ISCHEMIA-Chronic Kidney Disease Trial (ISCHEMIA-CKD)

International Study of Comparative Health Effectiveness With Medical and Invasive Approaches-Chronic Kidney Disease Trial

New York University, National Heart, Lung, and Blood Institute (NHLBI), Duke University, Stanford University, Columbia University

The purpose of the ISCHEMIA-CKD trial is to determine the best management strategy for patients with stable ischemic heart disease (SIHD), at least moderate inducible ischemia and advanced chronic kidney disease (CKD; estimated glomerular filtration rate [eGFR] <30 ml/min/1.73 m² or on dialysis). This is a multicenter randomized controlled trial of 777 randomized participants with advanced CKD. Participants were assigned at random to a routine invasive strategy (INV) with cardiac catheterization (cath) followed by revascularization (if suitable) plus optimal medical therapy (OMT) or to a conservative strategy (CON) of OMT, with cath and revascularization reserved for those who fail OMT. The trial is designed to run seamlessly in parallel to the main ISCHEMIA trial as a companion trial. SPECIFIC AIMS A. Primary Aim. The primary aim of the ISCHEMIA-CKD trial is to determine whether an invasive strategy of cardiac cath followed by optimal revascularization, in addition to OMT, will reduce the primary composite endpoint of death or nonfatal myocardial infarction in participants with SIHD and advanced CKD over an average follow-up of approximately 2.8 years compared with an initial conservative strategy of OMT alone with catheterization reserved for those who fail OMT. The primary endpoint is time to centrally adjudicated death or nonfatal myocardial infarction (MI). B. Secondary Aims. Major: To compare the incident of the composite of death, nonfatal MI, resuscitated cardiac arrest, or hospitalization for unstable angina or heart failure, and angina symptoms and quality of life, as assessed by the Seattle Angina Questionnaire, between the INV and CON strategies. Other secondary aims include: comparing the incidence of the composite of death, nonfatal MI, hospitalization for unstable angina, hospitalization for heart failure, resuscitated cardiac arrest, or stroke; composite of death, nonfatal MI, or stroke; composite endpoints incorporating cardiovascular death; composite endpoints incorporating other definitions of MI as defined in the clinical event charter; individual components of the primary and major secondary endpoints; stroke and health resource utilization, costs, and cost effectiveness. A major secondary aim of ISCHEMIA-CKD trial is to compare the quality of life (QOL) outcomes-patients' symptoms, functioning and well-being-between those assigned to an invasive strategy as compared with a conservative strategy. In the protocol, angina frequency and disease-specific quality of life measured by the Seattle Angina Questionnaire (SAQ) Angina Frequency and Quality of Life scales, respectively, are described as the tools that will be used to make this comparative assessment. Recent work has indicated that it is possible to combine the information from the individual domain scores in the SAQ into a new Summary Score that captures the information from the SAQ Angina Frequency, Physical Limitation and Quality of Life scales into a single overall score. The advantages of using a summary score as the primary measure of QOL effects of a therapy are a single primary endpoint comparison rather than two or three (eliminating concerns some may have about multiple comparisons) and a more intuitive holistic (patient-centric) interpretation of the effectiveness results. With these advantages in mind, the ISCHEMIA leadership has agreed that the SAQ Summary Score will be designated as the primary way this secondary endpoint will be analyzed and interpreted, with the individual SAQ scores being used in a secondary, explanatory and descriptive role. A key subgroup analysis will be to stratify the results among those with daily/weekly angina (baseline SAQ Angina Frequency score ≤60), monthly angina (SAQ Angina Frequency score 61-99) and no angina (SAQ Angina Frequency score = 100). Condition: Coronary Disease Procedure: Cardiac catheterization Phase: Phase III Condition: Cardiovascular Diseases Procedure: Angioplasty, Transluminal, Percutaneous Coronary, other catheter-based interventions Phase: Phase III Condition: Heart Diseases Procedure: Coronary Artery Bypass Surgery Phase: Phase III

