Influence of renal function on the effects of early revascularization in non-ST-elevation myocardial infarction: data from the Swedish Web-System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies (SWEDEHEART)

Kidney replacement therapy: trends in incidence, treatment, and outcomes of myocardial infarction and stroke in a nationwide Scottish study

BACKGROUND AND AIMS

Patients with kidney failure have a higher risk of cardiovascular disease compared with the general population. Whilst temporal trends of myocardial infarction and stroke are declining in the general population, these have not been evaluated in patients with kidney failure. This study aimed to describe national trends in the incidence, treatment, and outcomes of myocardial infarction and stroke in patients with kidney failure (i.e. on dialysis or with a kidney transplant) over a 20-year period, stratified by age and sex.

METHODS

In this retrospective national data linkage study, all patients with kidney failure in Scotland (UK) receiving kidney replacement therapy between January 1996 and December 2016 were linked to national hospitalization, prescribing, and death records. The primary outcomes were the incidence of myocardial infarction and stroke, and subsequent cardiovascular death. Generalized additive models were constructed to estimate age-standardized, sex-stratified incidence rates and trends in cardiovascular and all-cause death.

RESULTS

Amongst 16 050 patients with kidney failure [52 (SD 15) years; 41.5% women], there were 1992 [66 (SD 12) years; 34.8% women] and 996 [65 (SD 13) years; 45.1% women] incident myocardial infarctions and strokes, respectively, between January 1996 and December 2016. During this period, the age-standardized incidence of myocardial infarction per 100 000 decreased in men {from 4376 [95% confidence interval (CI) 3998-4785] to 1835 (95% CI 1692-1988)} and women [from 3268 (95% CI 2982-3593) to 1369 (95% CI 1257-1491)]. Similarly, the age-standardized incidence of stroke per 100 000 also decreased in men [from 1978 (95% CI 1795-2175) to 799 (95% CI 729-875)] and women [from 2234 (95% CI 2031-2468) to 903 (95% CI 824-990)]. Compared with the general population, the incidence of myocardial infarction was four- to eight-fold higher in patients with kidney failure, whilst for stroke it was two- to four-fold higher. The use of evidence-based cardioprotective treatment increased over the study period, and the predicted probability of cardiovascular death within 1 year of myocardial infarction for a 66-year-old patient with kidney failure (mean age of the cohort) fell in men (76.6% to 38.6%) and women (76.8% to 38.8%), and also decreased in both sexes following stroke (men, from 63.5% to 41.4%; women, from 67.6% to 45.8%).

CONCLUSIONS

The incidence of myocardial infarction and stroke has halved in patients with kidney failure over the past 20 years but remains significantly higher than in the general population. Despite improvements in treatment and outcomes, the prognosis of these patients following myocardial infarction and stroke remains poor.

Prognosis of patients with renal failure one year following non-ST-segment elevation myocardial infarction treated with percutaneous coronary intervention

OBJECTIVE

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).

METHODS

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.

RESULTS

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.

CONCLUSIONS

There is a J-curve relationship between the eGFR value and 1-year all-cause mortality in patients with NSTEMI and treated with PCI.

Associations between inflammatory and angiogenic proteomic biomarkers, and cardiovascular events and mortality in relation to kidney function

Background

The links between chronic kidney disease (CKD) and the high burden of cardiovascular disease remain unclear. We aimed to explore the association between selected inflammatory and angiogenic biomarkers, kidney function and long-term outcome in patients with an acute coronary syndrome (ACS) and to test the hypothesis that CKD status modifies this association.

Methods

A total of 1293 ACS patients hospitalized between 2008 and 2015 were followed until 31 December 2017. Plasma was collected on days 1-3 after admission. A total of 13 biomarkers were a priori identified and analysed with two proteomic methods, proximity extension assay or multiple reaction monitoring mass spectrometry. Boxplots and multiple linear regression models were used to study associations between biomarkers and kidney function and adjusted standardized Cox regression with an interaction term for CKD was used to assess whether CKD modified the association between biomarkers and major adverse cardiovascular events and death (MACE+).

