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5.3.8 Chronic kidney disease

Chronic kidney disease increases the risk of CAD progression and is associated with high mortality rates due to cardiovascular causes.1069,1070 Patients with CKD have a higher burden of atherosclerosis and more advanced plaque features.1070 Despite the higher prevalence of disease, non-invasive diagnostic testing is often less accurate, and guidance related to the use of pharmacological and interventional therapy is limited due to inconsistent definitions of CKD and underrepresentation of CKD patients in clinical trials.1070–1072 Careful assessment of the risk-to-benefit ratio is needed in patients with CKD before considering ICA, CCTA, or non-invasive tests requiring nephrotoxic agents.1073 Pre-existing CKD is the primary patientrelated risk factor for the development of acute kidney injury (AKI), whereas DM increases the susceptibility to develop AKI. The most important measures to prevent AKI are using the lowest necessary total dose of low-osmolality or iso-osmolality contrast medium and sufficient pre- and post-hydration.1073 CKD raises the risks associated with both CABG and PCI.316 The ISCHEMIA-CKD trial included patients with advanced CKD [estimated glomerular filtration rate (eGFR) of <30 mL/min/1.73 m2 or dialysis] and CCS with moderate or severe myocardial ischaemia detected by stress test. An invasive strategy of ICA and PCI was not superior to conservative management in reducing the primary endpoint of death or non-fatal MI.1074 In a propensity score-matched analysis involving 5920 CKD patients (2960 pairs), PCI utilizing second-generation DES displayed a reduced risk of death, stroke, and repeat revascularization at 30 days when compared with CABG.1075 However, PCI was associated with a higher risk of repeat revascularization over the long term. Conversely, among patients on dialysis, the findings favoured CABG over PCI. Additionally, a meta-analysis of 11 registries revealed lower rates of death, MI, and repeat revascularization with CABG in contrast to PCI among patients with eGFR of <60 mL/min/1.73 m2.1076 Nevertheless, there is a notable absence of large RCTs comparing revascularization modalities among CKD patients.

5.3.9 Cancer

Several cancer treatments are associated with an increased risk of CCS. Spontaneous bleeding in ACS and CCS patients has been associated with subsequent cancer diagnosis.1077 A prompt evaluation of bleeding may be useful to enable an early detection of cancer. The management of CCS is similar in patients with and without cancer. However, decisions regarding coronary revascularization should be undertaken by a multidisciplinary team. The approach should be individualized and based on life expectancy, additional comorbidities such as thrombocytopaenia, increased thrombosis, or bleeding risk, and potential interactions between drugs used in CCS management and anticancer therapy.1078,1079

5.3.10 Optimal treatment of patients with human

immunodeficiency virus Patients with human immunodeficiency virus (HIV) have longer life expectancy than before due to effective antiretroviral therapy (ART), but are twice as likely to develop CVD compared with the general population.1080 The long-term CVD outcomes in patients with HIV may change, given the relatively recent epidemiological transition of HIV to a chronic disease. Dyslipidaemia is a common condition in patients with HIV, whether treated or untreated with ART.1081 The treatment of dyslipidaemia in patients with HIV includes both non-pharmacological and pharmacological options. Special attention to the impact of polypharmacy, drug interactions between ART and lipid-lowering medications, and close monitoring for adverse events is critical to successfully managing dyslipidaemia and risk of CVD in patients with HIV. Hepatic cytochrome P450 3A4 (CYP3A4) metabolizes many statins; many ARTs are also metabolized by CYP3A4 and, thus, may have interactions with statins. Simvastatin and lovastatin are contraindicated with protease inhibitors; atorvastatin has less of a CYP3A4 interaction; pravastatin, fluvastatin, pitavastatin and rosuvastatin are not or minimally metabolized through CYP3A4.1082,1083 Ezetimibe has no interactions with CYP3A4 or ART.1081

A clinical trial investigating the impact of PCSK9 inhibitor therapy on lipids, inflammatory markers, and subclinical ASCVD (including noncalcified plaque and arterial inflammation) in HIV is currently being conducted [EPIC-HIV study (Effect of PCSK9 Inhibition on Cardiovascular Risk in Treated HIV Infection), NCT03207945]. Future studies are needed to evaluate the impact of PCSK9 inhibition on clinical events in HIV.

5.3.11 Socially and geographically diverse groups

A lower socioeconomic status has implications of increased CVD mortality1084 and poorer CVD risk factor profiles.1085 A multicohort study of 1.7 million adults followed up for any cause of death for an average of 13 years found that low socioeconomic status was associated with a 2.1-year reduction in life expectancy between the ages 40 and 85 years.1086 Education level, occupation, household income, health, disability, and living conditions also contribute to socioeconomic status. There were different rates of decline in mortality from CVD in Europe between the most and the least deprived.1087 It has been proposed that on this basis, CVD could become a disease prevalently of the lower socioeconomic groups by the mid-2020s.1088 Black patients with diabetes have a higher hospitalization burden with a concomitant disparity in comorbid presentation and outcome compared with other patients with diabetes.1089 South Asian ethnicity, even after adjustment for traditional risk factors, is associated with an increased risk of coronary heart disease outcomes. This risk was greater than other studied racial/ethnic groups and second only to diabetes in coronary heart disease risk prediction.1090 Within a large prospective study, South Asian individuals had a substantially higher risk of ASCVD than individuals of European ancestry.1091 South Asians have a more diffuse pattern with multivessel involvement. However, less is known about other morphological characteristics, such as atherosclerotic plaque composition and coronary diameter in South Asian populations. Despite a similar coronary calcification burden, higher non-calcified plaque contribution, elevated thrombosis, and inflammatory markers likely contribute to the disease pattern. Although the current evidence on the role of coronary vessel size remains inconsistent, smaller diameters in South Asians could play a potential role in the higher disease prevalence.1092 Individuals of South Asian descent have a high prevalence of CYP2C19 loss-of-function alleles (poor metabolizers: 13% vs. 2.4% in European populations),1093 which are associated with reduced efficacy of clopidogrel.

ESC Guidelines                                                                                                                                                                                          3487

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