Features of cardiorenal relationships in patients with ischemic heart disease and renal artery stenosis

Co-Existence of Carotid Artery Disease, Renal Artery Stenosis, and Lower Extremity Peripheral Arterial Disease in Patients With Coronary Artery Disease

The primary goal of this American Heart Association renal intervention writing group was to discuss current controversies related to renal interventions and to recommend important areas of clinical research and advocacy initiatives in this peripheral arterial bed. The 4 areas covered in this section include (1) management of asymptomatic renal artery disease, (2) treatment of ischemic nephropathy, (3) prevention and treatment of atheroembolism in renal artery interventions, and (4) treatment of renal in-stent restenosis (ISR). Atherosclerotic renal artery disease is an often unrecognized contributor to refractory hypertension, renal insufficiency, and increased risk of cardiovascular death.1,2 Renal artery disease is associated with increased cardiovascular events (myocardial infarction, stroke, and death), and when associated with symptomatic coronary artery disease, it independently doubles the risk of death.3 Additionally, the presence of bilateral renal artery stenoses is associated with a reduced 4-year survival rate when compared with unilateral disease (47% versus 59%, P <0.001).3 Hypertension, renal insufficiency, and multisystem atherosclerosis are common entities, and the independent occurrence of these conditions is frequent. Thus, the physician must distinguish between association and causation in the evaluation of patients with atherosclerotic renal artery disease and critically appraise the potential for clinical improvement in selecting patients for renal artery intervention. In contrast to other regional manifestations of atherosclerosis, it is impractical to classify patients with atherosclerotic renal artery disease into symptomatic or asymptomatic categories. Two of the cardinal manifestations of renal artery disease, hypertension and renal insufficiency, are frequently “silent” with regard to clinical manifestations until end-organ damage or uremia occurs. Thus, the majority of patients may be deemed asymptomatic. A more appropriate classification of patients with atherosclerotic renal artery disease may be to classify them in relation to potential clinical consequences. We propose the following classification scheme in patients with renal artery disease:

Analysis of the Third National Health and Nutrition Examination Survey (1988 to 1994) suggests that chronic kidney disease (CKD) is a major public health problem (1). Approximately 11% of the US population has CKD. Roughly half have a GFR <60 ml/min per 1.73 m2 with or without kidney damage (stages 3 to 4), and half have exclusively kidney damage as manifested by microalbuminuria (stages 1 to 2) (2). It is widely recognized that the prevalence of stage 5 CKD is also increasing at a rapid rate, and it is estimated that the number of patients who have ESRD may reach 2.24 million by 2030 (3). Evidence to establish reduced GFR as an independent risk factor for cardiovascular disease (CVD) mortality has emerged. Analysis of data from several population-based epidemiologic studies (4,5) demonstrates poorer outcomes regarding stroke, myocardial infarction, and congestive heart failure (CHF) in patients with even mild compromise of kidney function. The morbidity of this group of patients constitutes an economic burden both directly in terms of resource utilization and indirectly through loss of productivity and impaired quality of life (2). Atherosclerotic renovascular disease (ARVD) can result in renovascular hypertension. However, ARVD is an increasingly recognized cause of CKD (6,7). In this article, we focus mainly on ARVD or renal artery stenosis (RAS) secondary to atherosclerosis as a cause of ischemic nephropathy. ARVD is a disease of aging, and several studies have shown its strong association with extrarenal atherosclerotic disease (8–10). Patients with ARVD seem to be at a much greater risk for cardiovascular death than for progressing to renal replacement therapy (11). Whether renal revascularization can benefit renal and cardiovascular outcomes has not been established. Atherosclerosis is the cause of approximately 90% of RAS in adults who are older …

