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Lee SD, Kim RB, Seo CO, Kim M, Lee HJ, Kim H, Kim HR, Kim K, Kang MG, Park JR, Hwang SJ, Hwang JY, Jeong MH, Hur SH, Cha KS, Koh JS. Very early vs delayed invasive strategy in high-risk NSTEMI patients without hemodynamic instability: Insight from the KAMIR-NIH. PLoS One 2024; 19:e0304273. [PMID: 38843207 PMCID: PMC11156373 DOI: 10.1371/journal.pone.0304273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 05/09/2024] [Indexed: 06/09/2024] Open
Abstract
BACKGROUND High-risk non-ST-elevation myocardial infarction (NSTEMI) patients' optimal timing for percutaneous coronary intervention (PCI) is debated despite the recommendation for early invasive revascularization. This study aimed to compare outcomes of NSTEMI patients without hemodynamic instability undergoing very early invasive strategy (VEIS, ≤ 12 hours) versus delayed invasive strategy (DIS, >12 hours). METHODS Excluding urgent indications for PCI including initial systolic blood pressure under 90 mmHg, ventricular arrhythmia, or Killip class IV, 4,733 NSTEMI patients were recruited from the Korea Acute Myocardial Infarction Registry-National Institutes of Health (KAMIR-NIH). Patients were divided into low and high- global registry of acute coronary events risk score risk score (GRS) groups based on 140. Both groups were then categorized into VEIS and DIS. Clinical outcomes, including all-cause death (ACD), cardiac death (CD), recurrent MI, and cerebrovascular accident at 12 months, were evaluated. RESULTS Among 4,733 NSTEMI patients, 62% had low GRS, and 38% had high GRS. The proportions of VEIS and DIS were 43% vs. 57% in the low GRS group and 47% vs. 53% in the high GRS group. In the low GRS group, VEIS and DIS demonstrated similar outcomes; however, in the high GRS group, VEIS exhibited worse ACD outcomes compared to DIS (HR = 1.46, P = 0.003). The adverse effect of VEIS was consistent with propensity score matched analysis (HR = 1.34, P = 0.042). CONCLUSION VEIS yielded worse outcomes than DIS in high-risk NSTEMI patients without hemodynamic instability in real-world practice.
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Affiliation(s)
- Seung Do Lee
- Division of Cardiology, Department of Internal Medicine, Gyeongsang National University School of Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - Rock Bum Kim
- Department of Preventive Medicine and Institute of Health Sciences, Gyeongsang National University College of Medicine, Jinju, Korea
| | - Chang-Ok Seo
- Division of Cardiology, Department of Internal Medicine, Gyeongsang National University School of Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - Moojun Kim
- Division of Cardiology, Department of Internal Medicine, Gyeongsang National University School of Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - Hyo Jin Lee
- Division of Cardiology, Department of Internal Medicine, Gyeongsang National University School of Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - Hangyul Kim
- Division of Cardiology, Department of Internal Medicine, Gyeongsang National University School of Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - Hye Ree Kim
- Division of Cardiology, Department of Internal Medicine, Gyeongsang National University School of Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - Kyehwan Kim
- Division of Cardiology, Department of Internal Medicine, Gyeongsang National University School of Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - Min Gyu Kang
- Division of Cardiology, Department of Internal Medicine, Gyeongsang National University School of Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - Jeong Rang Park
- Division of Cardiology, Department of Internal Medicine, Gyeongsang National University School of Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - Suk Jae Hwang
- Division of Cardiology, Department of Internal Medicine, Gyeongsang National University School of Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - Jin Yong Hwang
- Division of Cardiology, Department of Internal Medicine, Gyeongsang National University School of Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - Myung Ho Jeong
- Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Seung-Ho Hur
- Keimyung University Dongsan Medical Center, Cardiovascular Medicine, Deagu, Republic of Korea
| | - Kwang Soo Cha
- Pusan National University Hospital, Busan, South Korea
| | - Jin-Sin Koh
- Division of Cardiology, Department of Internal Medicine, Gyeongsang National University School of Medicine, Gyeongsang National University Hospital, Jinju, Korea
