Patients with severe chronic kidney disease benefit from early revascularization after acute coronary syndrome

doi:10.1016/j.ijcard.2013.06.013

International Journal of Cardiology

Volume 168, Issue 4, 9 October 2013, Pages 3741-3746

https://doi.org/10.1016/j.ijcard.2013.06.013 Get rights and content

Abstract

Background

Early revascularization is associated with improved outcomes after non-ST-elevation acute coronary syndrome (ACS). It is unclear whether its benefits exist in patients with ACS and advanced chronic kidney disease (CKD), because these patients are often sub-optimally treated and excluded from clinical trials.

Methods

We undertook meta-analyses of short- and long-term mortality outcomes in comparative studies examining the effectiveness of early revascularization in patients with ACS and CKD (as estimated by Glomerular Filtration Rate, eGFR). A literature search between 1995 and 2010 identified 7 published reports enrolling 23,234 patients with at least mild reduction in eGFR (< 90 mL/min/1.73 m²), of whom 6276 and 16,958 patients received early revascularization versus initial medical therapy, respectively. Summary odds ratios (OR) and their 95% Confidence Intervals (CIs) were calculated using the random-effects models. Sensitivity analyses were performed by one-study removal, and publication bias was assessed by the funnel plot analysis.

Results

Early revascularization was associated with a reduction in 1-year mortality compared to initial medical therapy (OR = 0.46, 95% CI 0.26–0.82, P = 0.008) among ACS patients with eGFR < 60 mL/min/1.73 m². The mortality reduction with early revascularization occurred upfront (short term mortality OR = 0.69, 95% CI 0.56–0.87, P = 0.001), persisted at 3 years (OR = 0.54, 95% CI 0.31–0.96, P = 0.037), was evident across all CKD stages (including dialysis patients), and was independent of the influence of any single study.

Conclusions

Early revascularization after ACS is associated with reduced mortality in appropriately-selected patients with CKD, including those with severe CKD or receiving dialysis.

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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Cited by (51)

