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Therapeutic Apheresis and Dialysis 2014; 18(5):443–449 doi: 10.1111/1744-9987.12167 © 2014 The Authors Therapeutic Apheresis and Dialysis © 2014 International Society for Apheresis
Efficacy of Coronary Artery Screening Tests and Intervention in Hemodialysis Patients Shoichiro Daimon,1 Ichiro Mizushima,2 Ryoko Hamano,2 and Hidenobu Terai3 1 2
Department of Nephrology, Daimon Clinic for Internal Medicine, Nephrology and Dialysis, Nonoichi, Division of Rheumatology, Department of Internal Medicine, Kanazawa University Graduate School of Medicine, and 3Department of Cardiology, Kanazawa Cardiovascular Hospital, Kanazawa, Japan
Abstract: Although cardiovascular disease (CVD) is an important cause of death in patients on hemodialysis, evidence of a beneficial effect of percutaneous intervention (PCI) on stable heart disease is scarce. We investigated the cardiovascular outcomes of hemodialysis patients under our policy of encouraging coronary artery screening tests to the extent possible. A total of 147 hemodialysis patients have been treated in our clinic so far. In 98 of them, coronary artery screening tests were performed, three in unstable and 95 in asymptomatic patients. Significant coronary artery stenosis was detected in 29 at the first tests and in 11 during subsequent tests (40/98, 40.8%), and PCI or coronary artery bypass grafting (CABG) was performed. Multiple PCIs were needed in 21 patients. In the other 49 patients, coronary artery screening tests were not undertaken based on the nephrologist’s decision or patient
refusal. At the end of the study, 73 (74.5%) patients with tests, and 14 (28.6%) without tests were still outpatients (P < 0.01). Of 40 patients transferred to other hospitals for medical reasons or who died before transfer, there was cerebrovascular accident in eight, malignancy in six, congestive heart failure without CVD in four, infection in three, sudden cardiac death in one, and others 18. No patient with tests died of CVD and the only patient who died of sudden cardiac death probably due to myocardial infarction was a patient who had declined the screening tests. Coronary artery screening tests, intervention and subsequent periodic tests for asymptomatic hemodialysis patients can reduce the occurrence of cardiovascular events in this population. Key Words: Cardiovascular event, Coronary intervention, Hemodialysis, Screening.
In patients with chronic kidney disease (CKD), cardiovascular disease (CVD) is an important cause of death (1). Although acute myocardial infarction as a cause of death of dialysis patients in the United States is only 4.9% (2), HD patients are reported to tend to present less chest pain with acute myocardial infarction (3). It is estimated that about 30% of deaths in dialysis patients are related to sudden cardiac death, to which CVD is thought to be a substantial contributor (4). In patients without CKD, percutaneous coronary intervention (PCI) can reduce death or myocardial infarction in those with acute coronary syndromes (5). But in patients with stable heart disease, although exceptions exist (6), sufficient evidence shows that
PCI does not result in improved patient survival (7–9). Although the proportion of coronary artery stenosis in end-stage kidney disease is remarkably high (10), evidence of a beneficial effect of PCI on stable heart disease in patients with end-stage kidney disease is limited. In our clinic, to prevent the occurrence of cardiovascular events, we have been proposing coronary angiography (CAG), cardiac computed tomography (CCT) or myocardial perfusion scintigraphy (when contrast medium is contraindicated) to all our HD patients. In the present study, we investigated the rate of CVD and the prognosis of HD patients under this policy of encouraging coronary screening tests.
Received July 2013; revised September 2013. Address correspondence and reprint requests to Dr Shoichiro Daimon, Director, Department of Nephrology, Daimon Clinic for Internal Medicine, Nephrology and Dialysis, Oshino 1-400, Nonoichi, Ishikawa-pref 921-8802, Japan. Email: dai-clinic @m2.spacelan.ne.jp
PATIENTS AND METHODS A total of 147 consecutive HD patients treated in our clinic from 15 December 2004 to 28 February 2013 were studied.As coronary artery screening tests, 443
444
S Daimon et al.