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Mathew RO, Rangaswami J, Abramov D, Mahalwar G, Vellanki S, Abuazzam F, Fraser GE, Butler FM, Lo KB, Herzog CA, Shroff GR, Sidhu MS, Bangalore S. Proportional troponin changes and risk for outcomes with intervention strategies in non-ST-elevation acute coronary syndrome across kidney function. Catheter Cardiovasc Interv 2023; 102:1162-1176. [PMID: 37870080 DOI: 10.1002/ccd.30863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 08/17/2023] [Accepted: 10/05/2023] [Indexed: 10/24/2023]
Abstract
AIMS This analysis evaluates whether proportional serial cardiac troponin (cTn) change predicts benefit from an early versus delayed invasive, or conservative treatment strategies across kidney function in non-ST-elevation acute coronary syndrome (NSTE-ACS). METHODS Patients diagnosed with NSTE-ACS in the Veterans Health Administration between 1999 and 2022 were categorized into terciles (<20%, 20 to ≤80%, >80%) of proportional change in serial cTn. Primary outcome included mortality or rehospitalization for myocardial infarction at 6 and 12 months, in survivors of index admission. Adjusted hazard ratio (HR) with 95% confidence Intervals (95% confidence interval [CI]) were calculated for the primary outcome for an early invasive (≤24 h of the index admission), delayed invasive (>24 h of index admission to 90-days postdischarge), or a conservative management. RESULTS Chronic kidney disease (CKD) was more prevalent (45.3%) in the lowest versus 42.2% and 43% in middle and highest terciles, respectively (p < 0.001). Primary outcome is more likely for conservative versus early invasive strategy at 6 (HR: 1.44, 95% CI: 1.37-1.50) and 12 months (HR: 1.44, 95% CI: 1.39-1.50). A >80% proportional change demonstrated HR (95% CI): 0.90 (0.83-0.97) and 0.93 (0.88-1.00; p = 0.041) for primary outcome at 6 and 12 months, respectively, when an early versus delayed invasive strategy was used, across CKD stages. CONCLUSIONS Overall, the invasive strategy was safe and associated with improved outcomes across kidney function in NSTE-ACS. Additionally, >80% proportional change in serial troponin in NSTE-ACS is associated with benefit from an early versus a delayed invasive strategy regardless of kidney function. These findings deserve confirmation in randomized controlled trials.
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Affiliation(s)
- Roy O Mathew
- Division of Nephrology, Department of Medicine, Loma Linda VA Healthcare System, Loma Linda, California, USA
- Division of Nephrology, Department of Medicine, Loma Linda University School of Medicine, Loma Linda, California, USA
| | - Janani Rangaswami
- Division of Nephrology, Department of Medicine, Washington DC VA Medical Center, Washington, District of Columbia, USA
- Department of Medicine, George Washington University School of Medicine, Washington, District of Columbia, USA
| | - Dmitry Abramov
- Division of Cardiology, Department of Medicine, Loma Linda University School of Medicine, Loma Linda, California, USA
| | - Gauranga Mahalwar
- Department of Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Shaitalya Vellanki
- Department of Medicine, George Washington University School of Medicine, Washington, District of Columbia, USA
| | - Farah Abuazzam
- Division of Nephrology, Department of Medicine, Loma Linda University School of Medicine, Loma Linda, California, USA
| | - Gary E Fraser
- Division of Cardiology, Department of Medicine, Loma Linda University School of Medicine, Loma Linda, California, USA
- Center for Nutrition, Healthy Lifestyle, and Disease Prevention, School of Public Health, Loma Linda University, Loma Linda, California, USA
- Adventist Health Study, Loma Linda University, Loma Linda, California, USA
- Department of Preventive Medicine, School of Medicine, Loma Linda University, Loma Linda, California, USA
| | - Fayth Miles Butler
- Center for Nutrition, Healthy Lifestyle, and Disease Prevention, School of Public Health, Loma Linda University, Loma Linda, California, USA
- Adventist Health Study, Loma Linda University, Loma Linda, California, USA
- Department of Preventive Medicine, School of Medicine, Loma Linda University, Loma Linda, California, USA
| | - Kevin Bryan Lo
- Department of Medicine, Einstein Medical Center, Philadelphia, Pennsylvania, USA
- Department of Medicine, Sydney Kimmel College of Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Charles A Herzog
- Cardiology Division, Department of Internal Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA
| | - Gautam R Shroff