Prognosis of patients with renal failure one year following non-ST-segment elevation myocardial infarction treated with percutaneous coronary intervention
2024, Hellenic Journal of Cardiology
Kidney failure is highly prevalent in patients with non-ST-elevation myocardial infarction (NSTEMI). The aim of the study was to evaluate the prognostic significance of baseline renal function regarding in-hospital and 1-year mortality among patients with NSTEMI and treated with percutaneous coronary intervention (PCI).
Data were obtained from the Polish Registry of Acute Coronary Syndromes (PL-ACS) and included 47,052 NSTEMI patients treated with PCI between 2017 and 2021. The cumulative incidence of all-cause mortality during the 1-year follow-up was presented using the Kaplan-Meier curves. The multivariable Cox regression model was created to adjust the relationship between eGFR (as a spline term) and all-cause mortality for potential confounders.
After considering the exclusion criteria, 20,834 cases were evaluated, with a median eGFR of 72.7 (IQR 56.6-87.5) mL/min/1.73 m². The median age was 69 (62-76) years. The study comprised 4,505 patients with normal (90-120), 10,189 with mild (60-89), 5,539 with moderate (30-59), and 601 with severe eGFR impairment (15-29). Lower eGFR was associated with worse baseline clinical profile and longer in-hospital delay to coronary angiography. There was a stepwise increase in the crude all-cause death rates across the groups at 1 year. The Cox regression model with a spline term revealed that the relationship between eGFR and the risk of death at 1 year was non-linear (reverse J-shaped), and the risk was the lowest in patients with eGFR∼90 mL/min/1.73 m².
There is a J-curve relationship between the eGFR value and 1-year all-cause mortality in patients with NSTEMI and treated with PCI.
Editorial: Chronic kidney disease, the time to shine for the astute clinician
2024, Cardiovascular Revascularization Medicine
Coronary angiography in patients with kidney dysfunction and myocardial injury: A retrospective cohort study on management of myocardial injury in hospitalized patients with kidney disease
2024, Cardiovascular Revascularization Medicine
Although kidney insufficiency has been shown to be associated with increased risk of myocardial injury, benefit of coronary angiography (CAG) and revascularization remains uncertain, with implications on management strategies and outcomes. We aimed to compare rates of CAG and revascularization and subsequent risk of cardiovascular and kidney outcomes in hospitalized patients with myocardial injury and kidney dysfunction.
Retrospective cohort study encompassing hospitalized patients with myocardial injury i.e. elevated troponin I or T and an eGFR ≤60 ml/min/1.73 m² identified between 2011 and 2021 in Danish national registers. 30-day odds for CAG were computed across granular eGFR-categories based on multiple logistic regression. Standardized one-year risks of cardiovascular and kidney outcomes including mortality were determined based on hazards obtained in multiple Cox regression.
A total of 52,798 patients with myocardial injury were identified. CAG was performed in 14.3 % (n = 7549). 30-day odds ratios for CAG were 0.64 [0.60–0.68], 0.38 [0.34–0.42], 0.18 [0.14–0.22], and 0.35 [0.30–0.40] in patients with eGFR 31–45 ml/min/1.73 m², eGFR 15–30 ml/min/1.73 m² for eGFR<15 ml/min/1.73 m² and chronic dialysis, respectively (eGFR 46-60 ml/min/1.73 m² as reference). Median follow-up was 4.1 years. One-year mortality risk differences associated with CAG and revascularization (no CAG as reference) were −7.8 [−7.0; −8.7] and −9.1 [−8.4; −9.9] for eGFR 46-60 ml/min/1.73 m²; −7.0 [−5.7;-8–3] and −8.0 [−6.6; −9.5] for eGFR 31-45 ml/min/1.73 m²; −5.4 [−3.0; −7.2] and −5.2 [−2.2; −8.3] for eGFR 15-30 ml/min/1.73 m²; −8.8 [−3.1; −13.7] and −5.4 [3.1; −13.4] for eGFR<15 ml/min/1.73 m²; and −4.9 [−0.1; −9.7] and −4.2 [1.5; −9.2] for chronic dialysis, respectively.
Probability of CAG following myocardial injury declined with progressive kidney dysfunction. Overall, CAG was associated with lower mortality irrespective of kidney function and subsequent revascularization.
Outcomes of Non–ST-Segment Myocardial Infarction During Chronic Heart Failure and End-Stage Renal Disease
2023, American Journal of Cardiology
Non–ST-segment myocardial infarction (NSTEMI) occurs frequently in a growing population of patients with chronic heart failure (HF) and end-stage renal disease (ESRD) but outcomes with invasive management approaches are unknown. We sought to determine in-hospital outcomes with percutaneous coronary intervention (PCI) in comparison with medical management only. The National Inpatient Sample was used to capture hospitalizations in the United States from 2006 to 2019. Admissions for NSTEMI in patients with chronic HF and ESRD were identified by International Classification of Diseases codes. The cohort was divided into those that received PCI or medical management only. In-hospital outcomes were compared by multivariable logistic regression and propensity matching. In 27,433 hospitalizations, 8,004 patients (29%) underwent PCI, and 19,429 (71%) were managed with medications only. PCI was associated with lower adjusted odds of death during hospitalization (adjusted odds ratio 0.59, 95% confidence interval 0.52 to 0.66, p <0.01). This association remained consistent after propensity matching (adjusted odds ratio 0.56, 95% confidence interval 0.49 to 0.64, p <0.01) and was apparent across all subtypes of HF. Patients with PCI had greater duration (5, 3, to 9 vs, 5, 3 to 8 days, p <0.01) and cost of hospitalization ($107,942, 70,230 to $173,182 vs, $44,156, 24,409 to $80,810, p <0.01). In conclusion, patients with HF and ESRD admitted for NSTEMI experienced lower in-hospital mortality with PCI in comparison with medical therapy only. Invasive percutaneous revascularization may be reasonable for appropriately selected patients with HF and ESRD but randomized controlled trials are needed to determine its safety and efficacy in this high-risk population.
Monocentric experience of the RenalGuard® system to limit post-contrast acute kidney injury in patients at high-risk undergoing interventional coronary procedures
2022, Annales de Cardiologie et d'Angeiologie
