The relationship between carotid and coronary atherosclerotic damage in dialysis patients.

BACKGROUND: Data relating carotid ultrasound (CU) to atherosclerotic damage evaluated by coronary angiography in hemodialysis patients are scarce. METHODS: We carried out a cross-sectional study in 33 uremic subjects (age 55 +/- 12 years, 22 male, 7 diabetic), who have been on dialysis for 41 +/- 48 months (range 2-192). Twenty-two underwent a coronary angiography in order to complete clinical evaluation for inclusion on the kidney transplantation waiting list, and 11 because of coronary artery disease (CAD); Gensini's score was calculated. Intima-media thickness (IMT) and presence of plaques were related to the degree of coronary stenosis and to cardiovascular risk factors. Patients were divided into two groups depending on mean IMT (group 1 IM 0.9 mm, n=15). RESULTS: Group 2 was older (60 +/- 8 vs 50 +/- 12 year, p=0.01), had higher frequency of CAD (53 vs 16%, p=0.02) and had higher prevalence of coronary artery stenosis >or= 75% in the right (60 vs 22%, p=0.02), left anterior descending (46 vs 16%, p=0.06) and left circumflex coronary arteriers (60 vs 11%, p=0.05) than group 1. IMT was not related to the degree of CAD evaluated by Gensini's score. IMT sensibility and specificity in detecting the presence of hemodynamically significant coronary stenosis were 64% and 68%, respectively. Coronary narrowing was correlated with the degree of stenosis of common, internal and external carotid arteries (Spearman's rank correlation coefficient). During two years of follow-up, six major cardiac events were recorded and they were related to Gensini's score. CONCLUSIONS: In uremic patients, ultrasonographic evaluation of carotid arteries is a simple, noninvasive examination that could be a helpful tool in detecting coronary atherosclerotic damage, but IMT does not appear to add more information regarding risk stratification of CAD.

Relationship between diabetes mellitus and degree of coronary artery disease in uraemic patients investigated with coronary angiography.

Prevalence of cardiovascular disease is high in diabetic patients on renal replacement therapy (RRT); therefore we examined the role of diabetes mellitus on determining the degree of coronary artery stenosis. Twenty-five patients underwent coronary angiography, 12 were awaiting kidney transplantation and the examination was performed regardless of cardiac symptoms, 13 were affected by ischaemic heart disease (IHD). Diabetic and nondiabetic status together with the other risk factors for cardiovascular disease such as age, sex, length of time on RRT, smoking and elevated phosphorus levels history, clinical diagnosis of IHD, cerebrovascular and peripheral vascular disease, mean blood pressure, cholesterol, triglycerides, calcium, phosphate, albumin, haemoglobin, haematocrit and weekly dose of erythropoietin were derived from clinical records. All investigated parameters were matched in diabetic (group 1, n=10) and nondiabetic patients (group 2, n=15) and showed no differences. Clinical evidence of IHD was detected in 80% of patients in group 1 and 46% in group 2 and the percentage of patients on the renal transplant waiting list was not statistically different in the two groups (30 vs 60%). In 60% of patients in group 1 there were 3 or more stenotic lesions equal or greater than 75% of normal reference segment in the major coronary arteries, whilst in 53% in group 2 there were no haemodynamically significant narrowings. Narrowing percentage of the coronaries in group 1 and 2 were: right coronary artery 83 +/- 30 vs 32 +/- 41 (p<0.05), left anterior descending artery 80 +/- 25 vs 44 +/- 34 (p<0.05), left circumflex artery 46 +/- 37 vs 18 +/- 29 (p=0.05) respectively. Our study confirms that IHD is a clinical feature of uraemic diabetic patients and that diabetes is the main cardiovascular risk factor for determining the degree of coronary stenosis.

[Coronary angiography in uraemic patients awaiting kidney transplantation]. / L'indagine coronarografica negli uremici in lista di attesa per trapianto renale.

BACKGROUND: Cardiovascular disease is the leading cause of morbidity and mortality in uraemia. Coronary angiography (CA) in patients awaiting kidney transplantation (PAKT) is still a matter of debate. In order to evaluate atherosclerotic coronary damage in PAKT, CAs of 12 PAKT were matched with those of 13 dialysis patients (P) affected by ischaemic heart disease IHD. METHODS: Age sex, length of time on renal replacement therapy, diabetes, smoking and hyperphosphataemia history, clinical diagnosis of IHD, cerebrovascular (CV) and peripheral vascular (PV) disease, mean blood pressure (BP), cholesterol, triglycerides, calcium, phosphate, albumin, haemoglobin, haematocrit and weekly dose of erythropoietin (EPO-dose) were derived from clinical records. RESULTS: PAKT were younger (48 9 vs 63 9 years, p < 0.01) and had higher diastolic BP values (86+/-10 vs 79+/-4 mmHg, p < 0.05) than IHD P. On the contrary all the other parameters investigated were not different in the two groups of P. Prevalence of IHD in PAKT was 16% while frequency of CV and VP disease were not different in the two groups. In 9 of IHD P stenotic lesions >/=75% of normal reference segment were diagnosed in 3 or more vessels whilst in PAKT there were atherosclerotic lesions in right coronary artery, left anterior descending artery and left circumflex artery in 41, 66 and 33% respectively. Narrowing percentage of the coronaries in PAKT and IHD P were: right coronary artery 27+/-42 vs 75+/-35, p < 0.05, left anterior descending artery 29+/-25 vs 86+/-15, p < 0.001, left circumflex artery 11 16 vs 47+/-38, p < 0.05 respectively. CONCLUSIONS: Our study shows that atherosclerotic coronary damage is present in PAKT and, although not hemodynamically significant, it could be an important risk factor for clinical expression of IHD. We conclude that CA should be performed in PAKT especially in those over 45 years.

