Post on 30-Dec-2015
description
Training Slides_Protocol v.2.0CKD
ISCHEMIA-CKD TrialOptimal Revascularization Therapy
Training Slides_Protocol v.2.0CKD
Goal
Revascularization of all ischemic myocardial segments (detected by non-invasive imaging or by fractional flow reserve (FFR) testing) within 4 weeks after treatment assignment while minimizing the risk of contrast induced acute kidney injury (AKI)
Training Slides_Protocol v.2.0CKD
Risk of Contrast Induced Acute Kidney Injury
McCullough et al. J Am Coll Cardiol 2008;51:1419–28
Exponential increase in the risk of contrast induced AKI with eGFR <40
Acute kidney injury (AKI) was defined as serum creatinine increase of 25% and/or 0.5 mg/dl
Training Slides_Protocol v.2.0CKD
Mantra to prevent contrast induced AKI
Hydration!! Hydration!! Hydration!!
Use ultra low-volume contrast protocol for cath and PCI
Use IVUS-guided PCI Cath and PCI can be done with as little as 20-30
cc of contrast Avoid nephrotoxic agents
Consider staged procedure as needed
Training Slides_Protocol v.2.0CKD
Hydration
Protocol used in POSEIDON trial: Initiate 3mL/kg/h of normal saline IV, for at least 1 h
prior to angiography Measure LVEDP prior to contrast administration Adapt infusion rate based on LVEDP measurement
as follows: 5 mL/kg/hr for LVEDP < 13 mm Hg 3 mL/kg/hr for LVEDP of 13 mm Hg to 18 mm Hg 1.5 mL/kg/hr for LVEDP > 18 mm Hg
Continue fluid administration for 4 hours post procedure
Training Slides_Protocol v.2.0CKD
Hydration
Simplified protocol based on LVEF (expert opinion):
Patients with preserved EF IV 0.9% NS at 1 cc/kg/hour for 12 hours pre- and
post-procedure
Patients with EF<40% IV 0.45% NS at cc/cc replacement (match urine
output to maintain euvolemia) for 12 hours pre- and post-procedure
Training Slides_Protocol v.2.0CKD
Ultra-low volume contrast techniques
Use small diameter catheters (i.e., 5–6 F) without side-holes
All contrast injections require simultaneous cine angiogram, i.e., ‘‘no dye without the cine’s eye’’
Limit the volume of contrast injected to 1–2 cm3 per injection using a 3-cm3 syringe
During PCI, prior to exchange of devices such as balloon catheters, remove contrast from the guide catheter by back bleeding contrast out of the ‘‘Y’’ connector
Training Slides_Protocol v.2.0CKD
Ultra-low volume contrast techniques
If available, display previous angiographic images alongside active fluoroscopy screen as a reference to use as guidance during guide wire, balloon, stent and ultrasound passage
Absolutely no contrast ‘‘puffing’’/test injections during the procedure
Use IVUS liberally for pre-PCI assessment of the lesion, selection of therapeutic modalities, and post-PCI result assessment (IVUS guided PCI)
Training Slides_Protocol v.2.0CKD
Ultra-low volume contrast techniques
Use biplane angiography when available
Avoid ventriculography Pre-procedure statins if not already on statin therapy
Use iso- or low-osmolar contrast media (besides iohexol and ioxaglate)
Hold diuretics pre-procedure in euvolemic participants and those unlikely to have heart failure precipitated by administration of radiocontrast media
Avoid nephrotoxic agents prior to the procedure and at least 48 hours post procedure
Training Slides_Protocol v.2.0CKD
CABG vs. PCI
Low SYNTAX score (0-22): PCI or CABG
Intermediate SYNTAX score (23-33): CABG preferred
High SYNTAX score (>33): CABG strongly preferred
Consult ‘Heart-kidney’ team (Non invasive cardiologist, interventionalist, surgeon, and nephrologist) as needed
Decision should also be based on renal transplant considerations for the participants based on local practices
Training Slides_Protocol v.2.0CKD
Other Aspects of ORT
Given the increased risk of restenosis, the use of DES is favored in participants with advanced CKD (such as everolimus and zotarolimus-Resolute)
Emphasis on ischemia guided revascularization (decreases volume of contrast used)
For antiplatelet/anticoagulant choice, FFR use, stent choice, deployment technique and other aspects of ORT- please refer to ORT slideset/MOO for the main ISCHEMIA trial