Executive Summary: Cardiovascular Outcomes in Hemodialysis Patients and a Link to Sustainable Development Goal 3

A comprehensive analysis was conducted to evaluate the long-term prognosis of patients with Acute Coronary Syndrome (ACS) who are undergoing hemodialysis (HD). The study specifically compares outcomes based on the etiology of ACS, distinguishing between de novo coronary artery lesions and stent thrombosis (ST). The findings reveal a significantly poorer prognosis for patients on HD, particularly those experiencing ST-related ACS. These results underscore a critical challenge in achieving Target 3.4 of the United Nations Sustainable Development Goals (SDGs), which aims to reduce premature mortality from non-communicable diseases (NCDs). The disproportionately high rate of Major Adverse Cardiac Events (MACE) and mortality in this vulnerable population highlights the urgent need for targeted health interventions and strategies to ensure good health and well-being for all.

Introduction: The Intersection of Cardiovascular Disease and Global Health Goals

The Global Challenge of Non-Communicable Diseases and SDG 3

Cardiovascular diseases are a leading cause of mortality worldwide, representing a primary focus area for Sustainable Development Goal 3 (Good Health and Well-being). A central objective, outlined in SDG Target 3.4, is to reduce premature mortality from NCDs by one-third by 2030 through effective prevention and treatment. Patients with chronic conditions, such as those requiring hemodialysis, face an elevated risk and contribute significantly to this global health burden.

Health Inequities in Vulnerable Populations: The Case of Hemodialysis Patients

Patients undergoing HD represent a particularly vulnerable demographic with a high prevalence of coronary artery disease. This group experiences significant health disparities, aligning with the concerns of SDG 10 (Reduced Inequalities). The management of ACS in these patients is complex, with high rates of complications like restenosis and ST following percutaneous coronary intervention (PCI). Despite advances in treatment, long-term prognosis data has been limited, hindering the development of evidence-based strategies to improve outcomes and address these health inequities.

Study Objectives Aligned with SDG 3.4

This study aimed to investigate and compare the long-term prognosis of ACS in patients with and without HD, focusing on ACS caused by de novo lesions versus ST. By identifying the patient groups at the highest risk and the key predictors of adverse outcomes, this research provides critical evidence to inform clinical practice and health policies. The ultimate goal is to contribute to the achievement of SDG 3.4 by developing more effective treatment pathways that reduce premature mortality and improve the quality of life for this high-risk population.

Methodology for Evaluating Long-Term Prognosis

Study Design and Population

The research was conducted as a retrospective analysis, pooling data from two distinct patient cohorts:

1. The Osaka Cardiovascular Conference Long ST Registry: This multicenter registry provided data on 187 patients who experienced ACS due to definite ST between 2008 and 2017.
2. The Kansai Rosai Hospital Institutional Registry: This registry included 1,856 patients who presented with ACS due to de novo coronary artery lesions and underwent primary PCI between 2011 and 2023.

This combined approach allowed for a robust comparison across different ACS etiologies and patient conditions, essential for generating evidence to support SDG-related health improvements.

Patient Grouping and Outcome Measures

For comparative analysis, the study population was stratified into four distinct groups:

• ST-ACS with HD
• ST-ACS without HD
• de novo-ACS with HD
• de novo-ACS without HD

The primary outcome was the 6-year incidence of Major Adverse Cardiac Events (MACE), a composite measure including cardiac death, non-fatal myocardial infarction, target vessel revascularization, and subsequent ST. Secondary outcomes included all-cause death and individual components of MACE. This rigorous evaluation is fundamental to understanding the specific health challenges that impede progress toward SDG 3.

Key Findings: Stark Disparities in Clinical Outcomes

Major Adverse Cardiac Events (MACE) Over Six Years

The investigation revealed a clear and statistically significant hierarchy of risk among the patient groups. The 6-year MACE rate demonstrates the profound impact of both hemodialysis and stent thrombosis on patient prognosis, highlighting a critical area for intervention to meet SDG 3 targets.

1. ST-ACS with HD: 82.1% (Highest risk)
2. de novo-ACS with HD: 62.5%
3. ST-ACS without HD: 38.3%
4. de novo-ACS without HD: 24.2% (Lowest risk)

Mortality Rates and Independent Risk Factors

The long-term prognosis for patients on HD was exceptionally poor, with a 6-year all-cause mortality rate of approximately 70% for both the ST-ACS and de novo-ACS groups. This high mortality rate is a direct challenge to SDG 3.4. Multivariate analysis identified several independent predictors of MACE, providing clear targets for clinical management:

• Hemodialysis (HD) (Hazard Ratio: 2.50)
• ST-ACS (Hazard Ratio: 1.69)
• Diabetes Mellitus (Hazard Ratio: 1.36)
• History of Myocardial Infarction (Hazard Ratio: 1.56)
• Femoral Approach for PCI (Hazard Ratio: 1.60)

Conversely, imaging-guided PCI was found to be a negative predictor, suggesting its protective role in improving outcomes.

Discussion: Implications for Achieving Sustainable Development Goal 3

Poor Prognosis as a Major Barrier to SDG 3.4

The study’s findings confirm that the long-term prognosis following ACS is unfavorable for patients on HD, and critically so for those with ST-ACS. The 6-year mortality rate of 70% in this group represents a significant barrier to achieving the SDG 3.4 target of reducing premature NCD mortality. The primary causes of death, including arrhythmia, sudden death, and infection, point to specific areas where preventative and therapeutic strategies must be improved.

