an increasing trend in India. With the advancement of non-surgical methods of revascularisation, the patients coming for surgery are of less attractive anatomy. The role of coronary endarterectomy along with coronary artery bypass grafting for a selected group of these patients is quite promising. Materials and Methods From March 2000 to March 2005, out of 362 CABGs performed, 42 patients had undergone coronary endarterectomy. The age range being from 35 to 76 years, M: F is 38∶4 Hypertension was present in 26 (61%), diabetes mellitus in 20 (47.6%), smoking in 26 (61%) and dyslipidemia in 12 (28.5%) cases. Old myocardial infarction was present in 52.3% cases, unstable angina in 16.6%, stable angina in 23.8% and cardiogenic shock in 7.1% cases. All cases had undergone coronary artery bypass grafting with endarterectomy. Out of 18 LAD endarterectomies 17 cases LIMA was used as onlay patch. Result The average number of grafts anastomosed was 3.7. Single-vessel endarterectomy was done in 37, double vessel in 4 and four vessel in one case. LAD endarterectomy was done in 18, RCA in 12, diagonal in 10, intermediate in 1 and marginals in 8 cases. Postoperatively 3 patients had arrhythmia, two perioperative MI, one recurrent angina and one congestive cardiac failure (CCF). There was 2 (4.76%) mortality. Conclusion Hypertension and smoking are major risk factors. LAD is the most common artery requiring endarterectomy. Usage of LIMA following endarterectomy of LAD is quite satisfactory and short term results are encouraging.     

非体外循环下冠状动脉内膜剥脱后搭桥治疗弥漫性冠状动脉病变

目的探讨非体外循环心脏跳动下冠状动脉内膜剥脱后搭桥治疗弥漫性冠状动脉病变的早期临床结果和经验。方法2003年5月—2005年5月,对53例弥漫性冠状动脉病变患者行非体外循环下冠状动脉内膜剥脱后搭桥手术治疗。53例中,男性41例、女性12例,年龄55～79(64±7)岁。加拿大心脏病协会心绞痛分级：Ⅰ～Ⅱ级15例,Ⅲ级6例,Ⅳ级32例。有心肌梗死史26例(49%)。冠状动脉造影：双支病变3例,3支病变50例,其中合并左主于病变9例。左心室射血分数0．26～0．65(0．52±0．17)。53例共行70支冠状动脉内膜剥脱：左前降支系统38支,其中5例内膜剥脱后先用大隐静脉片行前降支成形,再在补片上用乳内动脉搭桥;回旋支的钝缘支8支;右冠状动脉系统24支。应用左乳内动脉53支,桡动脉2支,余均为大隐静脉桥,人均搭桥(3．8±1．1)支,再血管化指数1．03±0．07。结果术中桥血流测定显示63支桥血流满意,7支欠满意。术后2例发生围手术期心肌梗死,但对血流动力学无明显影响。53例皆痊愈出院。44例随访6～29个月,无心绞痛发作;9例失访。6例在手术后3～27个月复查冠状动脉造影,显示桥血管均通畅。结论非体外循环下冠状动脉内膜剥脱后搭桥,安全可行,再血管化程度高,是治疗弥漫性冠状动脉病变的有效方法。     

冠状动脉钙化积分评估经皮冠状动脉介入治疗术后稳定型心绞痛患者预后

目的评价冠状动脉钙化(CAC)积分在经皮冠状动脉介入治疗(PCI)术后稳定型心绞痛(SAP)患者预后的价值。方法对400例PCI术后SAP患者行MSCT检查,CAC积分根据标准Agatston钙化计分方法。根据CAC积分分为低CAC积分组(CAC积分≤300)235例,高CAC积分组(CAC积分300)165例,分析CAC积分与临床特征、手术并发症、重大不良事件(MACE)的关系。结果 CAC积分与年龄(r=0.34,P0.001)、收缩压(r=0.20,P=0.020)正相关;单因素分析显示,高CAC积分组手术并发症发生率比低CAC积分组增加4.62倍(P=0.020),经年龄、糖尿病史、多支血管病变校正后,CAC积分仍是手术并发症的独立危险因素(OR=4.56,P=0.033);Kaplan-Meier生存分析显示,低CAC积分组、高CAC积分组累积无事件生存率分别为88.94%和77.58%,差异有统计学意义(P=0.038)。结论 CAC积分是PCI术后SAP患者发生MACE的独立预测因素,与手术发症有关。     

Myocardial revascularization in patients with end-stage renal disease: Comparison of percutaneous transluminal coronary angioplasty and coronary artery bypass grafting

Background: Ischemic heart disease is the major cause of death inpatients with end-stage renal disease. The high prevalence of coronary artery disease results in a rising number of dialysis patients requiring myocardial revascularisation. Objective: The objective of this study was to compare the outcomes of recurrent angina, myocardial infarction, rate of reinterventions and cardiovascular death following percutaneous coronary angioplasty (PTCA) or coronary artery bypass grafting (CABG) inpatients with end-stage renal disease. Patients and methods: In a retrospective investigation 40 patients with chronic renal failure undergoing primarily PTCA and 65 patients undergoing CABG were included. Both groups were comparable for gender, duration on dialysis and the number of cardiovascular risk factors per patient. Patients undergoing PTCA were younger (53 ± 12 years vs. 57 ± 8 years; p < 0.05) and more often diabetics (30% vs. 14%; p < 0.05). Results: Most patients in both groups had a multi-vessel disease (95% in the CABG group vs. 74% in the PTCA group), in the CABG group there were significantly more patients with a triple-vessel disease (62% with vs. 40%in the PTCA group; p < 0.01), PTCA was primarily successful in 95% of the patients while complete revascularization was achieved in 88% of patients undergoing CABG. The perioperative mortality after CABG was 4.8% as compared to none after interventional revascularisation. The cumulative freedom of angina after 6, 12 and 24 months after intervention was significantly lower after PTCA (54%, 40%, 29%) than after bypass grafting (97%, 94%, 90%, p < 0.001). The frequency of reinterventions following PTCA was significantly higher compared to patients following CABG (p < 0.001). After PTCA 15 patients needed further revascularisations, 8 of them underwent CABG, whereas after CABG only two patients required additional myocardial revascularisation. There was no significant difference in the overall mortality between both groups; the survival rate after 12 and 24 months was 95% and 82% after PTCA and 93% and 86% after CABG, respectively. Condition: Although patients receiving CABG had a more severe coronary artery disease the overall mortality was comparable and clinical and functional outcome was improved compared to patients after coronary angioplasty. This revised version was published online in June 2006 with corrections to the Cover Date.