Results

The concentrations of nine biomarkers-endothelial cell-specific molecule-1 (ESM-1), fibroblast growth factor 23 (FGF-23), fractalkine (CX3CL1), interleukin-1 receptor antagonist (IL-1RA), interleukin-18 (IL-18), monocyte chemotactic protein-1 (MCP-1), placenta growth factor (PlGF), transmembrane immunoglobulin 1 (TIM-1) and vascular endothelial growth factor A (VEGFA)-were inversely associated with kidney function. ESM-1, FGF-23 and TIM-1 showed associations with MACE+. Only FGF23 remained independently associated after adjustment for the other biomarkers (hazard ratio per standard deviation increase 1.34; 95% Bonferroni corrected confidence interval 1.19-1.50). None of the biomarkers showed an interaction with CKD.

Conclusions

The concentrations of 9 of the 13 prespecified inflammatory and angiogenic proteomic biomarkers increased when kidney function declined. Only FGF-23 demonstrated an independent association with MACE+, and this association was not modified by CKD status. These findings further support FGF-23 as an independent prognostic marker in ACS patients with and without CKD.

Proportional troponin changes and risk for outcomes with intervention strategies in non-ST-elevation acute coronary syndrome across kidney function

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.

Meta-analysis of clinical adverse events after CABG vs. PCI in patients with chronic kidney disease and coronary artery disease

AIM

To investigate the efficacy and postoperative clinical adverse events of coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) for chronic kidney disease (CKD) study participants combined with coronary artery disease (CAD).

METHODS

All randomized controlled trials (RCTs) that focus on the therapeutic effect evaluation of CABG and PCI and their effect on postoperative clinical adverse events as well as main adverse cardiovascular and cerebrovascular events (MACCEs) in CKD study participants with CAD were screened from the following databases, including CNKI, CBM, Wan Fang, VIP, Embase, PubMed, as well as Cochrane library clinical controlled trials. The study was conducted under the PRISMA 2020 criteria. Data were extracted, and quality control was evaluated from the modified Jadad rating scale. Meta-analysis was then undertaken through STATA 16.0 software.

RESULTS

A total of 5 RCTs were obtained, including 1198 patients. Study participants were subdivided into two groups, including the PCI group (n = 604) and the CABG group (n = 594). Meta-analysis of clinical adverse events results showed that the long-term survival results of CAD patients with CKD who underwent PCI were worsened compared to CABG, such as long-term MACCEs (RR = 1.59, 95%CI: 1.04-2.43) and the long-term repeated revascularization (RR = 2.48, 95%CI: 1.76-3.49). Also, cardiac death (RR = 1.68, 95%CI:1.04-2.71), as well as cerebrovascular accident (RR = 1.74, 95%CI:1.04-2.90) in CABG group was significantly lower than that in PCI group.

CONCLUSION

This meta-analysis showed that CABG provided a better therapeutic effect than PCI in CKD patients with CAD when considering long-term prognosis. However, more prospective RCTs are needed to define the proper revascularization strategy for CAD patients with CKD.

Management and outcomes of myocardial infarction in people with impaired kidney function in England

BACKGROUND

Acute myocardial infarction (AMI) causes significant mortality and morbidity in people with impaired kidney function. Previous observational research has demonstrated reduced use of invasive management strategies and inferior outcomes in this population. Studies from the USA have suggested that disparities in care have reduced over time. It is unclear whether these findings extend to Europe and the UK.

METHODS

Linked data from four national healthcare datasets were used to investigate management and outcomes of AMI by estimated glomerular filtration rate (eGFR) category in England. Multivariable logistic and Cox regression models compared management strategies and outcomes by eGFR category among people with kidney impairment hospitalised for AMI between 2015-2017.

RESULTS

In a cohort of 5 835 people, we found reduced odds of invasive management in people with eGFR < 60mls/min/1.73m2 compared with people with eGFR ≥ 60 when hospitalised for non-ST segment elevation MI (NSTEMI). The association between eGFR and odds of invasive management for ST-elevation MI (STEMI) varied depending on the availability of percutaneous coronary intervention. A graded association between mortality and eGFR category was demonstrated both in-hospital and after discharge for all people.

CONCLUSIONS

In England, patients with reduced eGFR are less likely to receive invasive management compared to those with preserved eGFR. Disparities in care may however be decreasing over time, with the least difference seen in patients with STEMI managed via the primary percutaneous coronary intervention pathway. Reduced eGFR continues to be associated with worse outcomes after AMI.

Role of Invasive Strategy for Non-ST-Elevation Myocardial Infarction in Patients With Chronic Kidney Disease: A Systematic Review and Meta-Analysis

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.