- Cardiology Division, Department of Internal Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA
| | - Mandeep S Sidhu
- Division of Cardiology, Department of Medicine, Albany Medical College, Albany, New York, USA
| | - Sripal Bangalore
- Division of Cardiology, New York University Grossman School of Medicine, New York City, New York, USA
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Fong KY, Low CHX, Chan YH, Ho KW, Keh YS, Chin CT, Chin CY, Fam JM, Wong N, Idu M, Wong ASL, Lim ST, Koh TH, Tan JWC, Yeo KK, Yap J. Role of Invasive Strategy for Non-ST-Elevation Myocardial Infarction in Patients With Chronic Kidney Disease: A Systematic Review and Meta-Analysis. Am J Cardiol 2023; 205:369-378. [PMID: 37639763 DOI: 10.1016/j.amjcard.2023.07.178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 07/31/2023] [Indexed: 08/31/2023]
Abstract
Patients with chronic kidney disease (CKD) have traditionally been excluded from randomized trials. We aimed to compare percutaneous coronary intervention versus conservative management, and early intervention (EI; within 24 hours of admission) versus delayed intervention (DI; after 24 to 72 hours of admission) in patients with non-ST-segment elevation myocardial infarction (NSTEMI) and concomitant CKD. An electronic literature search was performed to search for studies comparing invasive management to conservative management or EI versus DI in patients with NSTEMI with CKD. The primary outcome was all-cause mortality; secondary outcomes were acute kidney injury (AKI) or dialysis, major bleeding, and recurrent MI. Hazard ratios (HRs) for the primary outcome and odds ratios for secondary outcomes were pooled in random-effects meta-analyses. Eleven studies (140,544 patients) were analyzed. Invasive management was associated with lower mortality than conservative management (HR 0.62, 95% confidence interval 0.57 to 0.67, p <0.001, I2 = 47%), with consistent benefit across all CKD stages, except CKD 5. There was no significant mortality difference between EI and DI, but subgroup analyses showed significant benefit for EI in stage 1 to 2 CKD (HR 0.75, 95% confidence interval 0.58 to 0.97, p = 0.03, I2 = 0%), with no significant difference in stage 3 and 4 to 5 CKD. Invasive strategy was associated with higher odds of AKI or dialysis and major bleeding, but lower odds of recurrent MI compared with conservative management. In conclusion, in patients with NSTEMI and CKD, an invasive strategy is associated with significant mortality benefit over conservative management in most patients with CKD, but at the expense of higher risk of AKI and bleeding. EI appears to benefit those with early stages of CKD. Trial Registration: PROSPERO CRD42023405491.
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Affiliation(s)
- Khi Yung Fong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Chloe Hui Xuan Low
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Yiong Huak Chan
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Kay Woon Ho
- Department of Cardiology, National Heart Centre Singapore, Singapore; Duke-NUS Medical School, Singapore
| | - Yann Shan Keh
- Department of Cardiology, National Heart Centre Singapore, Singapore; Duke-NUS Medical School, Singapore
| | - Chee Tang Chin
- Department of Cardiology, National Heart Centre Singapore, Singapore; Duke-NUS Medical School, Singapore
| | - Chee Yang Chin
- Department of Cardiology, National Heart Centre Singapore, Singapore; Duke-NUS Medical School, Singapore
| | - Jiang Ming Fam
- Department of Cardiology, National Heart Centre Singapore, Singapore; Duke-NUS Medical School, Singapore
| | - Ningyan Wong
- Department of Cardiology, National Heart Centre Singapore, Singapore; Duke-NUS Medical School, Singapore
| | - Muhammad Idu
- Department of Cardiology, National Heart Centre Singapore, Singapore; Duke-NUS Medical School, Singapore
| | - Aaron Sung Lung Wong
- Department of Cardiology, National Heart Centre Singapore, Singapore; Duke-NUS Medical School, Singapore
| | - Soo Teik Lim
- Department of Cardiology, National Heart Centre Singapore, Singapore; Duke-NUS Medical School, Singapore
| | - Tian Hai Koh
- Department of Cardiology, National Heart Centre Singapore, Singapore; Duke-NUS Medical School, Singapore
| | - Jack Wei Chieh Tan
- Department of Cardiology, National Heart Centre Singapore, Singapore; Duke-NUS Medical School, Singapore
| | - Khung Keong Yeo
- Department of Cardiology, National Heart Centre Singapore, Singapore; Duke-NUS Medical School, Singapore
| | - Jonathan Yap
- Department of Cardiology, National Heart Centre Singapore, Singapore; Duke-NUS Medical School, Singapore.
