Thread by @NicholasChiuMD

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⭐️How do we manage CAD in advanced CKD?

In this #Tweetorial, @BUMedicine classmates/future coresidents @RahulAggarwalMD and I review:

🔷#ISCHEMIA-CKD @NEJM #ACC2020
By @SripalBangalore @nyulangone & et al!

#MedTwitter #CardioTwitter #MedEd #COVID19 @MedTweetorials

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First off, a refresher pop-quiz on the #ISCHEMIA (Outcomes) trial @NEJM we summarized in last week's #Tweetorial!

Q: Patients with stable CAD and moderate/severe ischemia have better outcomes with which intervention?

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If you missed our #Tweetorial last week, here is the link to review our summary of the #ISCHEMIA Outcomes main trial results:

https://twitter.com/NicholasChiuMD/status/1245072513639550976

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Now back to the #ISCHEMIA-CKD⭐️ Trial…

KEY Q:

Do pts w/ stable CAD + ⭐️ADVANCED CKD⭐️+ moderate/severe ischemia have better outcomes when receiving invasive intervention + med therapy vs. med therapy alone?

Audience poll: Which do you think will be more effective?

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TLDR, short answer to question: NO EVIDENCE invasive strat. reduced risk of death or nonfatal MI.

We will now go on to review the study in greater detail…stay tuned!

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POPULATION:

🔷Pts w/ ESRD on dialysis or eGFR <30, AND
🔷MODERATE or SEVERE ischemia using trial defined criteria (see image)
🔷Age ≥ 21

*Note, in contrast to ISCHEMIA OUTCOMES trial, CT angiography not recommended as a screening test due to risk of AKI.

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INTERVENTION: 777 pts 1:1 RANDOMIZED to...
 
1) INVASIVE STRATEGY: angiography & revascularization (when feasible) + medical therapy (388 pts)
  
OR
 
2) CONSERVATIVE STRATEGY: medical therapy ALONE (angiography if med therapy failed) (389 pts)

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OUTCOME MEASURES:

PRIMARY OUTCOME: Death or nonfatal myocardial infarction

SECONDARY OUTCOME: death, nonfatal MI, or hospitalization for unstable angina, HF, or resuscitated cardiac arrest

FOLLOW-UP: 1.5, 3, 6, 12 mo & q6 mo thereafter

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MAIN RESULTS (PRIMARY OUTCOME):

Primary outcome occurred in 123 pts in INVASIVE vs. 129 in CONSERVATIVE GROUP

🔷Adjusted HR=1.01; 95CI 0.79-1.29; p=0.95
🔷Event rate @3yrs: 36.4% in INVASIVE vs 36.7% in CONSERVATIVE (diff, -0.4%; 95CI: -8.5, 7.8)

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RESULTS CONT'D (SECONDARY OUTCOME):

Secondary outcome occurred in 132 pts in INVASIVE vs. 138 in CONSERVATIVE GROUP

🔷Adjusted HR=1.01; 95CI 0.79-1.29; p=0.95
🔷Event rate @3yrs: 36.4% in INVASIVE vs 36.7% in CONSERVATIVE (diff, -0.4%; 95CI: -8.5, 7.8)

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RESULTS CONT'D (STROKE)

STROKE:
INVASIVE group had higher incidence of stroke than CONSERVATIVE group

🔷Adjusted HR=3.76; 95CI: 1.52-9.32; p=0.004
*Difference driven by higher incidence of NONPROCEDURE STROKES (those that occurred >30 d AFTER procedure)

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RESULTS CONT'D (SAFETY OUTCOMES)
 
INITIATION OF DIALYSIS OR DEATH:
INVASIVE group had higher incidence of dialysis initiation or death than CONSERVATIVE group
 
🔷Adjusted HR=1.48; 95CI: 1.04-2.11; p=0.03
*Difference driven by higher incidence of newly initiated dialysis

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DISCUSSION/CONCLUSIONS:

"Data from randomized trials involving patients with advanced kidney disease have been limited."

"These results provide information that may assist in treatment of such patients with stable coronary disease."

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CONCLUSION:

"Among patients with stable coronary disease, advanced kidney disease, and moderate or severe ischemia, we did not find evidence that an initial invasive strategy, as compared with an initial conservative strategy, reduced the risk of death or nonfatal MI."

Congrats to authors!
@SripalBangalore et al…@GreggWStone, @jspertus, @KAlexanderMD, & #ISCHEMIA authors not on twitter!
 
#MedTwitter #ACC2020: What are thoughts on the trial & further considerations re. intervention vs. med management in this pt group?
@thecurbsiders @CPSolvers