Renin-Angiotensin-Aldosterone System Inhibitions and Cardiovascular Outcomes in Acute Myocardial Infarction With Renal Impairment

OBJECTIVE

To compare the clinical outcomes of patients with acute myocardial infarction with renal impairment (AMI-RI) treated with either angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) in real-world clinical settings.

PATIENTS AND METHODS

A total of 4790 consecutive patients with AMI-RI between November 1, 2011, and December 31, 2015, were subdivided into ACEI (n=2845) and ARB (n=1945) treatment groups. The primary end points were major adverse cardiac and cerebrovascular events, including all-cause mortality, nonfatal myocardial infarction, any revascularization, cerebrovascular accident, rehospitalization, and stent thrombosis. Propensity score matching (PSM) was used to adjust for group differences.

RESULTS

The ARB group had a significantly higher incidence of major adverse cardiac and cerebrovascular events (at 3-year follow-up) than the ACEI group according to the unadjusted analysis (3-year hazard ratio [HR], 1.60; 95% CI, 1.43 to 1.78) and the PSM-adjusted analysis (3-year HR, 1.34; 95% CI, 1.15 to 1.56). However, any revascularization (3-year HR, 1.21; 95% CI, 0.95 to 1.54) and rehospitalization (3-year HR, 1.21; 95% CI, 0.88 to 1.67) were not significantly different between groups in the PSM-adjusted analysis. Compared with the ARB group, the ACEI group had lower rates of all-cause mortality at estimated glomerular filtration rates of at least 15 or less than 90 mL/min/1.73 m2 in the unadjusted data and at least 60 or less than 90 mL/min/1.73 m2 in the PSM-adjusted analysis.

CONCLUSION

Treatment with ACEIs seemed to be more beneficial than treatment with ARBs for patients with AMI-RI; further prospective studies are required to confirm these results.

Outcomes of Non-ST-Segment Myocardial Infarction During Chronic Heart Failure and End-Stage Renal Disease

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.

Invasive Management and Outcomes in Acute Coronary Syndromes and Chronic Kidney Disease (ANZACS-QI 70)

AIMS

Guidelines recommend management with an invasive coronary angiogram in acute coronary syndromes (ACS), but most studies excluded patients with advanced chronic kidney disease (CKD). Our aims were to describe, in a comprehensive ACS cohort, the incidence of CKD, coronary angiography utilisation and outcomes, according to CKD stage.

METHODS

National datasets were used to identify hospitalised ACS patients (2013 to 2018) in the Northern region of New Zealand. CKD stage was obtained from a linked laboratory dataset. Outcomes included all-cause and cause-specific mortality, and non-fatal myocardial infarction, heart failure and stroke.

RESULTS

Thirty-eight percent (38%) of the 23,432 ACS patients had CKD stage 3 or higher: 2,403 (10%) had stages 4/5 CKD. Overall 61% received coronary angiography. Compared with normal renal function the adjusted rate of coronary angiography was lower in CKD stage 3b (RR 0.75, 95% confidence intervals [CIs] 0.69, 0.82) and stages 4/5 without dialysis (RR 0.41, 95% CIs 0.36, 0.46), but similar for those on dialysis (RR 0.89, 95% CIs 0.77, 1.02). All-cause mortality (mean follow-up 3.2 years) increased with CKD stage from 8% (normal kidney function) to 69% (stages 4/5 CKD without dialysis). Compared with coronary angiography, the adjusted all-cause and CVD mortality risks were higher in those without coronary angiography, except for those on dialysis, where these risks converged.

CONCLUSIONS

Invasive management fell below an eGFR of 45 mL/min (≤ stage 3b), and nearly half of all deaths occurred in these patients. Clinical trials are needed to assess the role of invasive management in ACS and advanced CKD.

Prevalence and prognostic value of malnutrition in patients with acute coronary syndrome and chronic kidney disease

Background

Malnutrition is a rising global health issue associated with unfavorable outcomes of a variety of disorders. Currently, the prevalence and prognostic significance of malnutrition to patients with acute coronary syndrome (ACS) and chronic kidney disease (CKD) remained largely unclear.

Methods

A total of 705 patients diagnosed with ACS and CKD in the First Affiliated Hospital of Wenzhou Medical University between 2013 and 2021 were included in this retrospective cohort study. Malnutrition was assessed by the Controlling Nutritional Status (CONUT), the Geriatric Nutritional Risk Index (GNRI), and the Prognostic Nutritional Index (PNI), respectively. The relationships between malnutrition and all-cause mortality and major cardiovascular events (MACEs) were analyzed.

