Renal function and coronary bypass surgery in patients with ischemic heart failure

OBJECTIVE: Chronic kidney disease is a known risk factor in cardiovascular disease, but its influence on treatment effect of bypass surgery remains unclear. We assessed the influence of chronic kidney disease on 10-year mortality and cardiovascular outcomes in patients with ischemic heart failure treated with medical therapy (medical treatment) with or without coronary artery bypass grafting. METHODS: We calculated the baseline estimated glomerular filtration rate (Chronic Kidney Disease Epidemiology Collaboration formula, chronic kidney disease stages 1-5) from 1209 patients randomized to medical treatment or coronary artery bypass grafting in the Surgical Treatment for IsChemic Heart failure trial and assessed its effect on outcome. RESULTS: In the overall Surgical Treatment for IsChemic Heart failure cohort, patients with chronic kidney disease stages 3 to 5 were older than those with stages 1 and 2 (66-71 years vs 54-59 years) and had more comorbidities. Multivariable modeling revealed an inverse association between estimated glomerular filtration rate and risk of death, cardiovascular death, or cardiovascular rehospitalization (all P< .001, but not for stroke, P » .697). Baseline characteristics of the 2 treatment arms were equal for each chronic kidney disease stage. There were significant improvements in death or cardiovascular rehospitalization with coronary artery bypass grafting (stage 1: hazard ratio, 0.71; confidence interval, 0.53-0.96, P » .02; stage 2: hazard ratio, 0.71; confidence interval, 0.59-0.84, P<. 0001; stage 3: hazard ratio, 0.76; confidence interval, 0.53-0.96, P » .03). These data were inconclusive in stages 4 and 5 for insufficient patient numbers (N » 28). There was no significant interaction of estimated glomerular filtration rate with the treatment effect of coronary artery bypass grafting (P » .25 for death and P » .54 for death or cardiovascular rehospitalization). CONCLUSIONS: Chronic kidney disease is an independent risk factor for mortality in patients with ischemic heart failure with or without coronary artery bypass grafting. However, mild to moderate chronic kidney disease does not appear to influence long-term treatment effects of coronary artery bypass grafting. (J Thorac Cardiovasc Surg 2020; 1-9)

Optimal medical therapy use and long-term outcomes in cabg-eligible heart failure patients: insights from the stich trial

BACKGROUND: Coronary Artery Bypass Grafting (CABG) reduces mortality in Heart Failure (HF) and coronary artery disease (CAD) patients (pts). There is a paucity of data on the utilization of optimal medical therapy (OMT) in HF and CAD pts after revascularization and the impact on long term outcomes. We evaluate the impact of baseline use of OMT versus Non-OMT on long-term clinical outcomes in pts receiving CABG compared to patients with medical treatment alone (MED). METHODS: The STICH trial randomized 1212 pts with CAD and left ventricular ejection fraction (LVEF) ≤ 35% to CABG + MED versus MED alone. OMT was defined as a combination of 4 drugs: ACEI/ARB, BB, statin, and at least one antiplatelet drug at baseline, with a median follow up over 9.8 years. RESULTS: At baseline, 58.7% of the pts were on OMT (CABG 56.1%; MED 61.5%), remaining stable or increasing similarly for both groups during follow up, for example, at 1 year, CABG 73.2% and Med 74.3%. Age, gender, diabetes were similar. OMT pts had less atrial fibrillation, lower angina score class, less advance heart failure class and better renal function. There were no differences in LVEF and end systolic and diastolic volume index. OMT use at baseline was associated with a significantly lower all-cause mortality compared to Non- OMT pts (58.8% vs 67.6%, log-rank P<0.001), lower cardiovascular mortality (40.3% vs 51.4%, log-rank P<0.001) and lower HF death, 11.2% vs 15.6%, log-rank P<0.001). Sudden death was not different (21.5% vs 23.4%, P=0.058). In a multivariable Cox model, OMT was associated with a lower All-cause mortality (HR 0.78, 95%CI 0.66-0.91 P=0.001). The effect of OMT was similar for both CABG and MED only pts for these outcomes (p=0.189 for interaction). Hospitalization for HF was not reduced with OMT. CONCLUSION: OMT is associated with lower all-cause mortality in CABG eligible HF pts, regardless of the lower baseline risk among OMT pts and the performance of CABG. OMT should be strongly considered for all pts with ischemic cardiomyopathy regardless of whether CABG is performed. (AU)