[Diabetes and atherosclerotic coronary damage in uremia]. / Diabete e danno coronarico negli uremici.

BACKGROUND: Cardiovascular risk factors are common findings in uraemics, but the impact of each single factor on the development of atherosclerosis is still a matter of debate. PATIENTS AND METHODS: In order to evaluate the relationship between diabetes and ischaemic heart disease (IHD) in uraemia, we carried out a retrospective study comparing the results of 33 coronary angiographies performed in non-diabetic patients with those of 13 diabetics (2 had type 1 diabetes, 8 were treated with insulin, 2 with sulfonylureas and 3 received no therapy). Coronary angiography was performed in 29 patients awaiting kidney transplantation and in 17 subjects with IHD. RESULTS: Age, sex, length of time on renal replacement therapy, smoking history, clinical diagnosis of cerebrovascular and peripheral vascular disease, systolic blood pressure (BP), cholesterol, triglycerides, calcium, phosphate, albumin and degree of anaemia were comparable in the two groups. On the contrary, frequency of IHD (77 vs. 30%, p<0.01) and atrial fibrillation (23 vs. 3%, p<0.05) were higher, while diastolic BP (79 +/- 7 vs. 85 +/- 8 mmHg, p<0.05) and calcium phosphate product (47 +/- 10 vs. 57 +/- 15 mg2/dL2, p<0.05) were lower in diabetics than in non-diabetics. Stenotic lesions of the three major coronary arteries were more prevalent in diabetics than in non-diabetics (left anterior descending artery (LAD) 100 vs. 48%, p<0.01; right coronary artery (RCA) 77 vs. 39%, p<0.05; left circumflex artery (LCA) 69 vs. 24%, p<0.01) and in the same way diabetics showed higher narrowing percentage (LAD 74 +/- 30 vs. 30 +/- 36%, p<0.01; RCA 71 +/- 41 vs. 26 +/- 38, p<0.01; LCA 41 +/- 38 vs. 15 +/- 29, p<0.05). CONCLUSIONS: Our study demonstrates that although the uraemic milieu is a risk factor for IHD, diabetes increases the degree of atherosclerotic vascular damage independently of the other cardiovascular risk factors.

Relationship between major adverse cardiac events and angiographic findings in dialysis patients.

BACKGROUND: In dialysis patients, coronary angiography (CA) predicts major adverse coronary events (MACE) better than non-invasive tests. The aim of this study was to investigate in such patients the relationship between coronary atherosclerotic damage shown by angiography and MACE, during an average follow-up period of more than 5 years. PATIENTS AND METHODS: Coronary angiography was performed in 63 dialysis patients (mean age 56 ± 12 years, 49 men); 37 subjects awaiting kidney transplantation had no history of cardiac disease, whereas the remaining 26 patients had clinical evidence of coronary artery disease (CAD). During a follow-up period of 62 ± 20 months (range 12-109), all the MACE were recorded. Statistical analysis was carried out by dividing the patients into two groups, those who had MACE (MACE group) and those who were free of cardiac events (FCE group). Severe CAD on CA was defined as luminal stenosis ≥ 75% in at least one vessel. Logistic regression analysis and Cox regression analysis were carried out in order to evaluate which variable was associated with MACE. RESULTS: At the end of follow-up, 17 subjects had MACE and severe CAD was shown in the epicardial arteries of 31 patients (49%). Compared to the FCE group, the MACE group had older age (65 ± 10 vs 53 ± 11 years, P = 0.002), lower diastolic blood pressure (79 ± 7 vs 85 ± 7 mmHg, P = 0.0037), higher prevalence of CAD (82 vs 30%, P = 0.0002) and cerebrovascular disease (41 vs 15%, P = 0.0278). Coronary artery damage was higher in the MACE group than in the FCE group. Logistic and Cox regression analyses showed that age was the only variable independently associated with MACE (OR 1.109 95% CI 1.022-1.204, P = 0.0133, hazard ratio 1.066 95% CI 1.010-1.125, P = 0.02, respectively). After removal of age from the model, MACE were independently associated with haemodynamic stenosis of coronary arteries (OR 7.429 95% CI 1.829-30.173, P = 0.005, hazard ratio 5.992 95% CI 1.655-21.698, P = 0.006, respectively). Event-free survival was much better in the 37 renal transplant candidates with no history of CAD than in the 26 patients who had clinical evidence of CAD. CONCLUSIONS: This observational study confirms that in dialysis patients coronary atherosclerotic damage shown by angiography is strongly related to MACE and that age and severe CAD are major risk factors for MACE.