Research On The Prognosis Of Coronary Artery Disease With Mild To Moderate Renal Insufficiency

Part I The association between estimated glomerularfiltration rate and the prognosis of coronary arterydiseaseObjective: To evaluate the effect of estimated glomerular filtration rate(eGFR) on the major adverse cardiac and cerebrovascular events (MACCE),and mortality in patients with coronary artery disease (CAD).Methods: All the CAD patients who had been diagnosed by coronaryangiogram in Peking university people’s hospital and Peking Dongzhimenhospital between January2003and December2010were consecutivelyenrolled in this study. All of the clinical data in hospitalization wererecorded, and the medicinal therapy and clinical events were followed up.The patients were divided into4groups according to different eGFR levels:Group A: eGFR<60ml/min·1.73m2,336patients; Group B:60≤eGFR<75ml/min·1.73m2,625patients; Group C:75≤eGFR<90ml/min·1.73m2,1287patients; Group D: eGFR≥90ml/min·1.73m2,4319patients. The clinical data and end-points were compared, and the impact factors onprognosis of CAD patients were analyzed.Results: Totally,6567patients were enrolled with mean age of62.78±10.84years and mean followed-up of57months (12~119months),and68.65%of them were male; the mean SYNTAX score of all patientswas13.74±12.80; the rates of patients using asprin, statin, beta-blocker andACEI/ARB were86.19%,74.45%,66.32%, and37.34%, respectively; theproportion became67.70%,60.62%,55.21%, and25.20%, respectively inthe follow-up period. In group A, the age was higher, and more patients hadthe history of hypertension, diabetes, cerebrovascular and peripheralvascular disease; more male and smokers were in group D (P<0.0001). Themean SYNTAX scores of group A, group B, group C and group D were16.40±14.29,14.57±13.57,14.57±12.89and13.28±12.42, respectively,which was statistically different among4groups (P<0.0001). The using ofasprin and statins decreased in the groups with lower eGFR (P<0.0001).After Cox multivariate analysis, the hazard rates of all-cause death of groupA, B, and C (group D as reference) were2.857(95%CI:[1.902,4.290]),2.541(95%CI:[1.689,3.823]) and1.731(95%CI:[1.195,2.508])separately；the hazard rates of MACCE were1.946(95%CI:[1.471,2.573]),1.855(95%CI:[1.421,2.422]) and1.349(95%CI:[1.072,1.699])separately；the hazard rates of cardiac death were3.598(95%CI:[2.072,6.248]),2.451(95%CI:[1.455,4.129]) and1.667(95%CI:[1.037-2.681]) separately；the hazard rates of non-fatal myocardial infarction were2.409(95%CI:[1.106-5.245]),2.107(95%CI:[1.092-4.066]) and1.167(95%CI:[0.623-2.186]) separately; there were no statistical significance among thehazard rates of strock and re-revsaculariztion among three groups. The Coxpredictive analysis showed that decreased eGFR, PCI treatment, andincreased SYNTAX score were independent risk factors of all-causemotality or MACCE, and HGB>100g/L and asprin treatment wereprotective factors. The survival analysis showed that the survival rate andnon-MACCE rate were statistically different among4groups (P<0.0001)with group A as the lowest.Conclusion: Decreased eGFR was independent risk factor of all-causemotality or MACCE in CAD patients. However, not only the moderate tosevere renal insufficiency impacts the prognosis of CAD, but also the mildrenal insufficiency could increase the motality and the rate of MACCE. Inorder to avoid the damage of renal function and to improve the prognosis ofCAD, the eGFR of CAD patients should be paid attention to. Part II Comparison on prognosis of CAD patients withmild to moderate renal insufficiency treated by PCI,CABG, and medicinal therapyObjective: To compare the prognosis of CAD patients with mild tomoderate renal insufficiency treated by PCI, CABG, and medicinal therapy.Methods: The CAD patients who had been diagnosed by coronaryangiogram in Peking university people’s hospital and Peking Dongzhimenhospital between January2003and December2010were consecutivelyenrolled with eGFR between30and90ml/min·1.73m2. According todifferent treatment, the included patients were divided into PCI group (809patients), CABG group (439patients), and medicinal therapy group (852patients). All of the clinical data in hospitalization were recorded, and themedicinal therapy and clinical events were followed up. The clinical dataand end-point events were compared, and the impact factors on prognosisof CAD patients with mild to moderate renal insufficiency were analyzed.Results: Totally,2100patients were included with mean age of67.09±9.60years and mean followed-up of70months (12~119months),and60.24%of them were male; the mean SYNTAX score was14.59±13.28.In the PCI group, the mean age and the mean SBP were higher, and lesspatients had history of diabetes while relatively more patients diagnosedwith STEMI and NSTEMI; in the CABG group, more patients had cardiac function with NYHA III/IV or Killip III/IV. The mean left ventricle ejectionfraction (LVEF) and SYNTAX score in the CABG group were58.80%and8.44, both of which were significantly lower than that of the other twogroups (both P<0.0001). Statins and ACEI/ARB were