Results

During a median follow-up of 31 months, 153 (21.7%) patients died, and 165 (23.4%) had MACEs. The prevalence of malnutrition was 29.8, 80.6, and 89.8% for the PNI, CONUT, and GNRI, respectively. All the malnutrition indexes were correlated with each other (r = 0.77 between GNRI and PNI, r = -0.72 between GNRI and CONUT, and r = -0.88 between PNI and CONUT, all p < 0.001). Compared with normal nutrition, malnutrition was independently associated with an increased risk for all-cause mortality (adjusted hazard ratio for moderate and severe degrees of malnutrition, respectively: 7.23 [95% confidence interval (CI): 2.69 to 19.49] and 17.56 [95% CI: 5.61 to 55.09] for the CONUT score, 2.18 [95% CI: 0.93 to 5.13] and 3.16 [95% CI: 1.28 to 7.79] for the GNRI, and 2.52 [95% CI: 1.62 to 3.94] and 3.46 [95% CI: 2.28 to 5.25] for the PNI score. p values were lower than 0.05 for all nutritional indexes, except for moderate GNRI p value = 0.075). As for MACEs, similar results were observed in the CONUT and PNI. All the risk scores could improve the predictive ability of the Global Registry of Acute Coronary Events (GRACE) risk score for both all-cause mortality and MACEs.

Conclusion

Malnutrition was common in patients with ACS and CKD regardless of the screening tools used, and was independently associated with all-cause mortality and MACEs. Malnutrition scores could facilitate risk stratification and prognosis assessment.

Clinical outcomes in end stage renal disease on dialysis and severe coronary artery disease: A real-world study

BACKGROUND

The optimal management of patients with end-stage renal disease (ESRD) on dialysis with severe coronary artery disease (CAD) has not been determined.

METHODS

Between 2013 and 2017, all patients with ESRD on dialysis who had left main (LM) disease, triple vessel disease (TVD) and/or severe CAD for consideration of coronary artery bypass graft (CABG) were included. Patients were divided into 3 groups based on final treatment modality: CABG, percutaneous coronary intervention (PCI), optimal medical therapy (OMT). Outcome measures include in-hospital, 180-day, 1-year and overall mortality and major adverse cardiac events (MACE).

RESULTS

In total, 418 patients were included (CABG 11.0%, PCI 65.6%, OMT 23.4%). Overall, 1-year mortality and MACE rates were 27.5% and 55.0% respectively. Patients who underwent CABG were significantly younger, more likely to have LM disease and have no prior heart failure. In this non-randomized setting, treatment modality did not impact on 1-year mortality, although the CABG group had significantly lower 1-year MACE rates (CABG 32.6%, PCI 57.3%, OMT 59.2%; CABG vs. OMT p < 0.01, CABG vs. PCI p < 0.001). Independent predictors of overall mortality include STEMI presentation (HR 2.31, 95% CI 1.38-3.86), prior heart failure (HR 1.84, 95% CI 1.22-2.75), LM disease (HR 1.71, 95% CI 1.26-2.31), NSTE-ACS presentation (HR 1.40, 95% CI 1.03-1.91) and increased age (HR 1.02, 95% CI 1.01-1.04).

CONCLUSION

Treatment decisions for patients with severe CAD with ESRD on dialysis are complex. Understanding independent predictors of mortality and MACE in specific treatment subgroups may provide valuable insights into the selection of optimal treatment options.

Utilization and Outcomes of Clinically Indicated Invasive Cardiac Care in Veterans with Acute Coronary Syndrome and Chronic Kidney Disease

SIGNIFICANCE STATEMENT

Of studies reporting an association of CKD with lower use of invasive cardiac care to treat acute coronary syndrome (ACS), just one accounted for the appropriateness of such care. However, its findings in patients hospitalized nearly 30 years ago may not apply to current practice. In a more recent cohort of 64,695 veterans hospitalized with ACS, CKD was associated with a 32% lower likelihood of receiving invasive care determined to be clinically indicated. Among patients with CKD, not receiving such care was associated with a 1.39-fold higher risk of 6-month mortality. Efforts to elucidate the reasons for this disparity in invasive care in patients with ACS and CKD and implement tailored interventions to enhance its use in this population may offer the potential to improve clinical outcomes.

