Comparison of percutaneous coronary intervention versus medication in dialysis patients with coronary artery disease

Abstract

Abstract Background There is a lack of evidence for the optimal management of dialysis patients complicated with coronary artery disease (CAD). Based on the favorable results from patients with normal or near-normal kidney function, percutaneous coronary intervention (PCI) has extended to patients on maintenance dialysis. However, it is unknown whether this extrapolation is accurate. Purpose We sought to investigate the benefits of PCI in dialysis patients with CAD. Methods Between January 2015 and June 2021, 455 617 consecutive cardiac catheterizations from 30 cardiac centers in China were reviewed retrospectively through medical records. Patients with normal coronary anatomy, those who did not receive dialysis therapy or received dialysis for less than 3 months, those who received coronary artery bypass grafting, repeat admissions, and those with less than one year of follow-up were excluded. Patients were followed up via telephone interviews or clinic visits until June 2022. The primary outcome of interest was 1-year all-cause mortality, and the secondary outcome of interest was 1-year cardiac death. Cox proportional hazards regression model was used to assess the association of PCI with outcomes. Inverse probability of treatment weighting was used to control for imbalances in patient characteristics. Results Of 1 119 patients who met the final criteria, 799 (71.4%) received PCI. The mean age was 61.9±10.6 years, and 828 (74.0%) were male. Compared with medically treated patients, patients in the PCI group were more likely to present with a high Gensini score, be with multivessel diseases, and receive dual antiplatelet and statin therapy. Overall, 201 (16.4%) all-cause deaths were documented, with 153 (13.7%) cardiac deaths. Patients treated with PCI experienced significantly lower cumulative rates of 1-year all-cause deaths (15.5% vs. 24.1%, log-rank p<0.001) as well as cardiac deaths (11.5% vs. 19.1%, p<0.001). Multivariate analyses showed that PCI was independently associated with a lower risk of either all-cause deaths (hazard ratio 0.48, 95% confidence interval 0.36-0.64, p<0.001) or cardiac mortality (hazard ratio 0.45, 95% confidence interval 0.30-0.61, p<0.001). These findings were further confirmed in the inverse probability of treatment weighting cohort. Conclusion This cohort study found that in real-world practice, among dialysis with CAD, use of PCI was associated with significantly lower risks for 1-year all-cause death or cardiac mortality compared with medical management. Further prospective studies are needed to confirm these findings.