Atherosclerotic renal artery stenosis (RAS) is more common than has been previously appreciated1,2 and is an independent predictor of death regardless of the presence, severity, or method of revascularization of coronary artery disease.3–5 Among 1235 patients undergoing diagnostic coronary angiography, multivariate analysis demonstrated that RAS (>50%) was a stronger independent predictor of all-cause mortality (relative risk [RR], 2.9; 95% confidence interval [CI], 1.7 to 7.0) than congestive heart failure (RR, 2.3; 95% CI, 1.3 to 4.1), elevated left ventricular ejection fraction (RR, 1.7; 95% CI, 1.2 to 2.2), or decreased renal function (serum creatinine) (RR, 1.3; 95% CI, 1.1 to 1.5).3 A subsequent expansion of that study group, extended to 3987 patients undergoing abdominal aortography at the time of diagnostic cardiac catheterization, identified an incremental effect of the severity of RAS on the 4-year mortality rates. They found that a mild-to-moderate (50%) RAS was associated with a 30% 4-year mortality rate, which almost doubled (52%) with severe (>95%) RAS.4 The cause-and-effect relation between RAS and death is uncertain. It is possible that the presence of RAS is simply a marker for more diffuse or extensive atherosclerosis, which would result in more vascular-related deaths. However, there is one study5 that raises the possibility that the treatment of RAS with a renal stent in patients with renal insufficiency can improve mortality rates. In this trial, patients who improved their renal function after renal stent placement had significantly better survival rates compared with those whose renal function did not improve. A dedicated educational effort aimed at improving the diagnosis and treatment of peripheral arterial disease, including RAS, has been supported over the past 10 years by several professional societies.6–8 There is now objective evidence from the Medicare database that this effort to increase the number of patients …

Data about renal artery stenosis association with left ventricular remodeling in patients coexisting with coronary artery disease are scanty. Patients with suspected both coronary artery disease and renal artery stenosis undergoing coronary and renal arteriography between October 2013 and December 2015 were prospectively enrolled. Left ventricular remodeling patterns were compared among different severity of renal artery stenosis group. Logistic regression was done to investigate the determinants of the left ventricular morphology. The overall prevalence of left ventricular hypertrophy was 40.5%, the highest in bilateral renal artery stenosis group compared to unilateral or normal ones (65.4% versus 41.8% versus 34.8%, p = 0.012). Significantly lower estimated glomerular filtration rate and higher cystatin C level were found in bilateral renal artery stenosis group than that in other two groups. Multivariate regression analysis showed that bilateral renal artery stenosis was associated with increased left ventricular hypertrophy and concentric hypertrophy with statistical significance (adjusted odds ratio = 2.909 (95%CI: 1.063-7.961), and 3.021 (95%CI: 1.136-8.033)). In addition, estimated glomerular filtration rate level was also related to left ventricular hypertrophy, while there was no significant interaction between renal artery stenosis and coronary artery disease on left ventricular hypertrophy/concentric hypertrophy occurrence. Bilateral renal artery stenosis is significantly associated with increased left ventricular hypertrophy/concentric hypertrophy in patients with suspected concomitant coronary and renal artery disease, while no synergic effect could be found in coronary artery disease.

Analysis of Recent Papers in Hypertension Jan Basile, MD, Senior Editor

To explore the relationship between coronary artery disease and renal vascular disease, we performed renal arterial angiography in 609 patients undergoing coronary angiography for suspected coronary artery disease. We defined renal artery stenosis as nonsignificant (< 40%), borderline (40-60%) and significant (> 60%). One-hundred fifty-two patients had renal artery stenosis, while 457 did not. Two-hundred and ten patients had no coronary disease; of these, only 9 had renal artery stenosis. On the other hand, the 143 patients with renal artery stenosis, when subdivided, had similar degrees of coronary disease; three vessel disease was significantly more common than one or two vessel disease in all groups. Renal artery stenosis of all severity degrees was associated with common atherosclerotic risk factors. However, hypertension was not a clue to the presence of renal artery stenosis. To evaluate the effect of percutaneous revascularization on hypertension and renal function all 51 patients with significant renal artery stenosis were treated by primary stent implantation and were followed up for 6 months. Stent implantation showed a marked decrease in systolic and diastolic blood pressure (163 +/- 30 to 145 +/- 17 and 93 +/- 18 to 83 +/- 10 mmHg; p = 0.008) with a decrease in the amount of antihypertensive medication but without beneficial effect on serum creatinine during follow-up (1.46 +/- 0.70 mg/dl to 1.39 +/- 0.58 mg/dl, p = ns). We conclude that renal artery stenosis of any severity is strongly suggestive of three vessel coronary artery disease. The fact that renal stenting lowers blood pressure decreases antihypertensive drugs and increases medication flexibility in patients with coronary artery disease would support the notion of revascularization in patients with significant stenoses.

