CAD in CKD/ESKD – A Wolf in Sheep's Clothing? .',*2 · 5/2/2017  · Rutherford E, Mark PB et al....

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CAD in CKD/ESKD – A Wolf in Sheep's Clothing? Gautam R. Shroff Cardiologist Hennepin Healthcare System University of Minnesota KDIGO

Transcript of CAD in CKD/ESKD – A Wolf in Sheep's Clothing? .',*2 · 5/2/2017  · Rutherford E, Mark PB et al....

Page 1: CAD in CKD/ESKD – A Wolf in Sheep's Clothing? .',*2 · 5/2/2017  · Rutherford E, Mark PB et al. Scientific reports 2017 .',*2. Predictive value of MPS on cardiac death in CKD

CAD in CKD/ESKD – A Wolf in Sheep's Clothing?

GautamR.ShroffCardiologist

HennepinHealthcareSystemUniversityofMinnesota

KDIGO

Page 2: CAD in CKD/ESKD – A Wolf in Sheep's Clothing? .',*2 · 5/2/2017  · Rutherford E, Mark PB et al. Scientific reports 2017 .',*2. Predictive value of MPS on cardiac death in CKD

DISCLOSURES

None

KDIGO

Page 3: CAD in CKD/ESKD – A Wolf in Sheep's Clothing? .',*2 · 5/2/2017  · Rutherford E, Mark PB et al. Scientific reports 2017 .',*2. Predictive value of MPS on cardiac death in CKD

2013 – prior to re-do AVR 2014 - unstable angina

63 yr old with ESKD secondary to IgA nephropathy, failed LRDKT, on HD

Severe AS s/p bioprostheDc AVR 2010 – rapidly progressive bioprostheDc AS 2013

KDIGO

Page 4: CAD in CKD/ESKD – A Wolf in Sheep's Clothing? .',*2 · 5/2/2017  · Rutherford E, Mark PB et al. Scientific reports 2017 .',*2. Predictive value of MPS on cardiac death in CKD

AGENDA

1)  DifferencesinCADinCKD/ESKDvs.non-CKD

•  EpidemiologicalconsideraJons•  FuncJonal/structuralcardiovascularimaging•  CoronaryrevascularizaJon

2)Challengesfacingtheclinicianwhencaringforthishigh-riskpopulaJon

KDIGO

Page 5: CAD in CKD/ESKD – A Wolf in Sheep's Clothing? .',*2 · 5/2/2017  · Rutherford E, Mark PB et al. Scientific reports 2017 .',*2. Predictive value of MPS on cardiac death in CKD

Worsening CKD -- all-cause + CV mortality

Go AS; Hsu C et al. NEJM 2004 KDIGO Clinical Practice Guideline 2012

KDIGO

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Foley RN, Parfrey PS, Sarnak MJ. AJKD 1998 Sarnak MJ, Levey AS, et al. Circulation 2003

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Thompson S, Tonelli M et al. JASN 2015

Causes of death with advancing CKD (excluding dialysis/transplant)

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Causes of death in prevalent dialysis patients

United States Renal Data System 2013 EVOLVE, Wheeler DC, Herzog CA et al. JAHA 2013

KDIGO

Page 9: CAD in CKD/ESKD – A Wolf in Sheep's Clothing? .',*2 · 5/2/2017  · Rutherford E, Mark PB et al. Scientific reports 2017 .',*2. Predictive value of MPS on cardiac death in CKD

Wanner C, Amann K, Shoji T. Lancet 2016 Herzog CA, Shroff GR. JACC Imaging 2014

KDIGO

Page 10: CAD in CKD/ESKD – A Wolf in Sheep's Clothing? .',*2 · 5/2/2017  · Rutherford E, Mark PB et al. Scientific reports 2017 .',*2. Predictive value of MPS on cardiac death in CKD

Early mortality in incident HD patients

Chan KE, Hakim RM. CJASN 2011 Bradbury BD, Gillespie BW. CJASN 2007

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CKD and heart disease: do we understand the link?

Tangri N, Komenda PVJ, Rigatto C. Kidney International 2015

KDIGO

Page 12: CAD in CKD/ESKD – A Wolf in Sheep's Clothing? .',*2 · 5/2/2017  · Rutherford E, Mark PB et al. Scientific reports 2017 .',*2. Predictive value of MPS on cardiac death in CKD

Changes in uremic cardiomyopathy

Wanner C, Amann K, Shoji T. Lancet 2016

KDIGO

Page 13: CAD in CKD/ESKD – A Wolf in Sheep's Clothing? .',*2 · 5/2/2017  · Rutherford E, Mark PB et al. Scientific reports 2017 .',*2. Predictive value of MPS on cardiac death in CKD

Myocardial changes in incident HD over 6 months

Rutherford E, Mark PB et al. Scientific reports 2017

KDIGO

Page 14: CAD in CKD/ESKD – A Wolf in Sheep's Clothing? .',*2 · 5/2/2017  · Rutherford E, Mark PB et al. Scientific reports 2017 .',*2. Predictive value of MPS on cardiac death in CKD

