RESUMO
BACKGROUND: We assessed the results of a noninvasive therapeutic strategy on the long-term occurrence of cardiac events and death in a registry of patients with chronic kidney disease (CKD) and coronary artery disease (CAD). METHODS: We analyzed 519 patients with CKD (56+/-9 years, 67% men, 67% whites) on maintenance hemodialysis with clinical or scintigraphic evidence of CAD by using coronary angiography. RESULTS: In 230 (44%) patients, coronary angiography revealed significant CAD (lumen reduction > or =70%). Subjects with significant CAD were kept on medical treatment (MT; n=184) or referred for myocardial revascularization (percutaneous transluminal coronary angioplasty/coronary artery bypass graft-intervention; n=30) according to American College of Cardiology/American Heart Association guidelines. In addition, 16 subjects refused intervention and were also followed-up. Event-free survival for patients on MT at 12, 36, and 60 months was 86%, 71%, and 57%, whereas overall survival was 89%, 71%, and 50% in the same period, respectively. Patients who refused intervention had a significantly worse prognosis compared with those who actually underwent intervention (events: hazard ratio=4.50; % confidence interval=1.48-15.10; death: hazard ratio=3.39; % confidence interval 1.41-8.45). CONCLUSIONS: In patients with CKD and significant CAD, MT promotes adequate long-term event-free survival. However, failure to perform a coronary intervention when necessary results in an accentuated increased risk of events and death.
Assuntos
Angioplastia Coronária com Balão , Fármacos Cardiovasculares/uso terapêutico , Doenças Cardiovasculares/prevenção & controle , Ponte de Artéria Coronária , Estenose Coronária/terapia , Nefropatias/terapia , Transplante de Rim , Diálise Renal , Idoso , Brasil/epidemiologia , Doenças Cardiovasculares/etiologia , Doenças Cardiovasculares/mortalidade , Angiografia Coronária , Estenose Coronária/complicações , Estenose Coronária/diagnóstico por imagem , Estenose Coronária/mortalidade , Progressão da Doença , Intervalo Livre de Doença , Feminino , Humanos , Estimativa de Kaplan-Meier , Nefropatias/complicações , Nefropatias/mortalidade , Nefropatias/cirurgia , Masculino , Pessoa de Meia-Idade , Guias de Prática Clínica como Assunto , Modelos de Riscos Proporcionais , Sistema de Registros , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença , Fatores de Tempo , Resultado do Tratamento , Recusa do Paciente ao Tratamento , Listas de EsperaRESUMO
UNLABELLED: BACKGROUND: The best strategy for pre-transplant investigation and treatment of coronary artery disease (CAD) is controversial. METHODS: We evaluated 167 renal transplant recipients before transplantation to determine the incidence of cardiac events and death. We performed clinical evaluations and myocardial scans in all patients and coronary angiography in select patients. RESULTS: Asymptomatic patients with normal myocardial scans (n=57) had significantly fewer cardiac events (log-rank=0.0002) and deaths (log-rank=0.0005) than did patients with abnormal scans but no angiographic evidence of CAD (n=76) and individuals with CAD (n=34) documented angiographically. CAD increased the probability of events (HR=2.27, % CI 1.007-5.11; p=0.04). The incidence of cardiac events (log-rank=0.349) and deaths (log-rank=0.588) was similar among patients treated medically (n=23) or by intervention (n=11). CONCLUSION: Asymptomatic patients with normal myocardial scans had a better cardiac prognosis than did patients with or without CAD and positive for myocardial ischemia. Patients with altered scan and CAD had the poorer outcome. Guideline-oriented medical treatment is safe and yields results comparable to coronary intervention in renal transplant patients with CAD. The data do not support preemptive myocardial revascularization for renal transplant candidates.