Malgré un rapport bénéfices/risques souvent favorable de la cardiologie interventionnelle coronaire, les patients avec une insuffisance rénale chronique sévère sont parfois récusés en raison du risque d'insuffisance rénale aiguë post-contraste (IRA-PC). Un apport préventif important de fluide intraveineux peut être problématique dans cette population. Le système RenalGuard® permet une hyperhydratation en maintenant une volémie stable grâce à une diurèse renforcée.
Ce travail rapporte l’évaluation du système RenalGuard® chez 25 patients consécutifs insuffisants rénaux (débit de filtration glomérulaire < 40 mL/min/1,73 m²) nécessitant une procédure coronaire interventionnelle (coronarographies et/ou angioplasties coronaires) et à haut risque d'IRA-PC. Une augmentation de la créatininémie ≥ 26,5 µmol/L à 48–72 heures (critère d'IRA-PC) a été observée chez 4 patients (16 %). Le débit de filtration glomérulaire moyen était de 26 ± 8 mL/min/1,73 m² à 48–72 heures versus 25 ± 8 mL/min/1,73 m² à l’état basal. Aucun patient n'a présenté d'augmentation de la créatininémie ≥ 1,5 la valeur de base, d'IRA de stade 2 ou 3, ou d’œdème aigu du poumon. Aucun recours à une épuration extrarénale n'a été nécessaire. Un décès est survenu lors de la phase hospitalière sans lien avec une IRA-PC.
Cette étude observationnelle monocentrique suggère que le système RenalGuard® permettant une hyperhydratation ajustée à la diurèse, est sûr et utile pour les patients à haut risque d'IRA-PC après une procédure de cardiologie interventionnelle.
Despite an often favorable risk/benefit ratio, patients with severe chronic kidney disease are sometimes declined for interventional coronary procedures, due to the risk of acute kidney injury post-contrast (AKI-PC). A large preventive supply of intravenous fluid may be problematic in this population. The RenalGuard® system allows hyperhydration by maintaining a stable volemia through an enhanced diuresis.
This work reports the evaluation of the RenalGuard® system in 25 consecutive patients with chronic kidney disease (glomerular filtration rate < 40 mL/min/1.73 m²) requiring an interventional coronary procedure (coronary angiography and/or percutaneous coronary intervention) and at high risk of IRA-PC. An increase in serum creatinine ≥ 26.5 µmol/L at 48–72 hours (AKI-PC definition) was observed in 4 patients (16%). The mean glomerular filtration rate was 26 ± 8 mL/min/1.73 m² at 48–72 hours versus 25 ± 8 mL/min/1.73 m² at baseline. No patient presented with an increase in serum creatinine ≥ 1.5 from baseline, stage 2 or 3 AKI, or acute pulmonary edema. No renal replacement therapy was necessary. One death unrelated to AKI-PC occurred during hospital stay.
This single-center observational study suggests that the RenalGuard® system, allowing diuresis-adjusted hyperhydration, is safe and useful for patients at high risk of AKI-PC after an interventional coronary procedure.
Early Invasive Strategy and Outcome of Non–ST-Segment Elevation Myocardial Infarction Patients With Chronic Kidney Disease
2022, JACC: Cardiovascular Interventions
Citation 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.
Current guidelines suggest that an early invasive strategy should be considered for the treatment of non–ST-segment elevation myocardial infarction (NSTEMI). Although chronic kidney disease (CKD) is common among NSTEMI patients, these patients are under-represented in clinical trials, and data regarding their management are limited.
The authors sought to evaluate the association between early invasive strategy and long-term survival among patients with NSTEMI and CKD.
This was a retrospective analysis of 7,107 consecutive NSTEMI patients between 2008 and 2021. Patients were dichotomized into early (≤24 hours) and delayed invasive groups and stratified by kidney function. Inverse probability treatment weighting was used to adjust for differences in baseline characteristics. The primary outcome was all-cause mortality.
The final study population comprised 3,529 invasively treated patients with a median age of 66 years (IQR: 58-74 years), 1,837 (52%) of whom were treated early. There were 483 (14%) patients with at least moderate CKD (estimated glomerular filtration rate [eGFR] <45 mL/min/1.73 m²). During a median follow-up of 4 years (IQR: 2-6 years), 527 (15%) patients died. After inverse probability treatment weighting, an early invasive strategy was associated with a significant 30% lower mortality compared with a delayed strategy (HR: 0.7; 95% CI: 0.56-0.85). The association between early invasive strategy and mortality was modified by eGFR (P_interaction < 0.001) and declined with lower renal function, with no difference in mortality among patients with eGFR <45 mL/min/1.73 m² (HR: 0.89; 95% CI: 0.64-1.24).
Among NSTEMI patients, the association of early invasive strategy with long-term survival is modified by CKD and was not observed in patients with eGFR <45 mL/min/1.73 m².

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^☆: All authors had access to the data and a role in the writing of this manuscript.

¹: All authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.

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Published by Elsevier Ireland Ltd.

Patients with severe chronic kidney disease benefit from early revascularization after acute coronary syndrome☆

Abstract

Background

Methods

Results

Conclusions

Introduction

Section snippets

Search strategy

Results

Discussion

J Am Coll Cardiol

J Am Coll Cardiol

Am J Med

Am Heart J

J Am Coll Cardiol

Am J Cardiol

Am J Kidney Dis

Am Heart J

Heart disease and stroke statistics—2010 update: a report from the American Heart Association

Circulation

Circulation

Creatinine clearance and adverse hospital outcomes in patients with acute coronary syndromes: findings from the global registry of acute coronary events (GRACE)

Heart

Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization

N Engl J Med

Cystatin C: a novel predictor of outcome in suspected or confirmed non-ST-elevation acute coronary syndrome

Circulation

Relation between renal dysfunction and cardiovascular outcomes after myocardial infarction

N Engl J Med

Poor long-term survival after acute myocardial infarction among patients on long-term dialysis

N Engl J Med