Thread by @NamrataYParikh

This week at #NephJC we took a break from #COVID19 to discuss the @NEJM ISCHEMIA-CKD trial🧑‍🏫👨‍🏫
⚡️For those of you who missed it, here’s a recap in the form of a🧵
nejm.org/doi/full/10.10…

Thanks @amyaimei and @Vernisartan for being such great mentors and helping me out! #NSMC

But first, lets take a quick poll
👉Do you advise your patients with advanced CKD (GFR<30 mL/min/1.73m2) and moderate myocardial ischemia to go for coronary angiography?👈

<1> Background
First off, let’s appreciate 👏 @SripalBangalore and the ISCHEMIA-CKD group for this Herculean 💪 task.
All previous revascularization trials have neglected ✖️advanced CKD patients (GFR < 30 mL/min/1.73m2).

Perhaps good old ‘Renalism’ was at play? 🤔

<2> Background
That’s rather unfair! 😒 Considering that cardiovascular 💔 events ⏫as the eGFR ⬇️
nejm.org/doi/full/10.10…

<3> Background
ISCHEMIA-CKD is here to set the record straight!

Purpose⏩To determine benefit of invasive🆚conservative approach, in advanced CKD pts with moderate/severe myocardial ischemia

Design ⏩
🟪Randomized
🟦Open label
🟩International
🟨Interventional clinical trial

<4> Methods

Trial Arms ⏩
1⃣ Initial invasive strategy
2⃣ Conservative strategy

<5> Eligibility
The inclusion 👍and exclusion👎 criteria are shown in the figure 👇

<6> Trial Endpoints (EP)
🥇Primary Composite EP ⏩ ⏳ to death, non-fatal MI
🥈Major Secondary EP ⏩ ⌛️ to death, MI, hospitalization for unstable angina, heart failure or resuscitated cardiac arrest
🏅Composite Safety Outcome ⏩ Starting maintenance dialysis or death

<7> Statistical Considerations📈

▪️N➡️777⏩80% power to detect 22-24% relative reduction in prim EP
(Assumed agg 4 yr event rate➡️41-48% in cons group)
▪️Intention to treat
▪️Cox regression, covariate-adjusted
▪️Bayesian analysis➡️supplement conventional confidence intervals

<8> Results

⚫️802 pts across 118 sites in 30 countries
⚫️777 ( 96.9%) randomized
⚫️Median age➡️63 yrs
⚫️On dialysis➡️53.4%
⚫️Median eGFR in those not on dialysis➡️23 mL/min/1.73m2
⚫️Moderate ischemia➡️61.4%
⚫️Severe ischemia➡️37.8%

<9> Baseline Characteristics 📋

The figures below show
✅Key Baseline Characteristics
✅Key Stress Test and Angiographic Characteristics

<10> Primary EP
👉Composite of death or nonfatal MI
🔶Invasive strategy➡️36.4%
🔶Conservative strategy ➡️36.7%
✔️HR adj 1.01 (0.79-1.29, p = 0.95)

<11> Major Secondary EP

👉Composite of death, non-fatal MI, Hospitalization for Unstable Angina or Heart Failure or Resuscitated Cardiac Arrest
🔶Invasive strategy➡️38.5%
🔶Conservative strategy➡️39.7%
✔️HR adj 1.02 (0.79-1.29, p = 0.93)

<12> Other Secondary EP
Check out the results of time - to - event analyses of
🔴Death
🔴MI
🔴Hospitalization for Unstable Angina
🔴Hospitalization for Heart Failure
Note that there is no difference between the two groups👇

<13> Discussion
The invasive strategy was associated with a⏫incidence of stroke🙁

<14> Discussion
Invasive strategy also associated with ➡️
⏫incidence of death ☠️
⏫incidence of initiation of dialysis in patients who were not on dialysis to start with (may be related to atheroembolic complications ?) 😔

<15> Discussion
🔶CAG with invasive strategy➡️85%
🔹Revascularization➡️50% (Most common reason❌➡️No obstructive disease)

🔶CAG with conservative strategy➡️31.6%
🔹Revascularization➡️19.6% (Most common reason✅➡️Confirmed event)

<16> Limitations 👎

This trial had several limitations 👇

<17> Conclusion
➡️No evidence❌of⬇️risk of death or nonfatal MI with initial invasive strategy compared to conservative
➡️Initial invasive strategy associated with⬆️risk of
✴️Stroke
✴️Dialysis initiation

Want more?
Check out the extensive summary by @docanjuyadav and @drM_sudha 👇
nephjc.com/news/ischemiac…

And the awesome VA by @agrawalkris 👇nephjc.com/news/ischemiava 👇

Time for another poll 👉
Now, after reading this tweetorial, WOULD you advise your patients with advanced CKD (GFR<30 mL/min/1.73m2) and moderate myocardial ischemia to go for coronary angiography?🤔

For additional reading 🧐👉professional.heart.org/professional/S…

Hey guys!Thanks for the support!😇
Poll results are interesting🤔
🔹 After reading the 🧵24% people voted FOR CAG compared to only 6% before❗️
🔹49% people voted AGAINST CAG compared to 13% before‼️
🔹More importantly, 105 people voted in the 1st poll but only 77 in the 2nd😶