Bệnh mạch vành ổn định với tổn thương nhiều nhánh ở người có bệnh thận mạn khi nào nên can thiệp

Stable CKD: when we need PCI? Christoph K Naber Contilia Heart and Vascular Center Elisabeth Krankenhaus Essen Germany Conflicts of Interest Nothing to declare Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany Stages of CKD Sarnak et al Circulation 2003 Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany CKD and Mortality Sarnak et al Circulation 2003 Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany CKD and Cardiovascular Disease Sarnak et al Circulation 2003 Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany CKD and MACE N=16.958 Di Angelantonio et al BMJ 2010 Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany How should I treat? 67 year old patient on hemodialysis Symptoms: progressive over months (CCS II, NYHA III) Echo: hypokinesia of inferior wall, EF 45% Laboratory: mildly elevated Troponin T (0.2 µg/l) ECG: SR 70 and RBB Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany How should I treat? 67 year old patient on hemodialysis Symptoms: progressive over months (CCS II, NYHA III) Echo: hypokinesia of inferior wall, EF 45% Laboratory: mildly elevated Troponin T (0.2 µg/l) ECG: SR 70 and RBB Stable or instable patient? Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany Serum phosphorus and cardiac injury Wang et al Med Sci Mon 2014 Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany Phosphate and CMC Apoptosis Wang et al Med Sci Mon 2014 Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany Need for revascularization? Prognostic indication: ischemic burden > 10%? COURAGE NUCLEAR SUBSTUDY: Shaw et al Circulation 2008 Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany CKD in randomized trials* on CAD Trials where CKD is exclusion criterion Trials reporting CKD as baseline condition *(86 trials randomizing 411 653 patients) Charytan et al Kidney Int 2006 Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany CABG vs PCI in HD patients Gupta et al JACC 2004 Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany PCI vs CABG in CKD: all events Zheng et al EJCTS 2012 Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany PCI vs CABG in CKD: repeat revascularization Zheng et al EJCTS 2012 Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany PCI vs CABG in CKD: myocardial infarction Zheng et al EJCTS 2012 Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany PCI vs CABG in CKD: late mortality Zheng et al EJCTS 2012 Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany PCI vs CABG in CKD: early mortality Zheng et al EJCTS 2012 Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany MV-PCI vs CABG in CKD 21,981 CKD patients (US Renal Data System 1997-2009) undergoing MV-revascularization Chang et al JASON 2012 Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany CKD in the FREEDOM trial Baber et al EHJ 2016 Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany CKD in the FREEDOM trial Baber et al EHJ 2016 Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany Discussion in Heart Team 67 year old patient on hemodialysis Symptoms: progressive over months (CCS II, NYHA III) Echo: hypokinesia of inferior wall, EF 45% Laboratory: mildly elevated Troponin T (0.2 µg/l) remaining stable after and 12 hours ECG: SR 70 and RBB Patient refused by surgeons (porcelain aorta) Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany How did I treat RCA: 2xDES 3.0/18 mm LAD: DES 3.5/18 mm LCX: DES 3.0/18 mm Contilia Heart- and Vascular Center, Elisabeth Krankenhaus Essen, Germany Summary Chronic kidney disease patients are at a high risk for having ischemic heart disease and its complications Troponin dynamics rather than a single Tropnin measurement may be useful to diagnose ACS in these patients Indications for revascularization are assumed to be the the same as in other patients Despite randomized trials are lacking, available data indicate that CABG may be preferrable in therse patients Contilia Herz- und Gefäßzentrum, Elisabeth Krankenhaus Essen