Patients with severe chronic kidney disease benefit from early revascularization after acute coronary syndrome☆
Introduction
Cardiovascular disease is the leading cause of death for patients with chronic kidney disease (CKD) [1]. Renal dysfunction affects approximately 25–40% of patients hospitalized for acute coronary syndrome (ACS) [2]. Patients with CKD who present with ACS are at increased risk for both adverse cardiovascular outcomes and death compared to those with normal renal function [3], [4], [5], [6]. Cardiovascular hazards have been shown to be inversely related to the severity of CKD, and are highest for those with end-stage renal disease (ESRD) [5], [7], [8], [9]. Nevertheless, patients with ACS and CKD are less likely to receive coronary angiography or revascularization and other guideline-recommended therapies [2], [10], [11]. This treatment disparity is likely multi-factorial and may be caused by concerns for higher procedural complications, increased bleeding risk with long-term anti-platelet therapy, increased likelihood of restenosis and need for repeat revascularization, higher proclivity for de novo coronary artery disease, and hastening the progression to dialysis. [12], [13], [14], [15]
While randomized controlled trials (RCTs) and observational studies have shown reduction in MI and cardiovascular morbidity with an initial invasive strategy followed by early revascularization in ACS patients [16], it is unclear how these outcomes apply to the CKD subpopulation, as patients with advanced CKD were often excluded and largely under-represented in these studies [17]. Notably, SWEDEHEART, the largest registry to date examining the impact of early revascularization after ACS, was underpowered to detect outcome differences in patients with GFR < 30 mL/min/1.73 m2 [18].
Whether or not to refer patients with ACS and CKD for routine early revascularization is a frequently encountered clinical predicament, and will arise more commonly as the prevalence of patients with ESRD is expected to nearly double over the next decade [19], [20]. In the current meta-analysis, we sought to evaluate the comparative effectiveness of early revascularization versus initial medical therapy, with respect to short- and long-term mortality in patients presenting with ACS and various stages of CKD.
Section snippets
Search strategy
Relevant published reports were identified by a two-level search strategy. We conducted a computerized literature search using PubMed, Ovid, Google Scholar, and the Cochrane Central Register to identify relevant comparative reports published between January 1995 and June 2010. We used key words associated with CKD (chronic kidney disease, kidney), ACS (acute coronary syndrome, myocardial infarction, coronary disease), and intervention (angiography, revascularization, revascularization coronary
Results
The process of study selection and exclusion is outlined in Fig. 1. In total, there were 7 published reports that met inclusion and exclusion criteria for our analysis. A detailed description of the studies can be found in Table 1. Five reports were prospective or cohort studies and two were retrospective studies. A summary of patients' baseline characteristics revealed increasing medical co-morbidities with worsening CKD stage (Table 2). The analysis included 7 published reports enrolling
Discussion
To our knowledge, this is the largest report to date evaluating outcomes of early revascularization versus initial medical therapy in patients with ACS and advanced CKD. In the current comprehensive meta-analysis, we have shown consistent reduction in mortality associated with an early revascularization strategy across all CKD stages, including stages 4 and 5 CKD, among appropriately-selected patients presenting with ACS.
Patients with CKD have higher rates of CV morbidity and death following
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2022, JACC: Cardiovascular InterventionsCitation Excerpt :Several observational studies have suggested that although patients with CKD and ACS have an elevated baseline risk, revascularization is associated with a net improvement in outcomes. In a meta-analysis of observational studies published in 2013, Huang et al11 have shown a benefit in 1- and 3-year mortality with revascularization across all stages of CKD, including those on hemodialysis. In a recent observational study, Bhatia et al12 confirmed that NSTEMI patients treated with percutaneous coronary intervention have less likelihood of all-cause, in-hospital mortality compared with propensity score–matched medically managed patients across all CKD subgroups.
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All authors had access to the data and a role in the writing of this manuscript.
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All authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.