CAD in CKD/ESKD – A Wolf in Sheep's Clothing? .',*2 · 5/2/2017 · Rutherford E, Mark PB et al....
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](https://reader034.fdocuments.net/reader034/viewer/2022050219/5f645d03963675037e7c7916/html5/thumbnails/1.jpg)
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](https://reader034.fdocuments.net/reader034/viewer/2022050219/5f645d03963675037e7c7916/html5/thumbnails/2.jpg)
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](https://reader034.fdocuments.net/reader034/viewer/2022050219/5f645d03963675037e7c7916/html5/thumbnails/3.jpg)
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](https://reader034.fdocuments.net/reader034/viewer/2022050219/5f645d03963675037e7c7916/html5/thumbnails/4.jpg)
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](https://reader034.fdocuments.net/reader034/viewer/2022050219/5f645d03963675037e7c7916/html5/thumbnails/5.jpg)
Worsening CKD -- all-cause + CV mortality
Go AS; Hsu C et al. NEJM 2004 KDIGO Clinical Practice Guideline 2012
KDIGO
![Page 6: 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](https://reader034.fdocuments.net/reader034/viewer/2022050219/5f645d03963675037e7c7916/html5/thumbnails/6.jpg)
Foley RN, Parfrey PS, Sarnak MJ. AJKD 1998 Sarnak MJ, Levey AS, et al. Circulation 2003
KDIGO
![Page 7: 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](https://reader034.fdocuments.net/reader034/viewer/2022050219/5f645d03963675037e7c7916/html5/thumbnails/7.jpg)
Thompson S, Tonelli M et al. JASN 2015
Causes of death with advancing CKD (excluding dialysis/transplant)
KDIGO
![Page 8: 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](https://reader034.fdocuments.net/reader034/viewer/2022050219/5f645d03963675037e7c7916/html5/thumbnails/8.jpg)
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](https://reader034.fdocuments.net/reader034/viewer/2022050219/5f645d03963675037e7c7916/html5/thumbnails/9.jpg)
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](https://reader034.fdocuments.net/reader034/viewer/2022050219/5f645d03963675037e7c7916/html5/thumbnails/10.jpg)
Early mortality in incident HD patients
Chan KE, Hakim RM. CJASN 2011 Bradbury BD, Gillespie BW. CJASN 2007
KDIGO
![Page 11: 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](https://reader034.fdocuments.net/reader034/viewer/2022050219/5f645d03963675037e7c7916/html5/thumbnails/11.jpg)
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](https://reader034.fdocuments.net/reader034/viewer/2022050219/5f645d03963675037e7c7916/html5/thumbnails/12.jpg)
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](https://reader034.fdocuments.net/reader034/viewer/2022050219/5f645d03963675037e7c7916/html5/thumbnails/13.jpg)
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](https://reader034.fdocuments.net/reader034/viewer/2022050219/5f645d03963675037e7c7916/html5/thumbnails/14.jpg)
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](https://reader034.fdocuments.net/reader034/viewer/2022050219/5f645d03963675037e7c7916/html5/thumbnails/15.jpg)
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](https://reader034.fdocuments.net/reader034/viewer/2022050219/5f645d03963675037e7c7916/html5/thumbnails/16.jpg)
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](https://reader034.fdocuments.net/reader034/viewer/2022050219/5f645d03963675037e7c7916/html5/thumbnails/17.jpg)
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](https://reader034.fdocuments.net/reader034/viewer/2022050219/5f645d03963675037e7c7916/html5/thumbnails/18.jpg)
Association of renal function and CV events
Bittencourt MS; Blankstein R et al, KI 2015
KDIGO
![Page 19: 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](https://reader034.fdocuments.net/reader034/viewer/2022050219/5f645d03963675037e7c7916/html5/thumbnails/19.jpg)
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](https://reader034.fdocuments.net/reader034/viewer/2022050219/5f645d03963675037e7c7916/html5/thumbnails/20.jpg)
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](https://reader034.fdocuments.net/reader034/viewer/2022050219/5f645d03963675037e7c7916/html5/thumbnails/21.jpg)
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](https://reader034.fdocuments.net/reader034/viewer/2022050219/5f645d03963675037e7c7916/html5/thumbnails/22.jpg)
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](https://reader034.fdocuments.net/reader034/viewer/2022050219/5f645d03963675037e7c7916/html5/thumbnails/23.jpg)
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](https://reader034.fdocuments.net/reader034/viewer/2022050219/5f645d03963675037e7c7916/html5/thumbnails/24.jpg)
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](https://reader034.fdocuments.net/reader034/viewer/2022050219/5f645d03963675037e7c7916/html5/thumbnails/25.jpg)
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](https://reader034.fdocuments.net/reader034/viewer/2022050219/5f645d03963675037e7c7916/html5/thumbnails/26.jpg)
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](https://reader034.fdocuments.net/reader034/viewer/2022050219/5f645d03963675037e7c7916/html5/thumbnails/27.jpg)
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](https://reader034.fdocuments.net/reader034/viewer/2022050219/5f645d03963675037e7c7916/html5/thumbnails/28.jpg)
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](https://reader034.fdocuments.net/reader034/viewer/2022050219/5f645d03963675037e7c7916/html5/thumbnails/29.jpg)
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](https://reader034.fdocuments.net/reader034/viewer/2022050219/5f645d03963675037e7c7916/html5/thumbnails/30.jpg)
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](https://reader034.fdocuments.net/reader034/viewer/2022050219/5f645d03963675037e7c7916/html5/thumbnails/31.jpg)
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](https://reader034.fdocuments.net/reader034/viewer/2022050219/5f645d03963675037e7c7916/html5/thumbnails/32.jpg)
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](https://reader034.fdocuments.net/reader034/viewer/2022050219/5f645d03963675037e7c7916/html5/thumbnails/33.jpg)
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](https://reader034.fdocuments.net/reader034/viewer/2022050219/5f645d03963675037e7c7916/html5/thumbnails/34.jpg)
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](https://reader034.fdocuments.net/reader034/viewer/2022050219/5f645d03963675037e7c7916/html5/thumbnails/35.jpg)
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](https://reader034.fdocuments.net/reader034/viewer/2022050219/5f645d03963675037e7c7916/html5/thumbnails/36.jpg)
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](https://reader034.fdocuments.net/reader034/viewer/2022050219/5f645d03963675037e7c7916/html5/thumbnails/37.jpg)
Raggi P, JACC 2002 Bashir et al. AJKD 2015
KDIGO