BACKGROUND: Among patients with advanced CKD, cardiovascular disease is the leading cause of death,15-30 times higher than the age-adjusted cardiovascular mortality rate in the general population. The projected 4-year mortality is >50% in patients with advanced CKD and is worse than that for patients in the general population who have cancers, heart failure, stroke or MI. Participants with advanced CKD are 5-10 times more likely to die than to reach end stage renal disease (ESRD). Despite this, ~80% of contemporary coronary artery disease (CAD) trials exclude participants with advanced CKD. Most of the treatments aimed at reducing cardiovascular events in advanced CKD are therefore extrapolated from cohorts without advanced CKD. Participants with advanced CKD and cardiovascular disease are undertreated with less frequent use of statins and revascularization therapies, and the optimal management approach to these patients is unknown. Participants with advanced CKD are notably underrepresented in contemporary trials comparing revascularization with medical therapy in SIHD patients, such as the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial or the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial,making any assessment about the efficacy of revascularization plus medical therapy vs. initial medical therapy alone in this cohort problematic. Participants with advanced CKD are at increased risk for complications of the assigned invasive procedure, specifically contrast-induced acute kidney injury (AKI), dialysis, major bleeding and short-term risk of death. However, there is controversy in the medical literature regarding the incidence (<1% to >30%), effective treatment (saline hydration, N-acetyl cysteine, or sodium bicarbonate), and prognosis of contrast induced AKI (<0.5% to >5% requiring dialysis). In addition, although contrast induced AKI have been associated with increase in short-term mortality, residual confounding in these studies makes interpretation difficulty. Moreover, it is unknown if these short-term increased risks are offset by long-term benefits. Limited observational studies in the CKD cohort suggest a long-term survival benefit of revascularization when compared with medical therapy alone, despite an increase in short-term risks. However, the medical therapy in these trials was not optimized, drug eluting stents were rarely used and there is undoubtedly inherent selection and ascertainment bias with observational studies. The above has resulted in clinical equipoise in the management of these patients, with the rates of revascularization only around 10-45%. The results of ISCHEMIA-CKD will have profound implications for guidelines, health policy, and clinical practice.

Cardiovascular Diseases, Coronary Artery Disease, Heart Diseases, Myocardial Ischemia, Kidney Disease, End Stage Renal Failure on Dialysis

Routine invasive strategy with cardiac catheterization followed by revascularization (Percutaneous Coronary Intervention or Coronary Artery Bypass Graft Surgery) plus optimal medical therapy.

Optimal medical therapy with cardiac catheterization and revascularization reserved for patients with OMT failure.

Narrowed blood vessels can be opened without surgery using stents or can be bypassed with surgery. To determine which is the best approach for you the doctor needs to look at your blood vessels to see where the narrowings are and how much narrowing there is. This is done by a procedure known as a cardiac catheterization.

Artery narrowing is bypassed during surgery with a healthy artery or vein from another part of the body. This is known as coronary artery bypass grafting, or CABG (said "cabbage"). The surgery creates new routes around narrowed and blocked heart arteries. This allows more blood flow to the heart.

Percutaneous coronary intervention may be done as part of the cardiac catheterization procedure. With this procedure a small, hollow, mesh tube (stent) is inserted into the narrowed part of the artery. The stent pushes the plaque against the artery wall, and opens the vessel to allow better blood flow.

This measure represents the estimated cumulative probability of experiencing Death from any cause or Myocardial Infarction within the indicated timeframe in each treatment group. The interpretation of the measure is similar to Kaplan-Meier event rates. Estimates are expressed as percentages ranging from 0% (endpoint is certain not to occur) to 100% (endpoint is certain to occur).

