Skip To Main Content
 
  Figure 4.1 Cardiovascular disease in patients with or without CKD
  Figure 4.2 Patients with CHF who receive diagnostic testing within 90 days of diagnosis, by CKD status
  Figure 4.3 Rates of fatal & non-fatal AMI, by CKD status
  Figure 4.4 Probability of death following an AMI, by CKD status, 2007–2008
  Figure 4.5 Probability of death following a CVA/TIA, by CKD status, 2007–2008
  Figure 4.6 Probability of death following a CHF diagnosis, by CKD status, 2007–2008
  Figure 4.7 Probability of death following a cardiovascular procedure (PCI/CABG), by CKD status, 2007–2008
  Figure 4.8 Utilization of cardiac drugs, by drug class & CKD status, 2010
  Figure 4.9 Cumulative incidence of death following a diagnosis of CHF, by CKD stage & medication use, 2007
  Figure 4.10 Distribution of NHANES participants with diabetes, congestive heart failure, & markers of CKD, with GFR estimated by MDRD & CKD-EPI equations
  Table 4.a Cardiovascular disease & intervention (percent), by CKD stage, age, & race, 2010
  Table 4.b Cardiovascular dicease & pharmacological intervention (row percent), by diagnosis & CKD stage.
View
Download
Chapter (zip)*
Slides (zip)*
*corresponding data in Excel included
Search This Page
Search All
Translate

Chapter 4

Cardiovascular disease in patients with CKD

Introduction

This chapter highlights the epidemiology of the relationship between CKD and cardiovascular disease, and documents the impressive graded risk of mortality associated with advanced CKD. Additionally, we present a temporal analysis of the changing approach to diagnostic evaluation in patients with CKD and CHF, include a new investigation on the distribution of fatal and nonfatal myocardial infarction by CKD stage, and look at medication use and associated outcomes by CKD stage.

We begin with a Venn diagram detailing the prevalence of cardiovascular disease with respect to CKD; this figure also provides a rough temporal analysis, as data are presented for 2005 and 2010. In both years there is an increased prevalence of associated cardiovascular disease in patients with CKD compared to those without. In 2005, for example, nearly half of elderly CKD patients had a concomitant diagnosis of CHF, and 15 percent had an AMI; among their non-CKD counterparts, these numbers fell to 22 and 7 percent. Similar clustering occurs in 2010, but data suggest there may have been a reduction in certain types of associated cardiovascular comorbidity (e.g., an absolute 6 percent reduction in CHF).

Later in the chapter, in Table 4.b, we provide data on medication use with respect to cardiovascular condition and CKD stage. In patients with CHF, for example, one notable finding is the increased use of beta blockers. In elderly non-CKD patients, 52 percent of those with CHF received a beta blocker in 2007; this rose to 60 percent in 2010; in the CKD population, use rose from 56 to 66 percent. There was a more modest increase in the use of ACEIs/ARBs, from 54 to 57 percent in the non-CKD population, and from 47 to 52 percent in those with CKD. One conclusion derived from these data is that, in 2010, there is really no discernible impact of “therapeutic nihilism” related to the use of beta blockers in patients with advanced CKD. The proportion of patients receiving a beta blocker was actually higher, at about 70 percent, than the 60 percent seen in patients without CKD. One can speculate that this may reflect both a change in practice patterns and the availability of Part D coverage, facilitating the administration of these evidence-based therapies. In patients with AMI, there was a high penetration in the use of beta blockers, similar across CKD stages, and reaching 77–78 percent in both CKD and non-CKD patients.

For ACEIs/ARBs, in contrast, there appears to be an inverse relationship between CKD stage and the use of these agents following AMI, with the medications prescribed to 66 percent of non-CKD patients, compared to 57 percent of those with CKD. Importantly, only 46 percent of patients with Stage 4–5 CKD receive an ACEI/ARB. There also appears to be an inverse relationship between CKD stage and warfarin use in patients with AFIB. In 2010, 56 percent of non-CKD patients, and 49 percent of those with CKD, were identified as receiving warfarin, numbers higher than the 48 and 40 percent seen in 2007, and suggesting the progressive dissemination of this particular evidence-based therapy over time in the Medicare population (Shroff et al., Arch Internal Med, in press 2012, and Lakshminarayan et al.).

Finally, statins are widely used for secondary prevention in patients with known coronary artery disease, irrespective of CKD stage, a finding borne out in these data. In patients without identified cardiovascular events, the percentage receiving statins increased from 37 to 44 percent in the non-CKD population, and from 45 to 54 percent in those with CKD. December 31, 2005 & 2010 point prevalent Medicare enrollees, age 66 & older, with fee-for-service coverage for the entire calendar year.