肾的动脉狭窄(地岬) 是能引起不受管束的高血压并且导致肾的功能的进步恶化的一个经常俯看的临床的实体。经历了服、肾的动脉 angiography 并且联合了干涉治疗的有与服的动脉狭窄(CAS ) 复杂的地岬的 Weobserved 20 病人。临床的后续被执行超过 3 年。

Atherosclerotic renovascular disease in the United States

The coronary risk of unsuspected renal artery stenosis

Background/Objectives: Renal artery stenosis (RAS) is associated with coronary artery disease (CAD), exacerbation of arterial hypertension, and progression to heart failure, but remains frequently unrecognized in clinical practice. Methods: We conducted a systematic review and meta-analysis of studies by pooling data of patients undergoing CAG due to suspected or stable CAD that received a bilateral renal artery angiography. Results: A total of 31 studies with 31,689 patients were included (mean age 63.2 ± 8.7 years, 20.9% were female). Overall, 13.4% (95%CI 10.5-16.7%) of patients undergoing coronary angiography had significant RAS, with 6.5% (95% CI 4.5-8.9%) and 3.7% (95%CI 2.5-5.2%) having severe and bilateral RAS. The mean weighted proportion of patients with three-vessel coronary disease (3VD) was 25.1 (95%CI 19.6-30.9%) while 4.2% (95%CI 2.6-6.2%) had left main (LM) coronary disease. Patients with RAS compared to those without RAS were significantly older (mean difference, MD 4.2 years (95%CI 3.8-4.6)). The relative risk of RAS was greater for the female sex (risk ratio, 95%CI; RR 1.3, 1.03-1.57), presence of diabetes (RR 1.2, 1.10-1.36), arterial hypertension (RR 1.3, 1.21-1.46), dyslipidemia (RR 1.1, 1.06-1.14), peripheral artery disease (PAD) (RR 2.1, 1.40-3.16), chronic kidney disease (CKD) (RR 2.6, 2.04-3.37), 3VD (RR 1.6, 1.30-1.87), and LM disease (RR 1.8, 1.28-2.47). Smoking had a neutral effect on the risk of RAS occurrence (RR 1.0, 0.94-1.06). Conclusions: RAS is common in patients undergoing coronary angiography. CKD, PAD, older age, and severe CAD were among the strongest predictors for the presence of significant RAS.

Background: Aim of our present study was to evaluate the extent of Renal Artery Stenosis(RAS) in patients with Coronary Artery disease (CAD) in context of Bangladesh demographic distribution. Methods: Total 100 patients with renal artery disease were randomized from a pool of 1200 patients who were underwent routine diagnostic coronary angiogram for the evaluation of extent of their CAD. Renal arteries were studied at the same time. Among the patients, Male: 64 and Female: 36. Mean age were for Male: 62yrs, for Female: 58 yrs. Associated CAD risk factors were Dyslipidemia, High Blood pressure, Diabetes Mellitus, Positive FH for CAD and Smoking. Results: Our study results show 100 patients (12% of the sample) had RAS lesion out of total 1200 patient who underwent routine CAG. Sex distribution is male 64 (64%), Female 36 (36%). Among the study group; 79 (79%) were hypertensive; 57 (57%) were Dyslipidemic, 54 (54%) patients were Diabetic, 27 (27%) were smoker (all male) and 18(18%) were having positive FH for CAD. Female patients were more obese and developed CAD in advanced age (male: 53.5 Versus Female:64 yrs). We found that the Prevalence’s of RAS is more in patients with TVD (43%), followed by DVD (10%) and SVD (10%), Minor to mod CAD (14%) and angiographically normal coronaries (23%). Significant (&gt;50% Stenosis) Left renal artery stenosis were found in 27 patient and 23 had significant Right renal artery stenosis. Total 8 patents had significant both renal artery stenosis. Conclusion: Renal artery stenosis is one of the most important peripheral vascular disease, needing to be diagnosed early and subsequent intervention to keep continuity of renal blood flow. In the present study, we found that the significant association of Renal Artery Stenosis in patients with CAD. Incidence of RAS is more in patients with TVD. Therefore, we recommend routine Renal angiogram during coronary angiography. Keywords: Renal artery stenosis; Coronary Artery Disease DOI: 10.3329/cardio.v2i2.6636Cardiovasc. j. 2010; 2(2) : 179-183

Association of Plaque Composition and Vessel Remodeling in Atherosclerotic Renal Artery Stenosis: A Comparison With Coronary Artery Disease