BACKGROUND

Previous studies have shown that patients with CKD are less likely than those without CKD to receive invasive care to treat acute coronary syndrome (ACS). However, few studies have accounted for whether such care was clinically indicated or assessed whether nonuse of such care was associated with adverse health outcomes.

METHODS

We conducted a retrospective cohort study of US veterans who were hospitalized at Veterans Affairs Medical Centers from January 2013 through December 2017 and received a discharge diagnosis of ACS. We used multivariable logistic regression to investigate the association of CKD with use of invasive care (coronary angiography, with or without revascularization; coronary artery bypass graft surgery; or both) deemed clinically indicated based on Global Registry of Acute Coronary Events 2.0 risk scores that denoted a 6-month predicted all-cause mortality ≥5%. Using propensity scoring and inverse probability weighting, we examined the association of nonuse of clinically indicated invasive care with 6-month all-cause mortality.

RESULTS

Among 34,430 patients with a clinical indication for invasive care, the 18,780 patients with CKD were less likely than the 15,650 without CKD to receive such care (adjusted odds ratio, 0.68; 95% confidence interval, 0.65 to 0.72). Among patients with CKD, nonuse of invasive care was associated with higher risk of 6-month all-cause mortality (absolute risk, 21.5% versus 15.5%; absolute risk difference 6.0%; adjusted risk ratio, 1.39; 95% confidence interval, 1.29 to 1.49). Findings were consistent across multiple sensitivity analyses.

CONCLUSIONS

In contemporary practice, veterans with CKD who experience ACS are less likely than those without CKD to receive clinically indicated invasive cardiac care. Nonuse of such care is associated with increased mortality.

Non-ST-elevation acute coronary syndrome in chronic kidney disease: prognostic implication of an early invasive strategy

BACKGROUND

The optimal timing of PCI for NSTE-ACS with CKD is unclear. The aim of our study was to assess whether early percutaneous coronary intervention (PCI) (within 24 hours from admission) is associated with improved in-hospital (mortality or acute kidney injury) and long-term events (composite of mortality, myocardial infarction, stroke and bleeding events) in patients with non-ST-elevation acute coronary syndromes (NSTE-ACS) with chronic kidney disease (CKD).

METHODS

We retrospectively studied NSTE-ACS patients who underwent PCI in large tertiary centers. CKD was defined as estimated glomerular filtration rate (eGFR)<60 mL/min/1.73 m². A propensity score for the likelihood of an early invasive strategy was calculated. Relative risks (RR) and adjusted hazard ratios (HR) were estimated for in-hospital and follow-up events.

RESULTS

We included 821 patients, mean age was 69±12 years; 492 (60%) received an early PCI, and 273 (33%) had an eGFR <60. Median follow-up was 391 days. At univariate analysis, early treatment was associated with significantly lower in-hospital and follow-up events. However, after adjustment for major prognostic factors, there was no significant association with both in-hospital (RR=1.06; 95% CI 0.83-1.36) and follow-up events (RR=1.07; 95% CI 0.83-1.37). When the association was assessed in strata of CKD, lack of statistically significant association was confirmed, even if a trend emerged in patients with preserved renal function both on primary outcome (RR=0.47, 95% 0.18-1.22) and time to secondary outcome (HR=0.62, 95% CI 0.36-1.08).

CONCLUSIONS

In conclusion in a cohort of NSTE-ACS patients, an early invasive strategy does not independently affect prognosis.

Impact of complex percutaneous coronary intervention features on clinical outcomes in patients with or without chronic kidney disease

BACKGROUND

Patients with chronic kidney disease (CKD) are at higher risk of ischemic and bleeding events after percutaneous coronary intervention (PCI). Complex PCI (CPCI) is associated with higher rates of ischemic complications. Whether CPCI confers an additive risk of adverse events in CKD patients is unclear.

METHODS

Patients who underwent PCI at a single tertiary-care-center between 2012 and 2019 were stratified by CKD status and CPCI. The primary outcome was major adverse cardiac events (MACE), a composite of all-cause death, myocardial infarction (MI), and target-vessel revascularization (TVR) at 1-year follow-up. Secondary outcomes included the individual components of the primary outcome and major bleeding.

