Predictor of poor coronary collaterals in chronic kidney disease population with significant coronary artery disease

ABSTRACT: BACKGROUND: Coronary collateral circulation plays an important role to protect myocardium from ischemia, preserve myocardial contractility and reduce cardiovascular events. Chronic kidney disease (CKD) is associated with poor coronary collateral development and cardiovascular outcome. However, limited research investigates the predictors for collateral development in the CKD population. METHODS: We evaluated 970 consecutive patients undergoing coronary angiography and 202 patients with CKD, defined as a glomerular filtration rate less than 60 ml/min/1.73 m2, were finally analyzed. The collateral scoring system developed by Rentrop was used to classify patients into poor (grades 0 and 1) or good (grades 2 and 3) collateral group. RESULTS: The patients with poor collateral (n = 122) had a higher incidence of hypertension (82 % vs 63.8 %, p = 0.005), fewer diseased vessels numbers (2.1 [PLUS-MINUS SIGN] 0.9 vs 2.6 [PLUS-MINUS SIGN] 0.6, p < 0.001) and a trend to be diabetic (56.6 % vs. 43.8 %, p = 0.085) or female sex (37.7 % vs. 25.0 %, p = 0.067). Multivariate analysis showed hypertension (odd ratio (OR) 2.672, p = 0.006), diabetes (OR 1.956, p = 0.039) and diseased vessels numbers (OR 0.402, p < 0.001) were significant predictors of poor coronary collaterals development. Furthermore, hypertension and diabetes have a negative synergistic effect on collateral development (p = 0.004 for interaction). CONCLUSIONS: In the CKD population hypertension and diabetes might negatively influence the coronary collaterals development.     

Chronic kidney disease predicts poor prognosis in patients with stable premature coronary artery disease

ObjectiveThis study was performed to determine the prevalence of chronic kidney disease (CKD) as well as its association with mid-term prognosis in patients with stable premature coronary artery disease (CAD) in a Chinese population.MethodsFive hundred and twelve patients from Jiangsu Province, China with stable, premature CAD were enrolled using an estimated glomerular filtration rate (eGFR) to determine the presence of CKD. The patients were then monitored over a two-year follow up during which major adverse cardiac events (MACEs) were recorded and analyzed.ResultsOne hundred and eighty-three patients (35.74%) were determined to have CKD. Having CKD was associated with a higher ratio of type 2 diabetes mellitus, multi-vessel disease, higher levels of fasting blood sugar and lower levels of left ventricular ejection fraction (all P < 0.05). Patients with CKD had significantly higher incidences of composite MACEs than the non-CKD group at the end of the two- (45.35% vs 30.72%, P = 0.001) but not one-year follow up (30.64% vs 25.32%, P = 0.209). Furthermore, as eGFR decreased, more MACEs occurred (all P < 0.05). Multivariate analysis confirmed that both CKD (P < 0.001) and multi-vessel disease (P < 0.001) are independent risk factors for MACEs.ConclusionChinese patients diagnosed with stable, premature CAD and CKD have more risk factors and worse two-year outcomes than those with only CAD.     

Effects of statin treatment in patients with coronary artery disease and chronic kidney disease

Statins reduce cardiovascular morbidity and mortality from coronary artery disease (CAD). However, the effects of statin therapy in patients with CAD and chronic kidney disease (CKD) remain unclear. Within a single hospital-based cohort in the Shinken Database 2004–2010 comprising all patients (n = 15,227) who visited the Cardiovascular Institute, we followed patients with CKD and CAD after percutaneous coronary intervention (PCI). A major adverse cardiovascular and cerebrovascular event (MACCE) was defined by composite end points, including death, myocardial infarction, cerebral infarction, cerebral hemorrhage, and target lesion revascularization. A total of 391 patients were included in this study (median follow-up time 905 ± 679 days). Of these, 209 patients used statins. Patients with statin therapy were younger than those without. Obesity and dyslipidemia were more common, and the glomerular filtration rate (GFR) was significantly higher, in patients undergoing statin treatment. MACCE and cardiac death tended to be less common, and all-cause death was significantly less common, in patients taking statins. Multivariate analysis showed that low estimated GFR, poor left ventricular ejection fraction, and the absence of statin therapy were independent predictors for all-cause death of CKD patients after PCI. Statin therapy was associated with reduced all-cause mortality in patients with CKD and CAD after PCI.     