CAG, CCT or myocardial perfusion scintigraphy was offered to almost all of them. Decisions regarding the timing of the screening tests were made by a nephrologist, and were basically undertaken as soon as possible under the treatment in our clinic. If a significant perfusion defect or significant coronary artery stenosis was suspected by myocardial perfusion scintigraphy or CCT, CAG was performed to clarify the existence of the stenosis. 75% coronary artery stenosis was defined as significant and was treated by balloon angioplasty, stenting or coronary artery bypass grafting (CABG), with this decision left to a cardiologist. For all the patients undergoing PCI or CABG, follow-up coronary tests were proposed regardless of the presence/absence of any symptoms. Decisions regarding the timing of follow-up tests after PCI or CABG were made by a nephrologist in consultation with the cardiologist who performed the PCI or CABG. Even when significant coronary artery stenosis was not detected at the first coronary artery screening tests and the patient was asymptomatic, subsequent coronary artery screening tests were proposed to the patients periodically, usually at an interval of 1 to 3 years as decided by a nephrologist. Statistics Data were expressed as the mean ± SD. Unpaired t-tests and χ2 test were used to compare the data. Statistical significance is defined as P < 0.05. RESULTS In 98 of the 147 patients, CAG, CCT or myocardial perfusion scintigraphy was performed as the coro-
nary screening tests during the period of treatment in our clinic (76, 19 and three cases, respectively) (Table 1). Although basically coronary artery screening tests were performed in patients without symptoms, in three patients who had declined the test, CAG was done after symptoms did appear. The duration between the initiation of dialysis in our clinic to coronary screening tests was 443.9 ± 594.5 days. In 81 patients screening tests were done within 2 years. In the other 49 patients, coronary screening tests were not performed based on the nephrologist’s decision or patient refusal. Figure 1 shows the distribution of age of the patients at the initiation of dialysis in our clinic according to the performance of coronary artery screening tests. Although the mean ages of the group of patients with coronary artery screening tests and those without tests were similar, the distribution was quite different. The percentage of patients aged between 56 and 75 years was 71.4% (70/98) in the group with tests and 44.9% (22/49) in the group without tests, which reflects a reluctance to propose coronary artery screening tests to the younger and older patients without symptoms, mainly due to the low possibility of coronary artery stenosis in the former and the added burden imposed on the patients to undergo the tests at another hospital in the latter. Outcomes of the patients with and without coronary screening tests were shown in Figures 2 and 3, respectively, and Table 2. At the time of the study, the majority of patients in the group undergoing coronary screening tests were still being treated in our clinic (Fig. 2). On the other hand, as shown in Figure 3, in the group of patients without coronary screening tests, the majority of patients
TABLE 1. Patient characteristics
All (N = 147) Men Diabetes Age at the initiation of dialysis (years) Age at the initiation of dialysis in our clinic (years) Duration of dialysis (days) Duration of dialysis in our clinic (days) PCI or CABG before the treatment in our clinic TCH (mg/dL) LDL (mg/dL) HDL (mg/dL) TG (mg/dL)
110 (74.8%) 69 (46.9%) 63.2 ± 13.6 65.4 ± 12.3 2008 ± 2321 1266 ± 919 18 (12.2%) 148.4 ± 34.6 87.9 ± 28.9 41.4 ± 13.3 95.4 ± 48.1
Range
Median
(24–94) (29–94) (26–13505) (26–2978)
64 66 1381 955
(86–261) (40.6–182.8) (17–87) (23–295)
147 84 41 84
Coronary screenings were performed (N = 98)
Coronary screenings were not performed (N = 49)
P
76 (77.6%) 57 (58.2%) 63.7 ± 12.0 65.8 ± 10.3 2170 ± 2446 1521 ± 877 17 (17.3%) 150.9 ± 34.4 91.1 ± 29.5 40.2 ± 13.5 98.3 ± 44.9
34 (69.4%) 13 (26.5%) 62.3 ± 16.7 64.8 ± 15.8 1712 ± 2047 804 ± 822 1 (2.0%) 143.2 ± 35.0 81.5 ± 27.1 43.9 ± 12.9 89.4 ± 54.5
n.s.
