Context: Elderly persons with chronic kidney disease have substantial risk for cardiovascular mortality, but the relative importance of traditional and novel risk factors is unknown. Objective: To compare traditional ...Context: Elderly persons with chronic kidney disease have substantial risk for cardiovascular mortality, but the relative importance of traditional and novel risk factors is unknown. Objective: To compare traditional and novel risk factors as predictors of cardiovascular mortality. Design, Setting, and Patients: A total of 5808 community-dwelling persons aged 65 years or older living in 4 communities in the United States participated in the Cardiovascular Health Study cohort. Participants were initially recruited from 1989 to June 1990; an additional 687 black participants were recruited in 1992-1993. The average length of follow-up in this longitudinal study was 8.6 years. Main Outcome Measures: Cardiovascular mortality among those with and without chronic kidney disease. Chronic kidney disease was defined as an estimated glomerular filtration rate of less than 60 mL/min per 1.73 m2. Results: Among the participants, 1249(22%) had chronic kidney disease at baseline. The cardiovascular mortality risk rate was 32 deaths/1000 person-years among those with chronic kidney disease vs 16/1000 person-years among those without it. In multivariate analyses, diabetes, systolic hypertension, smoking, low physical activity, nonuse of alcohol, and left ventricular hypertrophy were predictors of cardiovascular mortality in persons with chronic kidney disease(all P values< .05). Among the novel risk factors, only log C-reactive protein(P=.05) and log interleukin 6(P< .001) were associated with the outcome as linear predictors. Traditional risk factors were associated with the largest absolute increases in risks for cardiovascular deaths among persons with chronic kidney disease: for left ventricular hypertrophy, there were 25 deaths per 1000 person-years; current smoking, 20 per 1000 person-years; physical inactivity, 15 per 1000 person-years; systolic hypertension, 14 per 1000 personyears; diabetes, 14 per 1000 person-years; and nonuse of alcohol, 11 per 1000 person-years vs 5 deaths per 1000 person-years for those with increased C-reactive protein and 5 per 1000 person-years for those with increased interleukin 6 levels. A receiver operating characteristic analysis found that traditional risk factors had an area under the curve of 0.73(95%confidence interval, 0.70-0.77) among those with chronic kidney disease. Adding novel risk factors only increased the area under the curve to 0.74(95%confidence interval, 0.71-0.78; P for difference=.15). Conclusions: Traditional cardiovascular risk factors had larger associations with cardiovascular mortality than novel risk factors in elderly persons with chronic kidney disease. Future research should investigate whether aggressive lifestyle intervention in patients with chronic kidney disease can reduce their substantial cardiovascular risk.展开更多
Background Limited data describe the cardiovascular benefit of HMG CoA reduc tase inhibitors(statins) in people with moderate chronic kidney disease (CKD). T he objective of this analysis was to determine whether prav...Background Limited data describe the cardiovascular benefit of HMG CoA reduc tase inhibitors(statins) in people with moderate chronic kidney disease (CKD). T he objective of this analysis was to determine whether pravastatin reduced the i ncidence of cardiovascular events in people with or at high risk for coronary di sease and with concomitant moderate CKD. Methods and Results We analyzed data f rom the Pravastatin Pooling Project(PPP), a subject level database combining re sults from 3 randomized trials of pravastatin(40mg daily) versus placebo. Of 19 700 subjects, 4491 (22.8%) had moderate CKD, defined by an estimated glomerular filtration rate of 30 to 59.99 mL/ min per 1.73 m2 body surface area. The prim ary outcome was time to myocardial infarction, coronary death, or percutaneous/s urgical coronary revascularization. Moderate CKD was independently associated wi th an increased risk of the primary outcome (adjusted HR 1.26, 95%CI 1.07 to 1. 49) compared with those with normal renal function. Among the 4491 subjects with moderate CKD, pravastatin significantly reduced the incidence of the primary ou tcome (HR 0.77, 95%CI 0.68 to 0.86), similar to the effect of pravastatin on th e primary outcome in subjects with normal kidney function (HR 0.78, 95%CI 0.65 to 0.94). Pravastatin also appeared to reduce the total mortality rate in those with moderate CKD (adjusted HR 0.86, 95%CI 0.74 to 1.00, P=0.045). Conclusions Pravastatin reduces cardiovascular event rates in people with or at risk for c oronary disease and concomitant moderate CKD, many of whom have serum creatinine levels within the normal range. Given the high risk associated with CKD, the ab solute benefit that resulted from use of pravastatin was greater than in those w ith normal renal function.展开更多
