Prognostic Study Of Coronary Heart Disease In Patients With Advanced Chronic Kidney Disease

BackgroundPatients with advanced chronic kidney disease(1GFR<30ml/min/1.73m2 or dialysis)and coronary heart disease(CHD)belong to a special group of people with CHD.The sample size is limited in the special group,and the symptoms of CHD in this group are diverse and atypical,and the progress is hidden[1].Because of the high baseline risk of mortality and cardiovascular events,clinicians are often trapped in the decision-making of revascularization[2]The composition and characteristics of coronary plaque[2],the accuracy of noninvasivG examination,the response and prognosis of revascularization and drug treatment between this special group and the general population are different,and these problems cannot be mechanically applied from the guidance of the general population.At present,most of the randomized controlled studies exclude the patients with coronary heart disease complicated with advanced chronic kidney disease.There is a lack of unified cognition and management for this special group.They are highly challenging to treat and has a poor prognosis,because of the complex and severe coronary lesions,which belongs to the "focal spot" touched by cardiologists.As for the patients with coronary heart disease complicated with advanced chronic kidney disease,which is the best choice between the three main treatment methods:coronary artery bypass grafting(CABG),percutaneous coronary intervention(PCI)and drug conservative therapy?There are still different opinions and no final conclusion.There is no unified treatment guideline at home and abroad.Does revascularization benefit this special group?It is still unknown.The choice of treatment plan is related to the clinical outcome and long-term prognosis of each patient,which is a medical problem that needs to be paid attention to and solved.ObjectiveTo investigate the effect of PCI,CABG and drug conservative therapy on the prognosis of patients with coronary heart disease and advanced chronic kidney disease.MethodsA retrospective study was conducted on 148 patients with advanced chronic kidney disease and coronary heart disease(CHD)from January 2011 to June 2019 in the central and northern areas of China Japan Friendship Hospital.According to the treatment strategy,the patients were divided into 20 patients in CABG group,85 patients in PCI group and 43 patients in drug conservative treatment group.The baseline clinical data of 148 patients during hospitalization were reviewed.All patients were followed-up by telephone,outpatient and email.The correlation of baseline clinical data,in-hospital mortality,all-cause death,cardiogenic death,adverse cardiovascular and cerebrovascular events(MACCE)and the difference between non dialysis patients and dialysis patients in each group was compared.The influencing factors of prognosis in patients with coronary heart disease complicated with advanced chronic kidney disease were analyzed.Results1.A total of 148 patients were included in the analysis,with an average age of 60.28 ±6.57 years.In CABG group,the proportion of hypertention was higher(16/80.00%),the dyslipidemia was higher(15/75.00%),and the LVEF was lower(51.50±6.92).The PCI group was younger(59.51 ± 6.77),the proportion of diabetes mellitus was higher(32/37.67%),and there was a higher proportion of smoking history(22/25.88%)and hyperparathyroidism(39/45.88%)and it had a higher mean systolic blood pressure(145.38 ±15.04).2.The laboratory index showed that HGB in CABG group was the lowest(106.45 ±17.80),and HGB in drug group was the highest(111.93±13.17).There was no significant difference in blood glucose,TG,TC,LDL-C and Scr.LVEF(51.50±6.92)of CABG group was the lowest,and the difference has statistically significant.3.Results of coronary angiography showed that the left main lesions,three vessel lesions,two vessel lesions and the diffuse lesions among 148 patients was15.54%、46.62%、35.14%and 45.27%,respectively.There was no significant difference between the three groups in terms of direct vascular structural lesions,and there was a significant difference in Gensini score(50.00 ± 19.62).CABG group(59.20 ± 21.23)got the highest score,and drug treatment group the lowest(38.09± 18.55).4.Results of drug using during the follow-up period revealed that all patients in each group had high compliance.The rates of patients using aspirin,clopidogrel,statin and beta-blocker were 96.62%,89.86%,88.51%and 69.59%,respectively.The utilization rate of ACEI/ARB was 50.00%.There was no statistical difference in drug use among the groups.5.End point event comparison showed that there was no significant difference in complications,mortality,all-cause death,cardiogenic death,adverse cardiovascular and cerebrovascular events(MACCE)and safety outcomes between CABG group,PCI group and drug treatment group(P>0.05).6.The survival analysis of CABG group,PCI group and drug treatment group was conducted by KM curve,and it was found that there was no statistical difference in all-cause death,cardiogenic death and MACCE.At the same time,KM curve survival analysis of three vessel lesions and non three vessel lesions showed that all-cause death,cardiogenic death and MACCE increased significantly compared with non three vessel lesions,among which all-cause death,cardiogenic death and MACCE all had statistical difference(P<0.05).The survival analysis of safety outcomes showed that there was no significant difference among the three groups(P>0.05).7.Cox multivariate prediction analysis showed that hypertention,diffuse lesions and hemoglobin reduction were independent risk factors of all-cause death.Hemoglobin reduction was an independent risk factor of cardiogenic death,and statin was an independent protective factor of cardiogenic death.Diffuse lesions,history of cerebral infarction and smoking history were independent risk factors of MACCE;LVEF elevation and CABG were independent protective factors of MACCE.8.Cox multivariate regression analysis found that compared with the drug group,the risk of all-cause death and cardiogenic death in CABG and PCI group had no statistical difference whether the model was adjusted or not.As to MACCE,there was no statistical difference whether the model was adjusted or not in PCI group.In CABG group,when the model was not adjusted,the risk of MACCE was no statistical difference between CABG group and drug treatment group;When the factors were adjusted,the hazard ratio was 0.139(95%CI:0.031-0.622)in model 2(adjusted gender,age,hypertension,diabetes,dyslipidemia,smoking history,history of early coronary heart disease,hyperparathyroidism,cerebral infarction),0.017(95%CI:0.002-0,165)in adjusted model 3(model 2+LVEF+hemoglobin)and 0.012(95%Cl:0.001-0.131)in adjusted model 4(model 3+ Gensini score).ConclusionCompared with drug conservative treatment,PCI do not reduce the incidence of all-cause death,cardiogenic death