Therapeutic Apheresis and Dialysis 2014; 18(5):443–449 doi: 10.1111/1744-9987.12167 © 2014 The Authors Therapeutic Apheresis and Dialysis © 2014 International Society for Apheresis
Efficacy of Coronary Artery Screening Tests and Intervention in Hemodialysis Patients Shoichiro Daimon,1 Ichiro Mizushima,2 Ryoko Hamano,2 and Hidenobu Terai3 1 2
Department of Nephrology, Daimon Clinic for Internal Medicine, Nephrology and Dialysis, Nonoichi, Division of Rheumatology, Department of Internal Medicine, Kanazawa University Graduate School of Medicine, and 3Department of Cardiology, Kanazawa Cardiovascular Hospital, Kanazawa, Japan
Abstract: Although cardiovascular disease (CVD) is an important cause of death in patients on hemodialysis, evidence of a beneficial effect of percutaneous intervention (PCI) on stable heart disease is scarce. We investigated the cardiovascular outcomes of hemodialysis patients under our policy of encouraging coronary artery screening tests to the extent possible. A total of 147 hemodialysis patients have been treated in our clinic so far. In 98 of them, coronary artery screening tests were performed, three in unstable and 95 in asymptomatic patients. Significant coronary artery stenosis was detected in 29 at the first tests and in 11 during subsequent tests (40/98, 40.8%), and PCI or coronary artery bypass grafting (CABG) was performed. Multiple PCIs were needed in 21 patients. In the other 49 patients, coronary artery screening tests were not undertaken based on the nephrologist’s decision or patient
refusal. At the end of the study, 73 (74.5%) patients with tests, and 14 (28.6%) without tests were still outpatients (P < 0.01). Of 40 patients transferred to other hospitals for medical reasons or who died before transfer, there was cerebrovascular accident in eight, malignancy in six, congestive heart failure without CVD in four, infection in three, sudden cardiac death in one, and others 18. No patient with tests died of CVD and the only patient who died of sudden cardiac death probably due to myocardial infarction was a patient who had declined the screening tests. Coronary artery screening tests, intervention and subsequent periodic tests for asymptomatic hemodialysis patients can reduce the occurrence of cardiovascular events in this population. Key Words: Cardiovascular event, Coronary intervention, Hemodialysis, Screening.
In patients with chronic kidney disease (CKD), cardiovascular disease (CVD) is an important cause of death (1). Although acute myocardial infarction as a cause of death of dialysis patients in the United States is only 4.9% (2), HD patients are reported to tend to present less chest pain with acute myocardial infarction (3). It is estimated that about 30% of deaths in dialysis patients are related to sudden cardiac death, to which CVD is thought to be a substantial contributor (4). In patients without CKD, percutaneous coronary intervention (PCI) can reduce death or myocardial infarction in those with acute coronary syndromes (5). But in patients with stable heart disease, although exceptions exist (6), sufficient evidence shows that
PCI does not result in improved patient survival (7–9). Although the proportion of coronary artery stenosis in end-stage kidney disease is remarkably high (10), evidence of a beneficial effect of PCI on stable heart disease in patients with end-stage kidney disease is limited. In our clinic, to prevent the occurrence of cardiovascular events, we have been proposing coronary angiography (CAG), cardiac computed tomography (CCT) or myocardial perfusion scintigraphy (when contrast medium is contraindicated) to all our HD patients. In the present study, we investigated the rate of CVD and the prognosis of HD patients under this policy of encouraging coronary screening tests.
Received July 2013; revised September 2013. Address correspondence and reprint requests to Dr Shoichiro Daimon, Director, Department of Nephrology, Daimon Clinic for Internal Medicine, Nephrology and Dialysis, Oshino 1-400, Nonoichi, Ishikawa-pref 921-8802, Japan. Email: dai-clinic @m2.spacelan.ne.jp
PATIENTS AND METHODS A total of 147 consecutive HD patients treated in our clinic from 15 December 2004 to 28 February 2013 were studied.As coronary artery screening tests, 443
444
S Daimon et al.
