Dialysis Patients with Complex Coronary Disease Fare Better at 5 Years with CABG vs PCI

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Patients who suffer from end-stage renal disease in addition to multivessel or left main coronary artery disease have poorer long-term outcomes with percutaneous coronary intervention (PCI) than with coronary artery bypass graft (CABG) surgery, reports a Japanese registry study published online June 9, 2014, ahead of print in the American Journal of Cardiology.

At 5 years, the less invasive treatment appears to double the risk of cardiac death and more than triple the risk of coronary revascularization, even when adjusting for baseline characteristics.

Yet researcher Akira Marui, MD, PhD, of the Kyoto University Graduate School of Medicine (Kyoto, Japan), cautioned to TCTMD in an email that because all-cause mortality among patients on dialysis is so high, the choice between PCI and CABG must be individualized.

 Unadjusted all-cause mortality was initially lower with PCI than with CABG at 30 days (2.7% vs 5.4%), though at 5 years that advantage was lost (52.3% vs 49.9%; P = .83). Median follow-up duration for the surviving patients was 1,821 days.

With propensity score adjustment, 5-year outcomes generally favored CABG. All-cause mortality and stroke rates were similar between the 2 treatment modalities, but PCI sharply increased the risks of cardiac death, sudden cardiac death, and any coronary revascularization. PCI also showed a trend toward higher risk of MI (table 1).

Table 1. Propensity-Adjusted Risk of 5-Year Outcomes: PCI vs CABG

Most cardiac deaths (37%) arose from ischemic heart disease. In all, 47% of deaths were due to noncardiac causes including stroke, respiratory failure, and renal failure.

Japanese Cohort Unique

By far the most interesting aspect of this study, Jeffrey A. Breall, MD, of Indiana University (Indianapolis, IN), noted in a telephone interview with TCTMD, is the fact that “all of these patients lived much longer than had ever been reported before…. Most were dead after 5 years, whereas previously every other report I had ever seen showed that they were dead after 2 years. That’s a big difference.”

The outcomes observed in CREDO-Kyoto may be unique to Japan, Dr. Marui acknowledged. “Thanks to the Japanese universal public insurance system, every patient can receive [optimal] medical management without financial burden. In other regions with insufficient healthcare [systems], a less invasive and more economical strategy can be selected.”

‘Clock Is Ticking Either Way’

But Dr. Breall stressed that outcomes are “terrible” for this population no matter which treatment is chosen. “If you use bypass surgery, they tend to live a little bit longer, but if you use PCI they tend to do a little better in the short-term and are more likely to get out of the hospital,” he commented. “It’s not entirely clear what’s best.”

Unfortunately, “‘long-term’ isn’t very long for these patients,” Dr. Breall added. “If I was a patient, [the question is whether I would] rather have my chest cracked open to live an extra few weeks to months as opposed to getting a stent, knowing the clock is ticking either way.”

Similarly, Dr. Marui emphasized that noncardiac mortality in dialysis patients is very high. “Thus, aggressive revascularization may not be associated with better long-term outcome after PCI or CABG,” he observed. “High-risk patients on dialysis who are expected to die of noncardiac comorbidities should be selected [for] PCI or less invasive CABG (off-pump or [fewer] bypass grafts).”

That being said, Dr. Marui cautioned that debate over the superiority of PCI or CABG in patients on dialysis misses the mark. “Appropriate selection of revascularization modality to minimize in-hospital mortality and strict general management after discharge [are] essential to improve long-term survival of dialysis patients,” he concluded.

Source:

Marui A, Kimura T, Nishiwaki N, et al. Percutaneous coronary intervention versus coronary artery bypass grafting in patients with end-stage renal disease requiring dialysis (five-year outcomes of the CREDO-Kyoto PCI/CABG Registry Cohort-2). Am J Cardiol. 2014;Epub ahead of print.

• Dr. Marui reports no relevant conflicts of interest.

• Dr. Breall reports serving as a consultant to Fujifilm and on the advisory board of Siemens Interventional Cardiology.

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