and MACCE.Although CABG can not decrease the incidence of all-cause death and cardiogenic death,it may decrease the incidence of MACCE.BackgroundIn the clinical follow-up process,we found that there was a considerable number of patients with death or MACCE,so it was particularly important to pay attention to the prognosis of such severe patients.At present,there is no specific prediction model for the prognosis of patients with coronary heart disease complicated with advanced chronic kidney disease at home and abroad,and we also lack a model to predict prognosis in patients with coronary heart disease complicated with advanced chronic kidney disease.If there is a simple prediction model that can early identify "the most high-risk patients "and predict the mortality and MACCE rate of this special population in advance,it will have an early warning effect on the short-term prognosis of patients.It will be very helpful to improve the emergency treatment ability of clinicians for this kind of high-risk patients,and has important clinical application value.Most of the coronary heart disease complicated with advanced chronic kidney disease belong to ACS.At present,the global acute coronary event registration study(GRACE)was one of the most widely used risk scores for prognosis judgment of ACS in the world.It was also the largest global ACS registration study at present.It was applicable to all kinds of ACS population,including ACS patients with renal insufficiency,and dialysis was also included in GRACE study.Therefore,we theoretically speculate that GRACE score can be used to predict the prognosis of ACS patients complicated with advanced chronic kidney disease,and it also has some clinical applications.However,theory is not equal to practice.Although patients on dialysis were included in the GRACE study,ACS patients complicated with advanced chronic kidney disease,after all,belonged to a small sample.With the development of medical technology,it has been 20 years since GRACE research.In the past 20 years,the development of various scientic techniques and the overall improvement of medical technology have improved the clinical outcome and prognosis of ACS patients complicated with advanced chronic kidney disease.Whether GRACE score can be used as an evaluation tool to accurately evaluate the prognosis of ACS patients complicated with advanced chronic kidney disease neither reported in China nor abroad.For ACS patients complicated with advanced chronic kidney disease,a simple and feasible risk prediction model is also needed to make an accurate judgment on the prognosis of this special group.Objective:To compare the difference of GRACE score and risk stratification between advanced chronic kidney disease group and normal renal function group,and to explore the predictive value of GRACE risk score in risk stratification and prognosis of patients with advanced chronic kidney disease and acute coronary syndrome.Methods:From January 2011 to June 2019,136 ACS patients with advanced chronic kidney disease(eGFR<30ml/min/1.73m2 or dialysis)were included as the experimental group.136 ACS patients with normal renal function were randomly selected as the control group.GRACE scores of all 272 ACS patients were calculated.According to GRACE score formula,136 patients in the experimental group were calculated the in-hospital mortality,mortality and incidence of myocardial infarction within six-month after discharge.1.The general clinical data(age,gender,hypertension,diabetes,dyslipidemia,blood glucose,TG,TC,LDL-C,HDL-C,creatinine,eGFR)of the two groups were compared.The GRACE score and risk stratification of the two groups were statistically analyzed.The in-hospital mortality,mortality and MACE within six-month after discharge between the two groups were statistically analyzed.2.To compare and analyze the difference between the actual in-hospital mortality and the in-hospital mortality predicted by GRACE score,and whether the difference is statistically significant.3.To compare and analyze the difference between the actual mortality and incidence of myocardial infarction within six-month after discharge and which predicted by GRACE score,and whether the difference is statistically significant.4.Logistic regression analysis was used to analyze the independent risk factors of in-hospital death and death within 6 months after discharge.5.Linear regression model was used to determine the correlation between the above independent risk factors and GRACE score.6.ROC and AUC were used to evaluate the predictive effect of the improved GRACE score on the in-hospital mortality and mortality within six-month after discharge of ACS patients complicated with advanced chronic kidney disease.Results:1.The score of GRACE in advanced chronic kidney disease group was significantly higher than that in normal renal function group,the number of high-risk group was significantly higher than that in normal renal function group,and the number of low-risk group was significantly lower than that in normal renal function group.2.The in-hospital mortality,mortality within 6 months after discharge and MACE in the advanced chronic kidney disease group were higher than those in the normal renal function group.3.The actual in-hospital mortality in the group of advanced chronic kidney disease was higher than that estimated by GRACE score(P<0.05);the mortality and incidence of myocardial infarction within six months after discharge of the group with advanced chronic kidney disease was also higher than that estimated by GRACE score(P<0.05).4.Gensini score is an independent risk factor of in-hospital death in patients with advanced chronic kidney disease and ACS.Hemoglobin reduction is an independent risk factor of death in patients with advanced chronic kidney disease and ACS within 6 months after discharge.5.There was a linear correlation between Gensini score and GRACE score.The higher Gensini score was,the higher GRACE score was.GRACE score was correlated with the degree of coronary lesions in ACS patients with advanced chronic kidney disease.The combination of GRACE score and Gensini score can improve the predictive value of mortality during hospitalization in ACS patients with advanced chronic kidney disease.ConclusionGRACE score can be used to classify the risk of ACS patients with advanced chronic kidney disease and identify the high-risk patients.The risk and prognosis of ACS patients with advanced chronic kidney disease are significantly different from those with normal renal function.GRACE score can not only predict death during hospitalization and six months after discharge,but also can predict the incidence of myocardial infarction six months after discharge,but it may underestimate the risk.The combination of Gensini score and GRACE score can improve the predictive value of ACS patients with advanced chronic kidney disease,which needs to be further verified by a large sample model.