Prevalence of microvascular disease in patients with significant coronary artery disease

Coronary flow velocity reserve (CFVR) measurement using intracoronary Doppler techniques has been increasing accepted for the assessment of physiological significance of epicardial stenosis and the functional changes after coronary interventions. However, large discrepancy exists concerning the acute changes of CFVR immediately after intervention. The purpose of this study was to investigate the prevalence of microvascular dysfunction in patients with significant coronary artery disease. Intracoronary Doppler flow measurements were performed in a total of 212 patients who underwent coronary interventions because of significant epicardial stenosis using 0.014" Doppler flow wire (Cardiometrics, Inc, Mountain View, CA). Intracoronary bolus injection of adenosine (12 micrograms for the right coronary and 18 micrograms for the left coronary arteries) was used to induce hyperemic reaction. CFVR was registered as the ratio of average peak velocity during hyperemia (hAPV) to at baseline (bAPV). Successful coronary interventions either by percutaneous transluminal coronary balloon angioplasty (PTCA) or by stenting could significantly improve the CFVR. In 80 patients with PTCA, the bAPV elevated from 16.6 +/- 2.1 cm/s to 20.6 +/- 13.4 cm/s and hAPV from 30.1 +/- 15.9 cm/s to 45.2 +/- 17.7 cm/s (both p < 0.001) with PTCA and the CFVR increased from 1.94 +/- 0.78 to 2.58 +/- 0.87 correspondingly (p < 0.001). Significant elevation of coronary flow parameters were also found in 132 patients with subsequent stent implantation (bAPV from 15.3 +/- 6.7 cm/s to 18.7 +/- 9.1 cm/s, hAPV from 28.7 +/- 14.4 cm/s to 44.3 +/- 17.7 cm/s and CFVR from 1.90 +/- 0.70 to 2.59 +/- 0.87, all p < 0.001). Reduction of CFVR (< 3.0) after intervention still existed in 46 (61.3%) of 80 patients after PTCA and 88 (66.7%) of 132 patients after stenting. Moreover, CFVR < 3.0 were found in 50 (45.9%) of 109 reference vessels in patients with single vessel disease. Significant improvement of coronary flow velocity and coronary flow velocity reserve could be obtained after successful angioplasty. However, microvascualr dysfunction existed in a large proportion of patients either in normal reference vessels or in target vessels after interventions.     

The clinical profile and outcomes associated with coronary collaterals in patients with coronary artery disease

Background

The clinical correlates of coronary collaterals and the effects of coronary collaterals on prognosis are incompletely understood.

Methods

We performed a study of 55,751 patients undergoing coronary angiography to evaluate the correlates of angiographically apparent coronary collaterals, and to evaluate their association with survival.

Results

The characteristic most strongly associated with the presence of collaterals was a coronary occlusion (odds ratio [OR], 28.9; 95% confidence interval [CI], 27.1-30.6). Collaterals were associated with improved adjusted survival overall (hazard ratio [HR] 0.89; 95% CI, 0.85-0.95), and in both acute coronary syndrome (ACS) (HR 0.90; 95% CI, 0.84-0.96) and non-ACS (HR 0.84; 95% CI, 0.77-0.92) patients. Collaterals were associated with improved survival in those receiving angioplasty (HR 0.78; 95% CI, 0.71-0.85) and those with low risk anatomy treated medically (HR 0.84; 95% CI, 0.72-0.98), but not for those treated with coronary bypass graft surgery or those with high-risk anatomy treated without revascularization.

Conclusions

The major correlate of coronary collaterals is the presence/extent of obstructive coronary artery disease. Collaterals are associated with better survival overall and in both ACS and non-ACS presentations, but not for those treated with coronary artery bypass graft (CABG) or those with high-risk anatomy who are not revascularized.     

