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CHANGES IN CARDIAC STRUCTURE AND FUNCTION AFTER
REVASCULARISATION VERSUS MEDICAL THERAPY FOR RENAL
ARTERY STENOSIS: THE ASTRAL HEART ECHOCARDIOGRAPHY SUBSTUDY
Darren Green1, Kelly Handley2, Keith Wheatley2, Tina Chrysochou1, Janet
Hegarty1, Julian Wright3, Jon Moss4, Rajan K Patel4, Chris Deighan5, John
Webster6, Wendy Crichton6, Peter Rowe7, Sue Carr8, Jenny Cross9, Jamie
O’Driscoll10, Natalie Ives2, Philip A Kalra1
1Salford
Royal Hospital, UK, 2University of Birmingham, UK, 3 Central
Manchester Foundation Trust, UK, 4Western Infirmary, Glasgow, UK, 5Glasgow
Royal Infirmary, UK, 6Aberdeen Royal Infirmary, UK. 7Derriford Hospital,
Plymouth, UK, 8Leicester Royal Infirmary, UK, 9Royal Free Hospital, London,
UK, 10St George’s Hospital, London, UK.
BACKGROUND: The ASTRAL trial showed no difference in clinical outcomes
between medical therapy and revascularisation for atherosclerotic renal vascular disease
(ARVD). Here we report a sub-study using echocardiography to assess differences in
cardiac structure and function at 12 months.
METHODS: ASTRAL patients from 7 participating centres underwent
echocardiography at baseline and 12 months after randomisation. Changes (mean ±
standard deviation) in left ventricular ejection fraction (LVEF), left ventricular mass
(LVM), left atrial diameter (LAD), aortic root diameter (AoRD), E:A, and E
deceleration time (EDT) were compared between study arms. Analysis was performed
using multivariate logistic regression adjusted for co-variates that may influence
cardiovascular outcome in ARVD or that were significantly different between groups on
baseline comparison.
RESULTS: 92 patients were included (50 medical versus 42 revascularisation).
There were no statistical differences in baseline co-morbidities or clinical characteristics
between the groups (mean age 71 versus 70 years, eGFR 43 versus 45mL/min, systolic
blood pressure 152 versus 146 mmHg, number of antihypertensives 3.0 versus 2.9)
except that more medical patients were on a statin (93% versus 76%, p=0.03).
Echocardiography showed no statistical difference between arms in any
echocardiographic parameter at baseline (LVEF medical = 54±11% versus
revascularisation 54±9%, LVM = 203±37g versus 202±34g, LAD = 3.8±0.5cm versus
3.9±0.5cm). Change in LVEF at 12 months was greater in medical patients: δLVEF
medical 0.8±8.7% versus revascularisation -2.8±6.8% (p=0.049). In a multivariate
model including age, blood pressure, renal function, degree of stenosis, beta blockade
and ACE-inhibitor use this was no longer significant. There were no significant
differences between arms for: δLVM -2.9±33.1 versus -1.7±38.9g, δLAD 0.1±0.4
versus 0.01±0.5cm, δAoRD 0.002±0.3 versus 0.1±0.3cm, δE:A 0.0±0.6 versus
0.03±0.7, δEDT -1.1±55.5 versus -9.0±70.2ms.
CONCLUSIONS: This sub-study did not show any significant differences in cardiac
structure and function accompanying renal revascularisation in ASTRAL. Limitations
include sample size, the relative insensitivity of echocardiography, as well as the
clinical heterogeneity of the ASTRAL patient population as described in the main study.
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