Comparisons of invasive versus conservative management in chronic kidney disease in the ISCHEMIA-CKD trials

1. Following invasive or conservative management of chronic coronary disease, patients with chronic kidney disease (CKD) stage 5 were found to have a significantly higher 3-year cumulative incidence of death and nonfatal myocardial infarction than patients with CKD stage 1.

2. In patients who received either conservative or invasive management of chronic coronary disease, there was no significant difference in 3-year cumulative incidence of death or nonfatal myocardial infarction between the two groups across the different stages of chronic kidney disease.

3. Invasive management versus conservative management of chronic coronary disease was associated with significant improvement of quality-of-life parameters 1 year following randomization, as measured by the Seattle Angina Questionnaire summary score, in patients with CKD stages 1, 2, and 3, but not in CKD stages 4 and 5.

Evidence Rating Level: 2 (Good)

Previous trials comparing invasive versus conservative management of patients with chronic coronary disease (CCD) typically exclude or involve very few patients with severe kidney disease. Thus, current treatment guidelines for CCD are not based on evidence that includes varying levels of kidney function. Prior studies have found that decreased kidney function is associated with higher risks of invasive procedures and increased rates of cardiovascular events. Given this, kidney function often influences treatment decisions, and it is important to investigate for any heterogeneity of treatment benefit based on existing kidney function. The International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA) trial recruited patients with varying levels of kidney function. This study is a post-hoc analysis of the ISCHEMIA and ISCHEMIA-CKD trials. The ISCHEMIA trial recruited participants with CCD and randomized them in a 1:1 ratio to either invasive or conservative management. Invasive management included coronary angiography followed by revascularization with either percutaneous intervention or a coronary artery bypass graft in addition to guideline-directed medical therapy (GDMT), while the conservative management group received GDMT only. 5956 participants were included in this analysis with 1889 (32%), 2551 (43%), 738 (12%), 311 (5%), 467 (8%) patients in CKD stages 1, 2, 3, 4, and 5 respectively. The primary clinical outcome was death or nonfatal myocardial infarction (MI), while the primary quality of life (QoL) outcome was based on the Seattle Angina Questionnaire (SAQ) summary score at 1 year after randomization. Patients with CKD stage 5 were found to have a significantly greater 3-year cumulative incidence of death and MI than patients with CKD stage 1 (p<.001). However, in terms of heterogeneity of treatment benefit, there was no significant difference in death or MI between the invasive and conservative management groups across the spectrum of kidney disease (p=.62). With respect to QoL, invasive management was associated with a significant improvement in QoL parameters in patients with CKD stages 1-3 (p<.001), but this significant improvement was not present in patients with CKD stages 4 and 5. Study findings, as with the ISCHEMIA trial, may be used to further inform practitioners during shared decision making with patients on the relative efficacy of invasive versus conservative management at different stages of disease.

Click here to read the study in JAMA Cardiology

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