慢性肾脏病与冠心病相关性的临床研究

目的:探讨包括轻度肾损害在内的慢性肾脏病(CKD)与冠心病(CAD)的相关性。方法:收集我院2000年1月至2004年12月心内科和心胸外科符合入选标准的冠脉造影患者733例进行回顾性分析。按有、无冠心病分组,探讨慢性肾脏损害与冠心病的相关性。统计学处理采用Log istic多因素回归分析。结果:慢性肾脏病、高血糖、高血压、男性均为冠心病的重要危险因素。其中慢性肾脏病的危险最大(优势比OR=3.977)。结论:包括轻度肾损害在内的慢性肾脏病与冠心病显著相关,是冠心病的重要危险因素。     

Ability of troponin T to predict angiographic coronary artery disease in patients with chronic kidney disease

Association between angiographic coronary artery disease and cardiac troponin T levels has been observed in patients with normal kidney function; however, this association remains unsettled in patients with chronic kidney disease (CKD) or end-stage renal disease (ESRD). Over a 12-month period we retrospectively reviewed coronary angiograms (CAs) performed in 194 hospitalized patients with presumed acute myocardial injury. About 50% of the ESRD and 30% of the CKD patients had normal CAs. Troponin T levels significantly correlated with CAs in patients with normal kidney function (r = 0.4, p = 0.005) but not in ESRD and CKD patients (r = 0.2, p = NS, respectively).     

Identifying frailty in hospitalized older adults with significant coronary artery disease

OBJECTIVES: To characterize physiological variation in hospitalized older adults with severe coronary artery disease (CAD) and evaluate the prevalence of frailty in this sample, to determine whether single-item performance measures are good indicators of multidimensional frailty, and to estimate the association between frailty and 6-month mortality. DESIGN: Observational cohort study. SETTING: Inpatient hospital cardiology ward. PARTICIPANTS: Three hundred nine consecutive inpatients aged 70 and older admitted to a cardiology service (n = 309; 70% male, 84% white) with minimum two-vessel CAD determined using cardiac catheterization. MEASUREMENTS: Two standard frailty phenotypes (Composite A and Composite B), usual gait speed, grip strength, chair stands, cardiology clinical variables, and 6-month mortality. RESULTS: Prevalence of frailty was 27% for Composite A versus 63% for Composite B. Utility of single-item measures for identifying frailty was greatest for gait speed (receiver operating characteristic curve c statistic = 0.89 for Composite A, 0.70 for Composite B) followed by chair-stands (c = 0.83, 0.66) and grip strength (c = 0.78, 0.57). After adjustment, composite scores and single-item measures were individually associated with higher mortality at 6 months. Slow gait speed (< or =0.65 m/s) and poor grip strength (< or =25 kg) were stronger predictors of 6-month mortality than either composite score (gait speed odds ratio (OR)=3.8, 95% confidence interval (CI) = 1.1-13.1; grip strength OR = 2.7, 95% CI = 0.7-10.0; Composite A OR = 1.9, 95% CI = 0.60-6.1; chair-stand OR = 1.5, 95% CI = 0.5-5.1; Composite B OR = 1.3, 95% CI = 0.3-5.2). CONCLUSION: Gait speed frailty was the strongest predictor of mortality in a population with CAD and may add to traditional risk assessments when predicting outcomes in this population.     

Estimating the likelihood of significant coronary artery disease

Among 23 clinical characteristics examined in 3,627 consecutive, symptomatic patients referred for cardiac catheterization between 1969 and 1979, nine were found to be important for estimating the likelihood a patient had significant coronary artery disease. A model using these characteristics accurately estimated the likelihood of disease when applied prospectively to 1,811 patients referred since 1979 and when used to estimate the prevalence of disease in subgroups reported in the literature. Since accurate estimates of the likelihood of significant disease that are based on clinical characteristics are reproducible, they should be used in interpreting the results of additional noninvasive tests and in quantitating the added diagnostic value.