BACKGROUND Clinical trials that have assessed the effect of revascularization in patients with stable coronary disease have routinely excluded those with advanced chronic kidney disease. METHODS We randomly assigned 777 patients with advanced kidney disease and moderate or severe ischemia on stress testing to be treated with an initial invasive strategy consisting of coronary angiography and revascularization (if appropriate) added to medical therapy or an initial conservative strategy consisting of medical therapy alone and angiography reserved for those in whom medical therapy had failed. The primary outcome was a composite of death or nonfatal myocardial infarction. A key secondary outcome was a composite of death, nonfatal myocardial infarction, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest. RESULTS At a median follow-up of 2.2 years, a primary outcome event had occurred in 123 patients in the invasive-strategy group and in 129 patients in the conservative-strategy group (estimated 3-year event rate, 36.4% vs. 36.7%; adjusted hazard ratio, 1.01; 95% confidence interval [CI], 0.79 to 1.29; P = 0.95). Results for the key secondary outcome were similar (38.5% vs. 39.7%; hazard ratio, 1.01; 95% CI, 0.79 to 1.29). The invasive strategy was associated with a higher incidence of stroke than the conservative strategy (hazard ratio, 3.76; 95% CI, 1.52 to 9.32; P = 0.004) and with a higher incidence of death or initiation of dialysis (hazard ratio, 1.48; 95% CI, 1.04 to 2.11; P = 0.03). CONCLUSIONS Among patients with stable coronary disease, advanced chronic kidney disease, and moderate or severe ischemia, we did not find evidence that an initial invasive strategy, as compared with an initial conservative strategy, reduced the risk of death or nonfatal myocardial infarction. (Funded by the National Heart, Lung, and Blood Institute and others; ISCHEMIA-CKD ClinicalTrials.gov number, NCT01985360.).

中文翻译：

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晚期肾病患者的冠心病管理。

背景 评估稳定型冠状动脉疾病患者血运重建效果的临床试验通常排除患有晚期慢性肾病的患者。方法 我们随机分配 777 名患有晚期肾病并在压力测试中出现中度或重度缺血的患者接受初始侵入性治疗策略，包括冠状动脉造影和血运重建（如果适用）加药物治疗，或初始保守策略仅包括药物治疗血管造影术是为药物治疗失败的患者保留的。主要结局是死亡或非致死性心肌梗死的复合结局。关键的次要结局是死亡、非致命性心肌梗死或因不稳定心绞痛住院、心力衰竭或复苏性心脏骤停的复合结局。结果 中位随访时间为 2.2 年，侵入性策略组有 123 名患者发生主要结局事件，保守性策略组有 129 名患者发生主要结局事件（预计 3 年事件发生率分别为 36.4% 和 36.7%） ；调整后的风险比，1.01；95% 置信区间 [CI]，0.79 至 1.29；P = 0.95）。关键次要结局的结果相似（38.5% vs. 39.7%；风险比，1.01；95% CI，0.79 至 1.29）。与保守策略相比，侵入性策略与更高的卒中发生率相关（风险比，3.76；95% CI，1.52 至 9.32；P = 0.004），并且死亡或开始透析的发生率更高（风险比，1.48；95% CI，1.52 至 9.32；P = 0.004）。 95% CI，1.04 至 2.11；P = 0.03）。结论 在患有稳定性冠心病、晚期慢性肾病和中度或重度缺血的患者中，我们没有发现证据表明与初始保守策略相比，初始侵入性策略可降低死亡或非致命性心肌梗死的风险。（由国家心肺血液研究所等资助；ISCHEMIA-CKD ClinicalTrials.gov 编号，NCT01985360。）。