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CABG surgery may be the optimal therapy for heart attack patients with end-stage renal disease

Cardiovascular disease is the most common cause of death in patients with end-stage renal disease (ESRD). Unfortunately, none of the clinical trials of the 1970s and 1980s comparing medical therapy with coronary artery bypass graft (CABG) surgery included patients with ESRD. However, a new study of ESRD patients suffering from acute myocardial infarction (AMI, heart attack) suggests that CABG is probably superior to medication alone or coronary angioplasty. Researchers from the University of California, San Francisco, and Harvard's Schools of Medicine and Public Health studied 640 ESRD patients with AMI during 1994-1995 as part of the Health Care Financing Agency's Cooperative Cardiovascular Project.

The majority of patients were treated with medication alone; 7 percent were treated with percutaneous transluminal coronary angioplasty (PTCA), and 5 percent underwent CABG. At 1 year, over half (53 percent) of the patients had died, with substantially lower survival seen among the elderly. Overall, 69 percent of ESRD patients who underwent CABG survived for 1 year compared with 54 percent of those who underwent PTCA and 45 percent of those on medication alone. After adjustment for other factors affecting death rates, the CABG group had a lower relative risk of death, but it was not significantly lower.

Nevertheless, given the lack of other clinical trial data on ESRD patients with AMI, CABG may be the optimal therapy for such patients as long as they are well enough to tolerate major cardiac surgery and their life expectancy is more than 6 months. Also, given the exceptionally poor outcomes observed for patients treated with medical therapy alone, it may be premature to dismiss PTCA and newer revascularization procedures (for example, stents) as a therapeutic option for this high-risk group of patients, conclude the researchers. Their work was supported in part by the Agency for Healthcare Research and Quality (HS06503 and HS08071).

More details are in "Survival after acute myocardial infarction in patients with end-stage renal disease: Results from the cooperative cardiovascular project," by Glenn M. Chertow, M.D., M.P.H., Sharon-Lise T. Normand, Ph.D., Laurie R. Silva, Ph.D., and Barbara J. McNeil, M.D., Ph.D., in the May 2000 American Journal of Kidney Diseases 35(6), pp. 1044-1051.

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