p.67 抽出テキスト
CLINICAL STATEMENTS AND GUIDELINES Circulation. 2023;148:e9–e119. DOI: 10.1161/CIR.0000000000001168 August 29, 2023 Virani et al 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Chronic Coronary Disease Guideline (Section 4.1.3) are particularly important when caring for older patients. A framework that considers the 5 Ms of geriatric care42 (Table 22) may be a useful approach to guide these discussions. 6.7 Chronic Kidney Disease Recommendation for CKD Referenced studies that support the recommendation are summarized in the Online Data Supplement. COR LOE Recommendation 1 C-LD 1 In patients with CCD and CKD, measures should be taken to minimize the risk of treatment-related acute kidney injury.*1–3 *Modified from the 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization.4 Synopsis CKD increases the risk of CAD progression and is associated with poor outcomes after interventions.5–8 The mortality rate for patients on hemodialysis is ∼20% per year, with approximately 50% attributable to a cardiovascular cause.9–12 Postmortem studies have revealed that patients with CKD not only have a higher burden of atherosclerosis but, also, the plaque features are more advanced, with evidence of increased inflammation.13–15 Despite the higher prevalence of disease, noninvasive diagnostic testing is often less accurate.20–24 Guidance related to the use of pharmacological and interventional therapy is limited by underrepresentation of patients with CKD in clinical trials16 and attributable to inconsistent definitions of CKD. It is unclear whether medical therapy is as efficacious in patients with CKD because of differences in the risk and benefit balance in the setting of underlying kidney disease.17,18–21 In the absence of data from dedicated RCTs, patients with CKD should receive similar medical therapy as patients without CKD.22 Given the complex interactions, a team-based approach (Section 4.1.1) that includes individuals from the cardiac and renal teams, to include shared decisionmaking (Section 4.1.3), would be beneficial, especially when considering decisions such as revascularization for which decreased short-term risk must be balanced with long-term benefit.23,24 For additional reference, please see patient education and SDOH (Sections 4.1.2 and 4.1.4) within this guideline. Recommendation-Specific Supportive Text 1 In the ISCHEMIA-CKD (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trial, patients with a moderate to severe burden of ischemia and estimated glomerular filtration rate [eGFR] of <30 mL/min/1.73 m2 of body-surface area or the receipt of dialysis did not have improved outcomes with the addition of revascularization to GDMT, suggesting that revascularization can be reserved for patients who remain symptomatic despite medical therapy,25 clarifying conflicting data from previous studies.8,26 When PCI is clinically needed, the risk of contrast-induced acute kidney injury (AKI) should not be a reason to withhold it in most patients with CKD.4 When possible, attempts to minimize the risk of contrast nephropathy should be made through the avoidance of nephrotoxic agents, use of adequate hydration before the administration of iodinated contrast-agent,27–29 and minimization of the volume of contrast media.30,31 Additionally, high-dose statins may reduce the occurrence of contrast-induced AKI.32 The use of radial access may minimize the role of atheroembolism on the development of AKI33–35; however, conflicting data exist.36,37 Delay of CABG in stable patients after angiography beyond 24 hours, when clinically feasible, can also help reduce the risk of AKI.38 There is no benefit of bicarbonate or N-acetyl-L-cysteine over normal saline for prevention of AKI.39 6.8 HIV and Autoimmune Disorders Recommendations for HIV and Autoimmune Disorders Referenced studies that support the recommendations are summarized in the Online Data Supplement. COR LOE Recommendations HIV 1 B-R 1 In adults with CCD and HIV, antiretroviral therapy is beneficial to decrease the risk of cardiovascular events.1,2 2a B-R 2 In adults with CCD and HIV, it is reasonable to choose antiretroviral therapy regimens associated with more favorable lipid and cardiovascular risk profiles with consideration of drug-drug interactions.3–5 3: Harm C-LD 3 In adults with CCD and HIV, lovastatin or simvastatin should not be administered with protease inhibitors as this may cause harm.6,7 Autoimmune Disorders in CCD 2a C-LD 4 In adults with CCD and rheumatoid arthritis, initia- tion and maintenance of disease-modifying antirheumatoid drugs is beneficial to decrease the risk of cardiovascular events.8–11 2b C-LD 5. In adults with CCD and autoimmune diseases, treatment with biologics and other immune modulating therapies that reduce disease activity may be considered to decrease the risk of cardiovascular events.10,11 3: Harm C-LD 6 In patients with CCD and rheumatoid arthritis, high- dose glucocorticoids should not be used long term if alternative therapies are available because of increased cardiovascular risk.11,12 Synopsis HIV and other chronic inflammatory conditions are associated with accelerated atherosclerosis and premature CVD. The 2018 ACC/AHA blood cholesterol guideline Downloaded from http://ahajournals.org by on October 7, 2026