Invasive Management of Coronary Disease Less Beneficial as CKD Worsens


A recent analysis of the ISCHEMIA program suggests invasive management of chronic coronary disease appeared to provide a greater degree of benefit in those with less advanced stages of chronic kidney disease.

An earlier version of this article appeared on

Sripal Bangalore, MD

Sripal Bangalore, MD

New research leveraging data from the ISCHEMIA study suggests quality of life outcomes may have better odds of improvement following invasive management in patients with less advanced chronic kidney disease (CKD).

An analysis assessing the benefits of invasive versus medical management of chronic coronary disease, the results of the study demonstrate a low degree of benefit was seen with invasive management compared to the benefit observed for patients with more advanced CKD.

“Invasive management was associated with an increase in stroke and procedural myocardial infarction and a reduced risk in spontaneous myocardial infarction, and the effect was similar across CKD stages with no difference in other outcomes, including death,” wrote study author Sripal Bangalore, MD, of the New York University Grossman School of Medicine.

The investigators noted the guideline recommendations on the treatment of patients with chronic coronary disease are therefore not predicated according to underlying kidney function or CKD stage. Thus, they aimed to evaluate clinical and quality of life outcomes across the spectrum of CKD following conservative and invasive treatment strategies.

Participants with moderate or severe ischemia on stress testing, with and without advanced CKD, were randomized in the ISCHEMIA-CKD and ISCHEMIA trials, respectively. They were categorized based on baseline kidney function into CKD

  • Stage 1 (estimated glomerular filtration rate [eGFR] 90 mL/min/1.73m2 or greater)
  • Stage 2 (eGFR 60 - 89 mL/min/1.73m2)
  • Stage 3 (eGFR 30-59 mL/min/1.73m2)
  • Stage 4 (eGFR 15-29 mL/min/1.73m2)
  • Stage 5 (eGFR less than 15 mL/min/1.73m2 or receiving dialysis)

The initial invasive management of coronary angiography and revascularization with guideline-directed medical therapy (GDMT) was compared to the initial conservative management of GDMT alone. Enrollment occurred between July 2021 and January 2018.

The primary clinical outcome was considered the composite of death or nonfatal myocardial infarction (MI), while the primary quality of life outcome was the Seattle Angina Questionnaire (SAQ) summary score.

A total of 5956 participants were included in the analysis (mean age, 64 years; 1410 [24%] female and 4546 [76%] male). From the total population, 1889 (32%) were in CKD stage 1, 2551 (43%) in stage 2, 738 (12%) in stage 3, 311 (5%) in stage 4, and 467 (8%) were in stage 5.

The self-report of demographics saw 18 participants (less than 1%) were American Indian or Alaska Native, 1676 (29%) were Asian, 267 (5%) were Black, 861 (16%) were Hispanic or Latino, 18 (less than 1%) were Native Hawaiian or other Pacific Islander, and 3884 (66%) were White. A total of 13 participants (less than 1%) were of multiple races or ethnicities.

Investigators observed an increase in the risk of primary endpoint (3-year rates, 9.52%, 10.72%, 18.42%, 34.21%, and 38.01%, respectively), death, cardiovascular death, myocardial infarction, and stroke in individuals with higher CKD stages).

Moreover, they found invasive management was associated with an increase in stroke (3-year event rate difference, 1%; 95% CI, 0.3 to 1.7) and procedural MI (1.6%; 95% CI, 0.9 - 2.3), with a decrease in spontaneous myocardial infarction (-2.5%; 95% CI, -3.9 to -1.1). This was noted to be similar across CKD stages.

Heterogeneity of treatment effect for quality of life outcomes was observed. Invasive management improved angina-related quality of life in patients with CKD stages 1 to 3 and not in those with CKD stages 4 to 5.

The study, “Clinical and Quality-of-Life Outcomes Following Invasive vs Conservative Treatment of Patients with Chronic Coronary Disease Across the Spectrum of Kidney Function,” was published in JAMA Cardiology.

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