To explore the prevalence and risk factors of atherosclerotic renal artery stenosis (ARAS) in patients undergoing coronary angiography. A total of 2506 patients with suspected and known coronary heart disease (CAD) at our hospital underwent simultaneous coronary and renal angiography. Renal artery stenosis was defined as at least one of renal artery stenosis ≥ 50% narrowing of luminal diameter. The prevalence of ARAS was summarized from the results of angiography. And single- and multi-variable logistic regression analysis was used to assess the relationship between clinical characteristics and ARAS. Among them, there were 1479 males and 1027 females with a mean age of 62.7 ± 11.4 years. ARAS was detected in 409 patients (16.3%), including 214 (8.5%) with significant stenosis (≥ 75%); Bilateral ARAS was detected in 98 patients (3.9%), including 27 (1.1%) with significant stenosis (≥ 75%). Left and right ARAS were detected in 162 patients (6.5%) and 148 patients (5.9%) respectively, including 84 patients (3.4%) with significant stenosis (≥ 75%) in left ARAS and 72 patients (2.9%) in right ARAS. Univariate analysis indicated that age, females, diabetes, hypertension, stroke, peripheral artery disease, coronary heart disease, renal insufficiency, dyslipidemia and hyperuricemia were the predictor for ARAS (P < 0.05 or 0.01). Multivariate regression analysis demonstrated that age ≥ 65 years (P = 0.025, OR = 1.358), females (P < 0.01, OR = 1.678), hypertension (P < 0.01, OR = 1.650), peripheral artery disease (P < 0.01, OR = 14.678), renal insufficiency (P < 0.01, OR = 1.835), coronary heart disease including 3-vessel (P < 0.01, OR = 1.746) and left main coronary (P < 0.01, OR = 3.416)disease were independent risk factors for ARAS. Renal angiography should be routinely performed in female patients aged ≥ 65 years with hypertension, peripheral artery disease, elevated creatinine and coronary heart disease, especially for 3-vessel and left main coronary disease to identify ARAS in time.

Multivessel coronary disease or peripheral arterial disease is the clinical clue to diagnosis of renal artery stenosis (RAS). RAS is considered equivalent to coronary artery disease in terms of cardiovascular risk. In this study, we evaluated the incidence of RAS in the patients who were proposed to undergo coronary artery bypass grafting (CABG). Diagnostic evaluations of coronary arteriography and renal artery angiography were performed during the same procedure; the patients who were proposed for CABG in terms of CAD anatomy and clinical manifestation were enrolled. RAS was evaluated and a diameter stenosis of ≥50% was considered as significant RAS; significant RAS patients were divided into five groups. The five groups of RAS were as follows: (1) unilateral RAS ≥50–70%, (2) unilateral RAS ≥70%, (3) bilateral RAS ≥50–70%, (4) one-renal-artery stenosis ≥50–70%, contralateral RAS ≥70%, and (5) bilateral renal artery stenosis ≥70%. A total of 151 patients were enrolled, and RAS (≥50% stenosis in either or both renal arteries) was identified in 47.02% (71/151) patients. Unilateral RAS ≥50–70% was identified in 16.6% (25/151) patients, unilateral RAS ≥70% in 4.6% (7/151) patients, bilateral RAS ≥50–70% in 7.9% (12/151) patients, one-renal-artery stenosis ≥50–70% and contralateral RAS ≥70% in 7.9% (12/151) patients, and bilateral RAS ≥70% was in 9.9%(15/151) patients. The incidence of RAS was 29.03% (18/62) in patients aged ≤60 years, 60% (36/60) in patients aged >60 and ≤70 years, and 58.62% (17/29) in patients aged >70 years. The incidence of RAS was significantly higher in patients aged >60 - ≤70, and >70 years than patients aged ≤60 years (P = 0.001 and P = 0.007, respectively). There was a trend that the incidence of RAS in patients with hypertension [HTN, 50.40% (64/127)] was higher than those without HTN (29.17%, 7/24), with P = 0.056. The incidence of RAS was 47.02% in patients who were proposed for CABG; bilateral RAS of ≥70% was 9.9%. Older age and HTN were associated with RAS in patients who were referred for CABG. This study indicates that the incidence of RAS was high in the patients referred for CABG, and the renal function should be taken care of.