more frequently usedin PCI patients (P<0.0001). However, there was no difference among theusing of asprin and beta-blocker in3groups. The all-cuase motality of PCIgroup, CABG group and medicinal therapy group were9.41%,9.90%and8.15%separately; the MACCE rates were19.60%,14.70%and17.09%separately; there was no significant difference among the3groups onall-cause motality (P=0.6059) and MACCE rate (P=0.1569). There-revascularization rate of PCI group was statistically higer than that in theCABG group (8.64%vs.2.56%, P=0.0004). After adjusted with age,gender, history, STEMI, NSTEMI, and LVEF, the Cox multivariate analysisresults showed that compared with the medicinal therapy group, the hazardrate of all-cause death in PCI and CABG groups were1.576(95%CI:[0.924,2.690]) and0.993(95%CI:[0.546,1.805]) separately; the hazardrates of MACCE were1.388(95%CI:[0.978,1.971]) and0.616(95%CI:[0.394,0.962]) separately; the hazard rates of non-fatal myocardialinfarction were3.208(95%CI:[1.086,9.479]) and1.329(95%CI:[0.373,4.728]) separately; the hazard rates of re-revasculariztion were1.221(95%CI:[0.736,2.025]) and0.279(95%CI:[0.115,0.676]) separately.After additionally adjusted with SYNTAX score, there were no statistical significancy of the hazard rates of all-cause death, MACCE, cardiac death,stroke, non-fatal myocardial infarction and re-revascularization. The Coxpredictive analysis showed that increased Cr, high age, and SYNTAX score>16were independent risk factors of all-cause motality while female andstatins therapy were protective factors; for the MACCE, decreased Cr andSYNTAX score>16were independent risk factors and CABG treatmentwas the protective factor. The survival analysis showed that there was nosignificant difference of the survival rate (P=0.1296) but there wassignificant difference of non-MACCE rate among the3groups (P<0.0001).Conclusion: Fot the CAD patients with mild to moderate renalinsufficiency, adjusted with baseline characteristics and SYNTAX score,there was no difference in all-cause motality and survival rate among PCI,CABG and medicinal therapy groups. However, the non-MACCE rate wassignificantly different among the3groups and possibly the patients in theCABG group get less long-term MACCE. Part III The association between SYNTAX score andprognosis of revascularization in CAD patients withmild to moderate renal insufficiencyObjective: Investigate the impact of SYNTAX score on the prognosisof CAD patients with mild to moderate renal insufficiency.Methods: The CAD patients who had been diagnosed by coronaryangiogram and undergone PCI or CABG in Peking university people’shospital and Peking Dongzhimen hospital between January2003andDecember2010were consecutively enrolled with eGFR between30and90ml/min·1.73m2. The SYNTAX score of the vessels (diameter≥1.5mm) with≥50%reduction in luminal diameter by visual was calculated based on the16segments of coronary atyerial trees combined with dominance type,lesion location, stenosis severity and lesion characteristics. According toSYNTAX score, the patients were divided into3groups:0-8group (156patients),8-16group (234patients) and>16group (544patients). All of theclinical data in hospitalization were recorded, and the medicinal therapyand clinical events were followed up. The clinical data and end-pointevents were compared.Results: Totally,934patients were included with mean age of67.65±9.65years and mean followed-up of69months (12~119months),and62.31%of them were male; the mean SYNTAX score of all included patients was14.27±12.44;806patients were treated with PCI and the meannumber of implanted stents was1.44;153patients were vtreated withCABG, and82patients were treated with internal mammary artery. Ingroup>16, the age was higher, and the mean left ventricle ejection fraction(LVEF) was lower (both P<0.0001). There were no difference of asprin,statin, beta-blocker and ACEI/ARB therapy in hospitalization andfollow-up period among the3groups (all P>0.05). The all-cause motalityin0-8group,8-16group and>16group were5.65%,8.42%and10.77%separately, and the rates of MACCE were10.48%,17.89%and22.01%separately. After adjusted with gender, STEMI, UAP, Cr, TG and HDL,Cox multivariate analysis showed that compared with group0-8, the hazardrates of motality of group8-16and group>16were2.262(95%CI:[1.021,5.010]) and2.325(95%CI:[1.131,4.780]); and the hazard rates ofMACCE were2.545(95%CI:[1.404-4.613]) and3.549(95%CI:[2.109,5.973]); however, there was no statistical significance of the hazard rate ofcardiac death, stroke, non-fatal myocardial infarction, andre-revascularization. The survival analysis showed that there was nosignificant diffence of the survival rate (P=0.0633) and there wasstatistically difference of non-MACCE rate among3groups (P<0.0090)with group>16as the worst.Conclusion: In the CAD patients with mild to moderate renalinsufficiency, the prognosis of revascularization was better in the patients with lower SYNTAX score. The SYNTAX score is a good predictor forpredicting the all-cause motality and MACCE of revasculation in CADpatients with mild to moderate renal insufficiency.