Figure 4.1 Cardiovascular disease in patients with or without CKD

Diagnostic testing & cardiovascular mortality

Table 4.a Cardiovascular disease & intervention (percent), by CKD stage, age, & race, 2010

This table provides a snapshot of cardiovascular disease prevalence related to demography and CKD stage. One uniform finding is the progressively increased representation for each cardiovascular condition with respect to advanced CKD stage and age. In the non-CKD population, for example, only 3.6 percent of patients age 66–69 have CHF, compared to 15 percent of those age 85 and older. Among patients with Stage 4–5 CKD, these numbers reach 34 and 48 percent. CHF is a common comorbid condition in elderly patients, particularly among those with advanced CKD. After CHF, the next most common condition is atrial fibrillation. Four percent of patients age 66–69 and without identified CKD have atrial fibrillation, compared to 17 percent of those age 85 or older. Among patients with Stage 4–5 CKD, in contrast, these numbers rise to 16 and 32 percent. Surprisingly, percentages are lower for black/African American patients compared to whites. December 31, 2010 point prevalent Medicare enrollees, age 66 & older.

Figure 4.2 Patients with CHF who receive diagnostic testing within 90 days of diagnosis, by CKD status

There is no clear temporal trend in the distribution of fatal and non-fatal myocardial infarctions (MIs), with the possible exception of a small increased rate of non-fatal MIs in patients with advanced CKD (this might reflect the dissemination of more sensitive cardiac biomarkers; most identified MIs are non-fatal). Mortality following MI in patients with advanced CKD, however, remains high, with long-term mortality approaching that reported in dialysis patients. Jan. 1 point prevalent Medicare pts. age 66 & older.

Figure 4.3 Rates of fatal & non-fatal AMI, by CKD status

There is a graded increased risk of mortality with advancing CKD; the two-year mortality rate after MI, for example, at 44 percent in patients with no CKD, rises to 58 and 68 percent for those with Stage 3 and 4–5 CKD. Jan. 1 point prevalent. Medicare pts. age 66 & older.

Figure 4.4 Probability of death following an AMI, by CKD status, 2007–2008

There is a graded increased risk of mortality with advancing CKD. Trends of death similar to those found in patients suffering an AMI are found following a CVA/TIA diagnosis. January. 1 point prevalen Medicare pts. age 66 & older.

Figure 4.5 Probability of death following a CVA/TIA, by CKD status, 2007–2008

There is a graded increased risk of mortality with advancing CKD. Trends of death similar to those found in patients suffering an AMI are found following a CVA/TIA diagnosis. January. 1 point prevalen Medicare pts. age 66 & older.

Figure 4.6 Probability of death following a CHF diagnosis, by CKD status, 2007–2008

There is a graded increased risk of mortality with advancing CKD. Trends of death similar to those found in patients suffering an AMI are found following a.CHF diagnosis. January. 1 point prevalen Medicare pts. age 66 & older.

Figure 4.7 Probability of death following a cardiovascular procedure (PCI/CABG), by CKD status, 2007–2008

There is a graded increased risk of mortality with advancing CKD. Trends of death similar to those found in patients with AMI are found following coronary revascularization. Although the probability of death is lower in patients with advanced CKD who have CABG surgery compared to PCI, these are observational data and there may be confounding by indication. » Figures 4.2–7; see page 143 for analytical methods. January 1 point prevalent Medicare pts. age 66 & older.

Medication use & survival in patients with CVD.

Table 4.b Cardiovascular dicease & pharmacological intervention (row percent), by diagnosis & CKD stage.

Figure 4.8 Utilization of cardiac drugs, by drug class & CKD status, 2010

Even in a short, three-year time period, the use of beta blockers has increased. Importantly, the number of patients receiving neither an ACEI/ARB nor a beta-blocker fell between 2007 and 2010. January 1 point prevalent patients with Medicare Parts A, B, & D enrollment, with a first diagnosis of CHF or MI in the year; patients with baseline disease are excluded.

Figure 4.9 Cumulative incidence of death following a diagnosis of CHF, by CKD stage & medication use, 2007

Figure 4.10 Cumulative incidence of death following a diagnosis of AMI, by CKD stage & medication use, 2007

Figures 4.9–10 demonstrate the apparent protective association, with respect to CKD, of combined ACEI/ARB therapy in patients with CHF and following MI. Although these are observational data (which should be interpreted with caution), it is interesting that results are concordant with clinical trial data on the use of ACEIs/ARBs and beta blockers in CHF and post-MI populations.

The cumulative incidence of death reported in these figures, and the relationship to the use of ACEIs/ARBs and beta blockers, are remarkably similar to what is shown in parallel figures in Chapter Four of Volume Two, with the main difference being the higher overall mortality in ESRD patients with these conditions and the smaller absolute difference in survival related to the individual therapies. The overall patterns, however, are similar, suggesting therapeutic benefit across all stages of CKD, including ESRD.

Although the figures in Volume Two pertain to ESRD rather than dialysis, their data are indicative of dialysis outcomes, as 92 and 94 percent of CHF and MI events, respectively, are among dialysis patients. The relative contribution of renal transplant recipients to these data is actually very small. » Figures 4.8–10; see page 143 for analytical methods. January 1 point prevalent patients with Medicare Parts A, B, & D enrollment, with a first diagnosis of CHF or MI in the year; patients with baseline disease are excluded.