Addressing Health Inequities (SDG 10) Through Targeted Strategies

The stark contrast in outcomes between HD and non-HD patients underscores a significant health inequity. To make meaningful progress toward the universal health coverage embedded in SDG 3, tailored interventions for this vulnerable population are essential. The research suggests several clinical strategies to mitigate risk and improve outcomes:

• Enhanced Prevention: Prioritize functional ischemia evaluation to avoid unnecessary stent placement, which can lead to complications like ST.
• Alternative Revascularization: Consider Coronary Artery Bypass Grafting (CABG) as a potentially superior long-term therapeutic option compared to PCI in this high-risk group.
• Sudden Death Prevention: Proactively use devices such as Implantable Cardioverter-Defibrillators (ICDs), including subcutaneous models to reduce infection risk, for patients at high risk of fatal arrhythmias post-ACS.

Conclusion: A Call for Action to Ensure Sustainable Health for All

This report provides compelling evidence that patients on hemodialysis who suffer an Acute Coronary Syndrome face a dire long-term prognosis, a situation that is particularly severe in cases of stent thrombosis. These findings are a crucial alert for the global health community, highlighting a specific, vulnerable population whose poor outcomes significantly challenge the ambitions of Sustainable Development Goal 3. To advance the goal of reducing premature mortality from non-communicable diseases and promoting well-being for all, it is imperative to develop and implement specialized prevention and treatment protocols tailored to the unique risks of ACS patients on hemodialysis.

1. Which SDGs are addressed or connected to the issues highlighted in the article?

The primary Sustainable Development Goal (SDG) addressed in the article is SDG 3, which focuses on ensuring healthy lives and promoting well-being for all at all ages. The article’s in-depth analysis of non-communicable diseases (NCDs) and their treatment outcomes directly aligns with the objectives of this goal.

• SDG 3: Good Health and Well-being

  The article is centered on medical research concerning cardiovascular diseases, specifically acute coronary syndrome (ACS), and chronic kidney disease requiring hemodialysis (HD). It investigates the long-term prognosis, mortality rates, and outcomes of treatments like percutaneous coronary intervention (PCI). As stated in the introduction, “Patients who undergo hemodialysis (HD) have been reported to have a high risk of cardiovascular diseases,” and “> 50% of deaths due to a known cause in patients on HD are attributed to cardiovascular diseases.” This focus on understanding and improving outcomes for patients with NCDs is a core component of SDG 3.

2. What specific targets under those SDGs can be identified based on the article’s content?

Based on the article’s focus on mortality from NCDs and the quality of healthcare services, two specific targets under SDG 3 are relevant.

1. Target 3.4: By 2030, reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being.

   The article directly addresses this target by investigating the high mortality rates associated with ACS, a major cardiovascular NCD, particularly in the high-risk population of patients on hemodialysis. The study’s primary outcome is the “6-year incidence of major adverse cardiac events (MACE) defined as a composite of cardiac death, non-fatal myocardial infarction, target vessel revascularization, and subsequent ST.” The findings, such as the 6-year MACE rate being highest in patients with ST-ACS and HD (82.1%) and the overall 6-year mortality rate of 70% for patients on HD after ACS, highlight the challenge in reducing premature mortality. The research aims to improve treatment strategies to lower these rates.

2. Target 3.8: Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all.

   The study evaluates the effectiveness and quality of essential, high-technology healthcare services for NCDs. The entire research is based on patients who received treatments such as “hemodialysis (HD),” “percutaneous coronary intervention (PCI),” and “drug-eluting stents (DES).” The analysis of outcomes for these treatments, comparing different patient groups and procedural factors like “imaging-guided PCI,” is an assessment of the quality of these essential services. The discussion about choosing between PCI and coronary artery bypass grafting (CABG) or using an implantable cardioverter-defibrillator (ICD) further relates to providing the most effective and high-quality care to improve patient survival, a key aspect of universal health coverage.

3. Are there any indicators mentioned or implied in the article that can be used to measure progress towards the identified targets?

The article provides direct and implied data for indicators corresponding to the identified targets.

• Indicator 3.4.1: Mortality rate attributed to cardiovascular disease, cancer, diabetes or chronic respiratory disease.

  The article is rich with data points that serve as direct measures for this indicator. It quantifies mortality from cardiovascular disease in a specific patient cohort.

  • The primary outcome is the “6-year incidence of major adverse cardiac events (MACE),” which includes cardiac death. The study reports MACE rates of “82.1 vs. 62.5 vs. 38.3 vs. 24.2%” for the four different patient groups.
  • It explicitly states, “The 6-year all-cause death rate was higher among patients on HD than among non-HD patients.”
  • It provides specific mortality figures: “among patients on HD with ACS due to de novo coronary artery lesions… 70% died within 6 years.”
  • It details the causes of death, noting that “arrhythmia and sudden death as CD [cardiac death]… were the leading causes of death in the ST-ACS and de novo-ACS with HD groups.”

• Indicator 3.8.1: Coverage of essential health services.

  While the article does not measure the overall coverage of services in a general population, it implicitly addresses this indicator by studying a population that has received highly specialized and essential health services. The existence of the study cohorts (“Osaka Cardiovascular Conference Long ST registry” and “Kansai Rosai Hospital institutional registry”) implies that these services are available and being utilized. The article’s focus is on the quality and outcomes of these services, which is a crucial dimension of the indicator.

  • The study population consists of patients who have undergone “primary PCI,” a key treatment for ACS.
  • The research analyzes the use and outcomes of specific essential medical technologies and procedures, including “hemodialysis (HD),” “drug-eluting stents (DES),” “imaging guided PCI,” and “coronary artery bypass grafting (CABG).”
  • The multivariate analysis identifies factors that predict outcomes, such as “imaging-guided PCI” being “negatively associated with MACE,” which is a direct evaluation of the quality of an essential health service.

4. Table of SDGs, Targets, and Indicators

Source: nature.com