Inclusion Criteria: At least moderate ischemia on an exercise or pharmacologic stress test End-stage renal disease on dialysis or estimated glomerular filtration rate (eGFR) <30mL/min/1.73m² Willingness to comply with all aspects of the protocol, including adherence to the assigned strategy, medical therapy and follow-up visits Willingness to give written informed consent Age ≥ 21 years Exclusion Criteria: Left Ventricular Ejection Fraction < 35% History of unprotected left main stenosis >50% on prior coronary computed tomography angiography (CCTA) or prior cardiac catheterization (if available) Finding of "no obstructive coronary artery disease" (<50% stenosis in all major epicardial vessels) on prior CCTA or prior catheterization, performed within 12 months Coronary anatomy unsuitable for either percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) Unacceptable level of angina despite maximal medical therapy Very dissatisfied with medical management of angina History of noncompliance with medical therapy Acute coronary syndrome within the previous 2 months PCI within the previous 12 months Stroke within the previous 6 months or spontaneous intracranial hemorrhage at any time History of ventricular tachycardia requiring therapy for termination, or symptomatic sustained ventricular tachycardia not due to a transient reversible cause NYHA class III-IV heart failure at entry or hospitalization for exacerbation of chronic heart failure within the previous 6 months Non-ischemic dilated or hypertrophic cardiomyopathy Severe valvular disease or valvular disease likely to require surgery or percutaneous valve replacement during the trial Allergy to radiographic contrast that cannot be adequately pre-medicated, or any prior anaphylaxis to radiographic contrast Planned major surgery necessitating interruption of dual antiplatelet therapy (note that patients may be eligible after planned surgery) Life expectancy less than the duration of the trial due to non-cardiovascular comorbidity Pregnancy High likelihood of significant unprotected left main stenosis, in the judgment of the patient's physician Enrollment in a competing trial that involves a non-approved cardiac drug or device Inability to comply with the protocol Body weight or size exceeding the limit for cardiac catheterization at the site Canadian Cardiovascular Society Class III angina of recent onset, OR angina of any class with a rapidly progressive or accelerating pattern Canadian Cardiovascular Society Class IV angina, including unprovoked rest angina High risk of bleeding which would contraindicate the use of dual antiplatelet therapy Cardiac transplant recipient Prior CABG, unless CABG was performed more than 12 months ago, and coronary anatomy has been demonstrated to be suitable for PCI or repeat CABG to accomplish complete revascularization of ischemic areas

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Patel AV, Bangalore S. Challenges with Evidence-Based Management of Stable Ischemic Heart Disease. Curr Cardiol Rep. 2017 Feb;19(2):11. doi: 10.1007/s11886-017-0820-7.

Bangalore S, Briguori C. Preventive Strategies for Contrast-Induced Acute Kidney Injury: And the Winner Is.... Circ Cardiovasc Interv. 2017 May;10(5):e005262. doi: 10.1161/CIRCINTERVENTIONS.117.005262. No abstract available.

Mathew RO, Bangalore S, Sidhu MS, Fleg JL, Maddux FW. Increasing inclusion of patients with advanced chronic kidney disease in cardiovascular clinical trials. Kidney Int. 2018 Apr;93(4):787-788. doi: 10.1016/j.kint.2017.11.028. No abstract available.

Chaudhry RI, Mathew RO, Sidhu MS, Sidhu-Adler P, Lyubarova R, Rangaswami J, Salman L, Asif A, Fleg JL, McCullough PA, Maddux F, Bangalore S. Detection of Atherosclerotic Cardiovascular Disease in Patients with Advanced Chronic Kidney Disease in the Cardiology and Nephrology Communities. Cardiorenal Med. 2018;8(4):285-295. doi: 10.1159/000490768. Epub 2018 Aug 3.

Bangalore S, Guo Y, Samadashvili Z, Blecker S, Xu J, Hannan EL. Revascularization in Patients With Multivessel Coronary Artery Disease and Chronic Kidney Disease: Everolimus-Eluting Stents Versus Coronary Artery Bypass Graft Surgery. J Am Coll Cardiol. 2015 Sep 15;66(11):1209-1220. doi: 10.1016/j.jacc.2015.06.1334.

