Guideline-directed medical therapy in Polish patients with chronic coronary syndrome and advanced chronic kidney disease: insights from the ISCHEMIA-CKD trial

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Introduction: The ISCHEMIA-CKD trial showed similar outcomes with an initial conservative vs invasive approach to chronic coronary syndrome in patients with advanced chronic kidney disease.Guideline-directed medical therapy (GDMT) was recommended regardless of the randomized strategy assignment.Aim: To describe GDMT attainment in ISCHEMIA-CKD participants in Poland compared to other world regions.Material and methods: Among 777 trial participants, 105 were randomized in Poland.Patients were followed for a median of 2.2 years with the following GDMT recommendations: not smoking, systolic blood pressure (SBP) < 140/ diastolic blood pressure (DBP) < 90 mm Hg, high/moderate-intensity statin, antiplatelet/anticoagulant, angiotensin-converting-enzyme inhibitors (ACE-I)/ angiotensin receptor blockers (ARB) and β-blocker therapy, glycated hemoglobin (HbA1c) < 8% when indicated.Results: Participants in Poland vs other regions of the world (age 67 [60, 76] vs. 63 [55, 70] years, p < 0.001, 32% vs. 31% females, p = 0.86) had higher incidence of prior myocardial infarction (25% vs. 16%, p = 0.04), peripheral vascular disease (12% vs. 5%, p = 0.009), atrial fibrillation (23% vs. 7%, p < 0.001), and less frequently diabetes (44% vs. 59%, p = 0.004).At baseline, Polish participants were more often on antiplatelets/anticoagulants (91% vs. 83%, p = 0.04), β-blockers (95% vs. 72%, p < 0.001), and ACE-I/ARBs (62% vs. 45%, p = 0.002), with better attainment of SBP < 140 (73% vs. 53%, p < 0.001), and HbA1c < 8% (86% vs. 56%, p = 0.003) and similar smoking and high-/moderate-intensity statin treatment frequencies.This degree of GDMT goal attainment was maintained at the last follow-up visit.Conclusions: In Polish patients with advanced kidney disease, high GDMT goal attainment was observed and maintained until the last follow-up visit under trial-specific, strict medical surveillance.The impact of GDMT on long-term outcomes remains to be studied in this patient population.Key words: chronic coronary syndrome, advanced chronic kidney disease, coronary revascularization, optimal medical therapy. S u m m a r yGuideline-directed medical therapy (GDMT) in chronic coronary syndrome (CCS) is recommended as the cornerstone of treatment, including in patients with advanced chronic kidney disease.However, this population presents with a high comorbidity burden, and medical treatment is complicated by drug interactions and treatment side-effects, with an uncertain efficacy and safety profile.Herein, we present the GDMT status of ISCHEMIA-CKD participants in Poland compared to other countries worldwide, summarizing for the first time in a systematic manner the profile of comorbidity and medical treatment of Polish patients with CCS and advanced kidney disease.Despite a higher comorbidity burden, Polish participants of ISCHEMIA-CKD showed high levels of GDMT goal attainment compared to other countries at enrollment into the trial, which were maintained through to the last follow-up visit.Patterns of statin therapy reflect ongoing controversies regarding its efficacy and safety, pointing to the need for further high-quality randomized trials.

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