文摘Context: Elderly persons with chronic kidney disease have substantial risk for cardiovascular mortality, but the relative importance of traditional and novel risk factors is unknown. Objective: To compare traditional and novel risk factors as predictors of cardiovascular mortality. Design, Setting, and Patients: A total of 5808 community-dwelling persons aged 65 years or older living in 4 communities in the United States participated in the Cardiovascular Health Study cohort. Participants were initially recruited from 1989 to June 1990; an additional 687 black participants were recruited in 1992-1993. The average length of follow-up in this longitudinal study was 8.6 years. Main Outcome Measures: Cardiovascular mortality among those with and without chronic kidney disease. Chronic kidney disease was defined as an estimated glomerular filtration rate of less than 60 mL/min per 1.73 m2. Results: Among the participants, 1249(22%) had chronic kidney disease at baseline. The cardiovascular mortality risk rate was 32 deaths/1000 person-years among those with chronic kidney disease vs 16/1000 person-years among those without it. In multivariate analyses, diabetes, systolic hypertension, smoking, low physical activity, nonuse of alcohol, and left ventricular hypertrophy were predictors of cardiovascular mortality in persons with chronic kidney disease(all P values< .05). Among the novel risk factors, only log C-reactive protein(P=.05) and log interleukin 6(P< .001) were associated with the outcome as linear predictors. Traditional risk factors were associated with the largest absolute increases in risks for cardiovascular deaths among persons with chronic kidney disease: for left ventricular hypertrophy, there were 25 deaths per 1000 person-years; current smoking, 20 per 1000 person-years; physical inactivity, 15 per 1000 person-years; systolic hypertension, 14 per 1000 personyears; diabetes, 14 per 1000 person-years; and nonuse of alcohol, 11 per 1000 person-years vs 5 deaths per 1000 person-years for those with increased C-reactive protein and 5 per 1000 person-years for those with increased interleukin 6 levels. A receiver operating characteristic analysis found that traditional risk factors had an area under the curve of 0.73(95%confidence interval, 0.70-0.77) among those with chronic kidney disease. Adding novel risk factors only increased the area under the curve to 0.74(95%confidence interval, 0.71-0.78; P for difference=.15). Conclusions: Traditional cardiovascular risk factors had larger associations with cardiovascular mortality than novel risk factors in elderly persons with chronic kidney disease. Future research should investigate whether aggressive lifestyle intervention in patients with chronic kidney disease can reduce their substantial cardiovascular risk.
文摘Background Limited data describe the cardiovascular benefit of HMG CoA reduc tase inhibitors(statins) in people with moderate chronic kidney disease (CKD). T he objective of this analysis was to determine whether pravastatin reduced the i ncidence of cardiovascular events in people with or at high risk for coronary di sease and with concomitant moderate CKD. Methods and Results We analyzed data f rom the Pravastatin Pooling Project(PPP), a subject level database combining re sults from 3 randomized trials of pravastatin(40mg daily) versus placebo. Of 19 700 subjects, 4491 (22.8%) had moderate CKD, defined by an estimated glomerular filtration rate of 30 to 59.99 mL/ min per 1.73 m2 body surface area. The prim ary outcome was time to myocardial infarction, coronary death, or percutaneous/s urgical coronary revascularization. Moderate CKD was independently associated wi th an increased risk of the primary outcome (adjusted HR 1.26, 95%CI 1.07 to 1. 49) compared with those with normal renal function. Among the 4491 subjects with moderate CKD, pravastatin significantly reduced the incidence of the primary ou tcome (HR 0.77, 95%CI 0.68 to 0.86), similar to the effect of pravastatin on th e primary outcome in subjects with normal kidney function (HR 0.78, 95%CI 0.65 to 0.94). Pravastatin also appeared to reduce the total mortality rate in those with moderate CKD (adjusted HR 0.86, 95%CI 0.74 to 1.00, P=0.045). Conclusions Pravastatin reduces cardiovascular event rates in people with or at risk for c oronary disease and concomitant moderate CKD, many of whom have serum creatinine levels within the normal range. Given the high risk associated with CKD, the ab solute benefit that resulted from use of pravastatin was greater than in those w ith normal renal function.