Predictive value of MPS on cardiac death in CKD

Hakeem A, Chang SM et al. Circulation 2008

KDIGO

Page 15: CAD in CKD/ESKD – A Wolf in Sheep's Clothing? .',*2 · 5/2/2017  · Rutherford E, Mark PB et al. Scientific reports 2017 .',*2. Predictive value of MPS on cardiac death in CKD

Accuracy of DSE/MPS in renal transplant candidates

Wang LW, Webster A et al. Cochrane database 2011

KDIGO

Page 16: CAD in CKD/ESKD – A Wolf in Sheep's Clothing? .',*2 · 5/2/2017  · Rutherford E, Mark PB et al. Scientific reports 2017 .',*2. Predictive value of MPS on cardiac death in CKD

CCTA vs. MPS in Kidney Transplant Candidates

Winther S et al. JACC Imaging 2015

KDIGO

Page 17: CAD in CKD/ESKD – A Wolf in Sheep's Clothing? .',*2 · 5/2/2017  · Rutherford E, Mark PB et al. Scientific reports 2017 .',*2. Predictive value of MPS on cardiac death in CKD

Prognostic value of MPS/DSE in kidney transplant candidates

Wang LW, Webster A et al. Transplantation 2015

KDIGO

Page 18: CAD in CKD/ESKD – A Wolf in Sheep's Clothing? .',*2 · 5/2/2017  · Rutherford E, Mark PB et al. Scientific reports 2017 .',*2. Predictive value of MPS on cardiac death in CKD

Association of renal function and CV events

Bittencourt MS; Blankstein R et al, KI 2015

KDIGO

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RCT – Revascularization vs. medical Rx in CKD

Manske CL, White CW et al, Lancet 1992

KDIGO

Page 20: CAD in CKD/ESKD – A Wolf in Sheep's Clothing? .',*2 · 5/2/2017  · Rutherford E, Mark PB et al. Scientific reports 2017 .',*2. Predictive value of MPS on cardiac death in CKD

Revascularization in CKD – CABG vs. PCI & competing mortality risk

Chang Tl, Hlatky MA, Go AS et al. Am H Journal 2013 (1996-2008)

KDIGO

Page 21: CAD in CKD/ESKD – A Wolf in Sheep's Clothing? .',*2 · 5/2/2017  · Rutherford E, Mark PB et al. Scientific reports 2017 .',*2. Predictive value of MPS on cardiac death in CKD

Revascularization in CKD – CABG vs. PCI & competing mortality risk

Charytan DM, Herzog CA et al. Circulation 2012 (2001-2007) Bangalore S, Hannan et al. JACC 2015 (2008-2011)

KDIGO

Page 22: CAD in CKD/ESKD – A Wolf in Sheep's Clothing? .',*2 · 5/2/2017  · Rutherford E, Mark PB et al. Scientific reports 2017 .',*2. Predictive value of MPS on cardiac death in CKD

CABG vs PCI in ESKD with multivessel CAD

Chang TL, Winkelmayer WC et al, JASN 2013

KDIGO

Page 23: CAD in CKD/ESKD – A Wolf in Sheep's Clothing? .',*2 · 5/2/2017  · Rutherford E, Mark PB et al. Scientific reports 2017 .',*2. Predictive value of MPS on cardiac death in CKD

Trends in coronary revascularization in ESKD in US

Chang TL, Winkelmayer WC et al, JASN 2013 Shroff GR, Herzog CA et al, Circulation 2013

KDIGO

Page 24: CAD in CKD/ESKD – A Wolf in Sheep's Clothing? .',*2 · 5/2/2017  · Rutherford E, Mark PB et al. Scientific reports 2017 .',*2. Predictive value of MPS on cardiac death in CKD

Revascularization: We eagerly await! CARSK

ISCHEMIA - CKD

KDIGO

Page 25: CAD in CKD/ESKD – A Wolf in Sheep's Clothing? .',*2 · 5/2/2017  · Rutherford E, Mark PB et al. Scientific reports 2017 .',*2. Predictive value of MPS on cardiac death in CKD

CKD/ESKD and CAD : why so challenging for the clinician? Paradoxes and conundrums

•  Obstruc-veCADishighlyprevalentinthatpopula-onathighriskofCVmortality•  Yet,ischemiceventsareovershadowedbynon-atherosclero-ccausesofdeathinESKD

•  Presenceofobstruc-veCADpredictsfuturecoronary,non-coronaryevents&death•  Yet,techniquestodetectobstruc-veCADhaveloweraccuracythannon-CKDpopula-on•  Revasculariza-onforobstruc-veCADhasnotbeenshownconclusivelytoimprovesurvivalinthecontemporaryera;andcanassociatewithhigherrisksofshort-termmortality

•  Cardiacriskstra-fica-onandmanagementparadigmsvaryconsiderablyfromthenon-CKDpopula-on;theyalsovaryduringapa-ent’sjourneywhileprogressingfromCKDtoESKD

KDIGO

Page 26: CAD in CKD/ESKD – A Wolf in Sheep's Clothing? .',*2 · 5/2/2017  · Rutherford E, Mark PB et al. Scientific reports 2017 .',*2. Predictive value of MPS on cardiac death in CKD

THANK YOU!

