An invasive management strategy is associated with improved outcomes in high-risk acute coronary syndromes in patients with chronic kidney disease

Abstract

Introduction: Chronic kidney disease (CKD) is associated with poor outcomes after acute coronary syndromes, yet selection for invasive investigation and management is low. Methods: Patients presenting with ST segment elevation myocardial infarction (STEMI) or intermediate- to high-risk non-ST segment elevation acute coronary syndrome (NSTEACS) (n=2597) were stratified into groups based on kidney function, defined as normal (glomerular filtration rate (GFR)>=60mL/min/1.73m²), moderate CKD (GFR 30-59mL/min/1.73m²) and severe CKD (GFR <30mL/min/1.73m²). Based on these stratums of kidney function, incidence and outcome measures were obtained for: rates of angiography and revascularization; 6-month mortality; and the incidence and outcome of in-hospital acute kidney impairment (AKI). Results: Patients with CKD were less likely to be offered coronary angiography after STEMI/NSTEACS (P<0.001); however, after selection, revascularization rates were similar (percutaneous coronary intervention (P=0.8); surgery (P=0.4)). Six-month mortality rates increased with CKD (GFR>=60, 2.8%; GFR 30-59, 9.9%; GFR<30, 16.5%, P<=0.001), as well as the combined efficacy/safety end-point (GFR>=60, 9.4%; GFR 30-59, 20.2%; GFR<30, 27.1%, P<=0.001). Six-month mortality was lower in patients who had received prior angiography (GFR>=60, 1.5% vs 3.6%, P=0.001; GFR 30-59, 5.1% vs 12.7%, P<0.001; GFR<30, 7.3% vs 18.5%, P=0.094). Risk of AKI increased with CKD (GFR>=60, 0.7%; GFR 30-59, 3.4%; GFR<30, 6.8%, P<=0.001), and was associated with high 6-month mortality (35.6% vs 4.1%, P<0.001). Conclusions: In patients with CKD after STEMI/NSTEACS, 6-month mortality and morbidity is high, selection for angiography is lower, yet angiography is associated with a reduced long-term mortality, and with comparable revascularization rates to those without CKD. In-hospital AKI is more common in CKD and predicts a high 6-month mortality. 2011 The Authors. Internal Medicine Journal 2011 Royal Australasian College of Physicians.<br />