Myocardial viability and impact of surgical ventricular reconstructionon outcomes of patients with severe left ventricular dysfunctionundergoing coronary artery bypass surgery: results of the surgical treatment for ischemic heart failure trial

Objectives: In the Surgical Treatment for Ischemic Heart Failure trial, surgical ventricular reconstruction pluscoronary artery bypass surgery was not associated with a reduction in the rate of death or cardiac hospitalizationcompared with bypass alone. We hypothesized that the absence of viable myocardium identifies patients withcoronary artery disease and left ventricular dysfunction who have a greater benefit with coronary artery bypassgraft surgery and surgical ventricular reconstruction compared with bypass alone.Methods: Myocardial viability was assessed by single photon computed tomography in 267 of the 1000 patientsrandomized to bypass or bypass plus surgical ventricular reconstruction in the Surgical Treatment for IschemicHeart Failure. Myocardial viability was assessed on a per patient basis and regionally according to prespecifiedcriteria.Results: At 3 years, there was no difference in mortality or the combined outcome of death or cardiachospitalization between those with and without viability, and there was no significant interaction between thetype of surgery and the global viability status with respect to mortality or death plus cardiac hospitalization.Furthermore, there was no difference in mortality or death plus cardiac hospitalization between those withand without anterior wall or apical scar, and no significant interaction between the presence of scar in theseregions and the type of surgery with respect to mortality.Conclusions: In patients with coronary artery disease and severe regional left ventricular dysfunction,assessment of myocardial viability does not identify patients who will derive a mortality benefit from addingsurgical ventricular reconstruction to coronary artery bypass graft surgery.

Myocardial viability and impact of surgical ventricular reconstruction on outcomes of patients with severe left ventricular dysfunction undergoing coronary artery bypass surgery: results of the surgical treatment for ischemic heart failure trial

In the Surgical Treatment for Ischemic Heart Failure trial, surgical ventricular reconstruction plus coronary artery bypass surgery was not associated with a reduction in the rate of death or cardiac hospitalization compared with bypass alone. We hypothesized that the absence of viable myocardium identifies patients with coronary artery disease and left ventricular dysfunction who have a greater benefit with coronary artery bypass graft surgery and surgical ventricular reconstruction compared with bypass alone.MethodsMyocardial viability was assessed by single photon computed tomography in 267 of the 1000 patients randomized to bypass or bypass plus surgical ventricular reconstruction in the Surgical Treatment for Ischemic Heart Failure. Myocardial viability was assessed on a per patient basis and regionally according to prespecified criteria.ResultsAt 3 years, there was no difference in mortality or the combined outcome of death or cardiac hospitalization between those with and without viability, and there was no significant interaction between the type of surgery and the global viability status with respect to mortality or death plus cardiac hospitalization. Furthermore, there was no difference in mortality or death plus cardiac hospitalization between those with and without anterior wall or apical scar, and no significant interaction between the presence of scar in these regions and the type of surgery with respect to mortality.ConclusionsIn patients with coronary artery disease and severe regional left ventricular dysfunction, assessment of myocardial viability does not identify patients who will derive a mortality benefit from adding surgical ventricular reconstruction to coronary artery bypass graft surgery.

Peptídeo natriurético tipo-B e doenças cardiovasculares / B-type natriuretic peptide and cardiovascular disease

A descoberta de uma ligação endocrinológica entre o coração e os rins baseia-se em achados de microscopia eletrônica em que células de músculo estriado dos átrios de mamíferos se diferenciam tanto em células contráteis como em células endócrinas. O fator natriurético atrial (FNA), um peptídeo circulante com propriedades natriuréticas, diuréticas e vasodilatadoras, foi descoberto em 1980 por A. J. de Bold, e considerado, na ocasião, como a ligação hormonal entre o coração e os rins. Desde então, um imenso número de investigações multidisciplinares tem sido conduzido para esclarecer o real papel deste peptídeo na patogênese das doenças cardiovasculares, na regulação da pressão arterial e na excreção de sal e água. Essas investigações acabaram se tornando um excelente exemplo de pesquisa evoluída da bancada do laboratório à beira do leito do paciente. Hoje, o peptídeo natriurético tipo-B (PNB) vem gradual e lentamente se estabelecendo na área clínica. O objetivo deste artigo é prover o clínico de uma revisão atualizada dos progressos ocorridos até o momento, a fim de incluir o peptídeo natriurético tipo-B na prática clínica diária.