CAG, CCT or myocardial perfusion scintigraphy was offered to almost all of them. Decisions regarding the timing of the screening tests were made by a nephrologist, and were basically undertaken as soon as possible under the treatment in our clinic. If a significant perfusion defect or significant coronary artery stenosis was suspected by myocardial perfusion scintigraphy or CCT, CAG was performed to clarify the existence of the stenosis. 75% coronary artery stenosis was defined as significant and was treated by balloon angioplasty, stenting or coronary artery bypass grafting (CABG), with this decision left to a cardiologist. For all the patients undergoing PCI or CABG, follow-up coronary tests were proposed regardless of the presence/absence of any symptoms. Decisions regarding the timing of follow-up tests after PCI or CABG were made by a nephrologist in consultation with the cardiologist who performed the PCI or CABG. Even when significant coronary artery stenosis was not detected at the first coronary artery screening tests and the patient was asymptomatic, subsequent coronary artery screening tests were proposed to the patients periodically, usually at an interval of 1 to 3 years as decided by a nephrologist. Statistics Data were expressed as the mean ± SD. Unpaired t-tests and χ2 test were used to compare the data. Statistical significance is defined as P < 0.05. RESULTS In 98 of the 147 patients, CAG, CCT or myocardial perfusion scintigraphy was performed as the coro-
nary screening tests during the period of treatment in our clinic (76, 19 and three cases, respectively) (Table 1). Although basically coronary artery screening tests were performed in patients without symptoms, in three patients who had declined the test, CAG was done after symptoms did appear. The duration between the initiation of dialysis in our clinic to coronary screening tests was 443.9 ± 594.5 days. In 81 patients screening tests were done within 2 years. In the other 49 patients, coronary screening tests were not performed based on the nephrologist’s decision or patient refusal. Figure 1 shows the distribution of age of the patients at the initiation of dialysis in our clinic according to the performance of coronary artery screening tests. Although the mean ages of the group of patients with coronary artery screening tests and those without tests were similar, the distribution was quite different. The percentage of patients aged between 56 and 75 years was 71.4% (70/98) in the group with tests and 44.9% (22/49) in the group without tests, which reflects a reluctance to propose coronary artery screening tests to the younger and older patients without symptoms, mainly due to the low possibility of coronary artery stenosis in the former and the added burden imposed on the patients to undergo the tests at another hospital in the latter. Outcomes of the patients with and without coronary screening tests were shown in Figures 2 and 3, respectively, and Table 2. At the time of the study, the majority of patients in the group undergoing coronary screening tests were still being treated in our clinic (Fig. 2). On the other hand, as shown in Figure 3, in the group of patients without coronary screening tests, the majority of patients
TABLE 1. Patient characteristics
All (N = 147) Men Diabetes Age at the initiation of dialysis (years) Age at the initiation of dialysis in our clinic (years) Duration of dialysis (days) Duration of dialysis in our clinic (days) PCI or CABG before the treatment in our clinic TCH (mg/dL) LDL (mg/dL) HDL (mg/dL) TG (mg/dL)
110 (74.8%) 69 (46.9%) 63.2 ± 13.6 65.4 ± 12.3 2008 ± 2321 1266 ± 919 18 (12.2%) 148.4 ± 34.6 87.9 ± 28.9 41.4 ± 13.3 95.4 ± 48.1
Range
Median
(24–94) (29–94) (26–13505) (26–2978)
64 66 1381 955
(86–261) (40.6–182.8) (17–87) (23–295)
147 84 41 84
Coronary screenings were performed (N = 98)
Coronary screenings were not performed (N = 49)
P
76 (77.6%) 57 (58.2%) 63.7 ± 12.0 65.8 ± 10.3 2170 ± 2446 1521 ± 877 17 (17.3%) 150.9 ± 34.4 91.1 ± 29.5 40.2 ± 13.5 98.3 ± 44.9
34 (69.4%) 13 (26.5%) 62.3 ± 16.7 64.8 ± 15.8 1712 ± 2047 804 ± 822 1 (2.0%) 143.2 ± 35.0 81.5 ± 27.1 43.9 ± 12.9 89.4 ± 54.5
n.s.
