Drug-Eluting Stents in Patients with Chronic Kidney Disease: A Prospective Registry Study

BACKGROUND: Chronic kidney disease (CKD) is strongly associated with adverse outcomes after percutaneous coronary intervention (PCI). There are limited data on the effectiveness of drug-eluting stents (DES) in patients with CKD. METHODOLOGY/PRINCIPAL FINDINGS: Of 3,752 consecutive patients enrolled in the Guthrie PCI Registry between 2001 and 2006, 436 patients with CKD - defined as a creatinine clearance <60 mL/min - were included in this study. Patients who received DES were compared to those who received bare metal stents (BMS). Patients were followed for a mean duration of 3 years after the index PCI to determine the prognostic impact of stent type. Study end-points were all-cause death, myocardial infarction (MI), target vessel revascularization (TVR), stent thrombosis (ST) and the composite of major adverse cardiovascular events (MACE), defined as death, MI or TVR. Patients receiving DES in our study, by virtue of physician selection, had more stable coronary artery disease and had lower baseline risk of thrombotic or restenotic events. Kaplan-Meier estimates of proportions of patients reaching the end-points were significantly lower for DES vs. BMS for all-cause death (p = 0.0008), TVR (p = 0.029) and MACE (p = 0.0015), but not MI (p = 0.945) or ST (p = 0.88). Multivariable analysis with propensity adjustment demonstrated that DES implantation was an independent predictor of lower rates of all-cause death (hazard ratio [HR] 0.48, 95% confidence interval [CI] 0.25-0.92), TVR (HR 0.50, 95% CI 0.27-0.94) and MACE (HR 0.62, 95% CI 0.41-0.94). CONCLUSIONS: In a contemporary PCI registry, selective use of DES in patients with CKD was safe and effective in the long term, with lower risk of all-cause death, TVR and MACE and similar risk of MI and ST as compared with BMS. The mortality benefit may be a result of selection bias and residual confounding, or represent a true finding; a hypothesis that warrants clarification by randomized clinical trials

Clinical Characteristics.

<p><i>p</i><0.05 for pairwise comparison between DES and BMS groups.</p><p>Continuous variables are expressed as mean ± standard deviation (median). Categorical variables are expressed counts (percentages).</p><p>BMS  =  bare metal stent; CABG  =  coronary artery bypass graft surgery; DES  =  drug-eluting stents; MI  =  myocardial infarction; NSTEMI  =  non-ST-segment elevation myocardial infarction; PCI  =  percutaneous coronary intervention; STEMI  =  ST-segment elevation myocardial infarction.</p

Study Patients.

<p>BMS  =  bare metal stent; Creatinine clearance  =  creatinine clearance; DES  =  drug-eluting stents; PCI  =  percutaneous coronary intervention.</p

Multivariable Analysis with Propensity Adjustment Denoting the Impact of Stent Type on All-Cause Death, TVR and MACE.

<p>BMS  =  bare metal stent; DES  =  drug-eluting stents; MACE  =  major adverse cardiovascular events; TVR  =  target vessel revascularization.</p

Kaplan-Meier Curves of Estimated Cumulative Incidence of Outcomes.

<p>The estimated cumulative incidences of all-cause death (A), MI (B), ST (C), TVR (D) and MACE (E) are shown. BMS  =  bare metal stent; DES  =  drug-eluting stents; MACE  =  major adverse cardiovascular events; PCI  =  percutaneous coronary intervention; MI  =  myocardial infarction; ST  =  stent thrombosis; TVR  =  target vessel revascularization.</p

Prognostic significance of transient no-reflow during primary percutaneous coronary intervention for ST-elevation acute myocardial infarction.

We found that of 1,192 patients who underwent primary percutaneous coronary intervention and who had final Thrombolysis In Myocardial Infarction grade 3 flow at the conclusion of the procedure, transient no-reflow occurred in 16 patients (1.3%). Compared with patients without transient no-reflow during the procedure, those with transient no-reflow had higher in-hospital (2% vs 13%, p=0.04) and 6-month mortality (3% vs 31%, adjusted odds ratio 5.4, 95% confidence interval 1.01 to 29.0, p=0.0001)

Usefulness of the presence of peripheral vascular disease in predicting mortality in acute myocardial infarction patients treated with primary angioplasty (from the Primary Angioplasty in Myocardial Infarction Database).

Patients with acute myocardial infarction (AMI) often have multiple co-morbidities that influence outcome. We sought to evaluate the impact of peripheral vascular disease (PVD) on the outcome of patients with AMI treated with primary angioplasty. We evaluated 3,716 patients with AMI who underwent emergency catheterization with planned primary angioplasty in the Primary Angioplasty in Myocardial Infarction trials. Patients with a history of PVD (claudication, stroke, or transient ischemic attack) were compared with patients without PVD. Of the 3,716 patients, 394 (10.6%) had PVD and were older, more often women, and more frequently had a history of diabetes mellitus, hypertension, smoking, congestive heart failure, angina, myocardial infarction, and coronary revascularization. They presented more often with a heart rate \u3e100 beats/min, Killip class \u3e1, lower ejection fraction, and multivessel disease. No difference was found in stent use, final percentage of stenosis, or Thrombolysis In Myocardial Infarction 3 flow. Patients with PVD had a twofold increased in-hospital mortality (5.3% vs 2.6%, p = 0.0021). The difference remained significant at 1 month, 6 months, and 1 year (12.6% vs 6%, p \u3c 0.0001). In multivariate logistic regression analysis, a history of PVD was an independent predictor of in-hospital mortality and death at 1 year (odds ratio 1.64, 95% confidence interval 1.04 to 2.57, p = 0.032). In conclusion, patients with AMI with PVD have increased co-morbidities and higher mortality despite treatment with primary angioplasty. The presence of PVD is an independent predictor of in-hospital mortality and death at 1 year