Bangalore S. Stress testing in patients with chronic kidney disease: The need for ancillary markers for effective risk stratification and prognosis. J Nucl Cardiol. 2016 Jun;23(3):570-4. doi: 10.1007/s12350-015-0264-7. Epub 2015 Aug 22. No abstract available.

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Mathew RO, Maron DJ, Anthopolos R, Fleg JL, O'Brien SM, Rockhold FW, Briguori C, Roik MF, Mazurek T, Demkow M, Malecki R, Ye Z, Kaul U, Miglinas M, Stone GW, Wald R, Charytan DM, Sidhu MS, Hochman JS, Bangalore S. Guideline-Directed Medical Therapy Attainment and Outcomes in Dialysis-Requiring Versus Nondialysis Chronic Kidney Disease in the ISCHEMIA-CKD Trial. Circ Cardiovasc Qual Outcomes. 2022 Oct;15(10):e008995. doi: 10.1161/CIRCOUTCOMES.122.008995. Epub 2022 Oct 4.

Chaitman BR, Cyr DD, Alexander KP, Pracon R, Bainey KR, Mathew A, Acharya A, Kunichoff DF, Fleg JL, Lopes RD, Sidhu MS, Anthopolos R, Rockhold FW, Stone GW, Maron DJ, Hochman JS, Bangalore S. Cardiovascular and Renal Implications of Myocardial Infarction in the ISCHEMIA-CKD Trial. Circ Cardiovasc Interv. 2022 Aug;15(8):e012103. doi: 10.1161/CIRCINTERVENTIONS.122.012103. Epub 2022 Aug 16.

Briguori C, Mathew RO, Huang Z, Mavromatis K, Hickson LJ, Lau WL, Mathew A, Mahajan S, Wheeler DC, Claes KJ, Chen G, Nolasco FEB, Stone GW, Fleg JL, Sidhu MS, Rockhold FW, Chertow GM, Hochman JS, Maron DJ, Bangalore S. Dialysis Initiation in Patients With Chronic Coronary Disease and Advanced Chronic Kidney Disease in ISCHEMIA-CKD. J Am Heart Assoc. 2022 Mar 15;11(6):e022003. doi: 10.1161/JAHA.121.022003. Epub 2022 Mar 9.

Herzog CA, Simegn MA, Xu Y, Costa SP, Mathew RO, El-Hajjar MC, Gulati S, Maldonado RA, Daugas E, Madero M, Fleg JL, Anthopolos R, Stone GW, Sidhu MS, Maron DJ, Hochman JS, Bangalore S. Kidney Transplant List Status and Outcomes in the ISCHEMIA-CKD Trial. J Am Coll Cardiol. 2021 Jul 27;78(4):348-361. doi: 10.1016/j.jacc.2021.05.001. Epub 2021 May 11.

Bangalore S, Maron DJ, O'Brien SM, Fleg JL, Kretov EI, Briguori C, Kaul U, Reynolds HR, Mazurek T, Sidhu MS, Berger JS, Mathew RO, Bockeria O, Broderick S, Pracon R, Herzog CA, Huang Z, Stone GW, Boden WE, Newman JD, Ali ZA, Mark DB, Spertus JA, Alexander KP, Chaitman BR, Chertow GM, Hochman JS; ISCHEMIA-CKD Research Group. Management of Coronary Disease in Patients with Advanced Kidney Disease. N Engl J Med. 2020 Apr 23;382(17):1608-1618. doi: 10.1056/NEJMoa1915925. Epub 2020 Mar 30.

Spertus JA, Jones PG, Maron DJ, Mark DB, O'Brien SM, Fleg JL, Reynolds HR, Stone GW, Sidhu MS, Chaitman BR, Chertow GM, Hochman JS, Bangalore S; ISCHEMIA-CKD Research Group. Health Status after Invasive or Conservative Care in Coronary and Advanced Kidney Disease. N Engl J Med. 2020 Apr 23;382(17):1619-1628. doi: 10.1056/NEJMoa1916374. Epub 2020 Mar 30.