Impact of chronic kidney disease on short term clinical outcomes of patients undergoing coronary revascularization

When compared with medical treatment, coronary revascularization is an effective tool to restore cardiac functions in patients suffering from chronic kidney disease but at times it is associated with poor clinical outcome. This study was done to determine the short term clinical outcome in chronic kidney disease patients undergoing coronary revascularization i.e coronary artery bypass graft or percutaneous coronary intervention. Cross sectional study, conducted at coronary revascularization center of Aga Khan University Hospital, Karachi between January 2012 and August 2013. All chronic kidney disease patients were enrolled and grouped into mild, moderate and severe kidney disease cases according to creatinine clearance estimated by the Cockroft-Gault equation. The primary outcome was in-hospital major adverse cardiac cerebral events, including myocardial infarction, stroke, and death. A total of 159 patients were included in the study [122 males and 37 females] whose mean age was 65 +/- 9.6 years. Based on the creatinine clearance, 59 cases had severe, 79 moderate and 21 mild chronic kidney disease. Before revascularization, 20 patients with severe, 3 patients with moderate and 2 patients with mild kidney disease were on long term hemodialysis. In the moderate to severe group, 79 patients underwent percutaneous coronary intervention whereas, in the mild group, 15 patients underwent coronary artery bypass graft. Though the rate of failed PCI [uncrossable total occlusions of coronary artery] was similar among the 3 groups but complete revascularization was more evident 18 [85.7% and 60 [75.9%] in mild to moderate cases respectively. During hospitalization, 9 [15.3%] patients died in severe cases out of whom 2 [3.4%] died due to cardiogenic cause and 7 [11.9%] died due to non-cardiogenic causes. Mortality in moderate group was similar 9 [11.4%] and among them, 2 patients died due to cardiogenic cause and rest due to non-cardiogenic cause but none died in mild group. Though all 3 groups of chronic kidney disease patients had similar clinical and angiographic findings but poor clinical outcome was noted in patients having moderate to severe chronic kidney disease irrespective of whether they underwent PCI or CABG

Mode of coronary revascularization and short term clinical outcomes in patients with chronic kidney disease

Percutaneous coronary intervention [PCI] and coronary artery bypass graft [CABG] surgery are two alternative methods for coronary revascularization, but it remains controversial as which one is associated with lower risks of worse clinical outcomes for chronic kidney disease [CKD] patients. We determined the mode of coronary revascularization [PCI vs. CABG] which is associated with lower risk of mortality and morbidity in CKD patients. In this cross sectional study, 159 patients with CKD were enrolled from single center of coronary revascularization at Aga Khan University Hospital Karachi between January 2012 and August 2013. All patients with CKD underwent PCI or CABG. The primary outcome was in-hospital composite of death, myocardial infarction [MI], or stroke. We evaluated which mode of coronary revascularization was associated with reduced risks of clinical outcomes. Out of 159 patients with CKD, 85 [53.5%] received PCI and 74 [46.5%] received CABG. The primary finding of this study is that more patients with moderate to severe CKD underwent PCI and more patients with mild to moderate CKD underwent CABG. In both these categories, no difference was observed in clinical outcomes. There are few factors like age, ST- elevation myocardial infarction [STEMI], non-ST elevation myocardial infarction [NSTEMI] and number of coronary artery disease predicted PCI as treatment strategy in patients with moderate to severe CKD. Patients with moderate to severe CKD have similar rates of short term clinical outcomes whether they underwent PCI or CABG. Therefore, PCI can be acceptable and less invasive treatment option alternative to CABG, particularly in patients with moderate to severe CKD

Spontaneous multivessel coronary artery dissection associated with elevated homocysteine levels

A case of spontaneous multi-vessel coronary artery dissection in a young man, with markedly elevated serum homocysteine levels, is reported. The effects of elevated homocysteine levels on arterial endothelial function and possible plaque rupture leading to coronary dissection and acute coronary syndrome and / or sudden cardiac death are also discussed

Clinical and echocardiographic characteristics of patients with significant pericardial effusion requiring pericardiocentesis

Clinical and echocardiographic features of significant pericardial effusion [PE] have been reported from the west. Currently there is lack of published data from this part of the world, we reviewed all consecutive cases of significant PE requiring echocardiographic assisted pericardiocentesis to analyze the clinical and echocardiographic features of these patients. Forty four consecutive patients who underwent echocardiography assisted pericardiocentesis at the Aga Khan University Hospital [AKUH] between January 1988 and May 2001 are included in this review. Most common presenting symptoms were dyspnea [89%] and fever [36%]. Elevated JVP and pulsus paradoxus were documented in 59% and 41% of patients respectively. Sinus tachycardia [75%] and low voltage [34%] were the most common ECG findings. Malignancy [45-51%] and tuberculosis [27%] were among the most frequent causes of PE. One patient died during echocardiography-assisted pericardiocentesis. Majority of the pregnant females delivering at Aga Khan University Hospital were aware of epidural analgesia for labour. However, only a small proportion are availing this service, due to fears and misconceptions [JPMA 55:63;2005]. The symptoms and physical findings of haemodynamically significant PE are frequently nonspecific. Transthoracic echocardiography is the gold standard for rapid and confirmatory diagnosis of PE and cardiac tamponade. The most common cause of PE was malignancy followed by tuberculosis. Pericardiocentesis under echocardiographic guidance is a safe and effective treatment for significant PE