TheclinicalcareofCADinthepa-entwithCKD/ESKDisextremelycomplexand

necessitatesinputfromamul$disciplinary“cardiorenal”teamcomprisingthe

cardiologistandnephrologistworkinginclosetandemwithinterven-onal

cardiology/cardiothoracicsurgerytoassistinmakingindividualizedmanagement/

revasculariza-ondecisionscenteredonthepa-ent’spreferencesaQerathorough

understandingofrisksvbenefitsofvariousapproaches.KDIGO

Page 27: CAD in CKD/ESKD – A Wolf in Sheep's Clothing? .',*2 · 5/2/2017  · Rutherford E, Mark PB et al. Scientific reports 2017 .',*2. Predictive value of MPS on cardiac death in CKD

KDIGO

Page 28: CAD in CKD/ESKD – A Wolf in Sheep's Clothing? .',*2 · 5/2/2017  · Rutherford E, Mark PB et al. Scientific reports 2017 .',*2. Predictive value of MPS on cardiac death in CKD

United States Renal Data System; Annual Data Report 2013

KDIGO

Page 29: CAD in CKD/ESKD – A Wolf in Sheep's Clothing? .',*2 · 5/2/2017  · Rutherford E, Mark PB et al. Scientific reports 2017 .',*2. Predictive value of MPS on cardiac death in CKD

Clinical risk stratification + DSE in CKD

Rakhit DJ, Marwick TH et al. Am Heart Journal 2006

KDIGO

Page 30: CAD in CKD/ESKD – A Wolf in Sheep's Clothing? .',*2 · 5/2/2017  · Rutherford E, Mark PB et al. Scientific reports 2017 .',*2. Predictive value of MPS on cardiac death in CKD

Are we barking up the wrong tree?

Wang LW, Webster A et al. Transplantation 2015

KDIGO

Page 31: CAD in CKD/ESKD – A Wolf in Sheep's Clothing? .',*2 · 5/2/2017  · Rutherford E, Mark PB et al. Scientific reports 2017 .',*2. Predictive value of MPS on cardiac death in CKD

Trends in coronary revascularization in ESKD in US

Chang TL, Winkelmayer WC et al, JASN 2013 Shroff GR, Herzog CA et al, Circulation 2013

KDIGO

Page 32: CAD in CKD/ESKD – A Wolf in Sheep's Clothing? .',*2 · 5/2/2017  · Rutherford E, Mark PB et al. Scientific reports 2017 .',*2. Predictive value of MPS on cardiac death in CKD

RENAL-DES

Tomai F, Vassanelli C et al, Circulation 2013

KDIGO

Page 33: CAD in CKD/ESKD – A Wolf in Sheep's Clothing? .',*2 · 5/2/2017  · Rutherford E, Mark PB et al. Scientific reports 2017 .',*2. Predictive value of MPS on cardiac death in CKD

Shroff GR, Herzog CA et al, Circulation 2013

KDIGO

Page 34: CAD in CKD/ESKD – A Wolf in Sheep's Clothing? .',*2 · 5/2/2017  · Rutherford E, Mark PB et al. Scientific reports 2017 .',*2. Predictive value of MPS on cardiac death in CKD

KDIGO

Page 35: CAD in CKD/ESKD – A Wolf in Sheep's Clothing? .',*2 · 5/2/2017  · Rutherford E, Mark PB et al. Scientific reports 2017 .',*2. Predictive value of MPS on cardiac death in CKD

Pretransplant screening and uncertainties

Hart A, Kasiske BL. Kidney InternationaI 2015

KDIGO

Page 36: CAD in CKD/ESKD – A Wolf in Sheep's Clothing? .',*2 · 5/2/2017  · Rutherford E, Mark PB et al. Scientific reports 2017 .',*2. Predictive value of MPS on cardiac death in CKD

Kasiske BL, et al. JASN 2006

Waiting list and posttransplant myocardial infarction

KDIGO

Page 37: CAD in CKD/ESKD – A Wolf in Sheep's Clothing? .',*2 · 5/2/2017  · Rutherford E, Mark PB et al. Scientific reports 2017 .',*2. Predictive value of MPS on cardiac death in CKD

Raggi P, JACC 2002 Bashir et al. AJKD 2015

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Four multi-channel models: CKd-604, CKd-608, CKd-1204 and ...

Four multi-channel models: CKd-604, CKd-608, CKd-1204 and ...

A Wolf In Sheep's Clothing by Barbara Unković

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