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Limpijankit T, Chandavimol M, Srimahachota S, Kanoksilp A, Jianmongkol P, Siriyotha S, Thakkinstian A, Buddhari W, Sansanayudh N. Dose-dependent effect of impaired renal function on all-cause mortality in patients following percutaneous coronary intervention. Clin Cardiol 2022; 45:882-891. [PMID: 35758306 PMCID: PMC9346964 DOI: 10.1002/clc.23877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 05/21/2022] [Accepted: 05/31/2022] [Indexed: 11/06/2022] Open
Abstract
Objective To determine the risk prediction of various degrees of impaired renal function on all‐cause mortality in patients following percutaneous coronary intervention (PCI). Background Patients with chronic kidney disease (CKD) are at high risk of all‐cause mortality after PCI. However, there are less data of various degrees of impaired renal function to predict those risks. Methods This was a subgroup analysis of nationwide PCI registry of 22 045 patients. Patients were classified into six CKD stages according to preprocedure estimated glomerular filtration rate (eGFR) (ml/min/1.73 m2): I (≥90), II (60−89), III (30−59), IV (15−29), or V (<15) without or with dialysis. Baseline clinical and angiographic characteristics were compared among patients in each stage. One‐year all‐cause mortality was reported with risk prediction based on CKD stages and other risk factors. Results Patients with CKD stage I−V without and with on dialysis were found in 26.9%, 40.8%, 23.2%, 3.9%, 1.5%, and 3.7%, respectively. PCI procedural success and complication rates ranged from 94.0% to 96.2% and 2.8% to 6.1%, respectively. One‐year overall survival among CKD stages I−V was 96.3%, 93.1%, 84.4%, 65.2%, 68.0%, and 69.4%, respectively (p < .001 by log‐rank test). After adjusting covariables, the hazard ratios of all‐cause mortality for CKD stages II−V as compared to stage I by multivariate Cox regression analysis were 1.5, 2.6, 5.3, 5.9, and 7.0, respectively, (p < .001). Conclusion Among patients undergoing PCI, lower preprocedure eGFR is associated in a dose‐dependent effect with decreased 1‐year survival. This finding may be useful for risk classification and to guide decision‐making.
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Affiliation(s)
- Thosaphol Limpijankit
- Department of Medicine, Division of Cardiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Mann Chandavimol
- Department of Medicine, Division of Cardiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Suphot Srimahachota
- Department of Medicine, Division of Cardiovascular Diseases, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Anek Kanoksilp
- Department of Cardiology, Central Chest Institute of Thailand, Nonthaburi, Thailand
| | - Poj Jianmongkol
- Department of Cardiology, Buddhachinaraj Hospital, Phitsanulok, Thailand
| | - Sukanya Siriyotha
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Ammarin Thakkinstian
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Wacin Buddhari
- Department of Medicine, Division of Cardiovascular Diseases, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Nakarin Sansanayudh
- Department of Internal Medicine, Cardiology Unit, Pharmongkutklao Hospital, Bangkok, Thailand
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Hulten EA, Gallagher RM. Coronary revascularization for patients with non-ST elevation myocardial infarction and chronic kidney disease: Better three hours too soon than a minute too late? Atherosclerosis 2022; 344:57-59. [DOI: 10.1016/j.atherosclerosis.2022.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 01/20/2022] [Accepted: 01/21/2022] [Indexed: 11/28/2022]
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