RESULTS

Out of 15,071 patients, 4537 (30.1%) had CKD and 10,534 (69.9%) had no CKD. Patients undergoing CPCI were 1151 (25.4%) and 2983 (28.3%) in the two cohorts, respectively. At one year, CPCI compared with no CPCI was associated with higher risk of MACE in both CKD (Adj. HR 1.72, 95% confidence interval [CI] 1.45-2.06, p < 0.001) and no-CKD patients (Adj. hazard ratios [HR] 2.19, 95% CI 1.91-2.51, p < 0.001; p of interaction 0.057), determined by an excess of death, MI and TVR in CKD patients and of TVR and MI only in no-CKD. CPCI was related with a consistent increase of major bleeding in the CKD (Adj. HR 1.49, 95% CI 1.18-1.87, p < 0.001) and no-CKD group (Adj. HR 1.23, 95% CI 0.98-1.54, p = 0.071, p of interaction 0.206).

CONCLUSION

At 1-year follow-up, CPCI was associated with higher risk of MACE and major bleeding irrespective of concomitant CKD. CPCI predicted mortality in CKD patients only.

Comparison of revascularization with conservative medical treatment in maintenance dialysis patient with coronary artery disease: a systemic review and meta-analysis

Background

The primary cause of death among maintenance dialysis patients is coronary artery disease (CAD). However, the best treatment plan has not yet been identified.

Methods

The relevant articles were retrieved from various online databases and references from their inception to October 12, 2022. The studies that compared revascularization [percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG)] with medical treatment (MT) among maintenance dialysis patients with CAD were selected. The outcomes evaluated were long-term (with a follow-up of at least 1 year) all-cause mortality, long-term cardiac mortality, and the incidence rate of bleeding events. Bleeding events are defined according to TIMI hemorrhage criteria: (1) major hemorrhage, intracranial hemorrhage or clinically visible hemorrhage (including imaging diagnosis) with decrease of hemoglobin concentration ≥5 g/dl; (2) minor hemorrhage, clinically visible bleeding (including imaging diagnosis) with a drop in hemoglobin of 3-5 g/dl; (3) minimal hemorrhage, clinically visible bleeding with hemoglobin drop <3 g/dl. In addition, revascularization strategy, CAD type, and the number of diseased vessels were considered in subgroup analyses.

Results

A total of eight studies with 1,685 patients were selected for this meta-analysis. The current findings suggested that revascularization was associated with low long-term all-cause mortality and long-term cardiac mortality but a similar incidence rate of bleeding events compared to MT. However, subgroup analyses indicated that PCI is linked to decreased long-term all-cause mortality compared to MT but CABG did not significantly differ from MT in terms of long-term all-cause mortality. Revascularization also showed lower long-term all-cause mortality compared to MT among patients with stable CAD, single-vessel disease, and multivessel disease but did not reduce long-term all-cause mortality among patients with ACS.

Conclusion

Long-term all-cause mortality and long-term cardiac mortality were reduced by revascularization in comparison to MT alone in patients undergoing dialysis. Larger randomized studies are needed to confirm the conclusion of this meta-analysis.

Revascularization in Patients With Non-ST Elevation Myocardial Infarction and Advanced Chronic Kidney Disease

OBJECTIVE

To investigate the impact of revascularization on long-term survival and renal outcome in non-ST-elevation myocardial infarction (NSTEMI) patients with severe chronic kidney disease (CKD).

PATIENTS AND METHODS

This study includes NSTEMI patients with an estimated glomerular filtration rate <30 mL/min per 1.73 m², including those on chronic hemodialysis who were identified from the multicenter Chang Gung Research Database from January 1, 2007, to December 31, 2017. Inverse probability of treatment weighting was used to generate comparable groups. The survival and the risk of progression to chronic hemodialysis between those receiving revascularization, either percutaneous coronary intervention or coronary artery bypass graft, and those receiving medical therapy during index hospitalization were compared.

RESULTS

A total of 2821 NSTEMI patients with severe CKD, including 1141 patients on chronic hemodialysis, were identified. Of these, 1149 patients received revascularization and 1672 received medical therapies. The differences in demographics, comorbidities, and presentations between groups were balanced after inverse probability of treatment weighting. After a mean follow-up of 1.82 years, revascularization was associated with a lower risk of all-cause mortality (adjusted HR, 0.61; 95% CI, 0.54-0.70). For non-dialysis-dependent patients who had survival to discharge, revascularization had a higher risk of progression to chronic hemodialysis (adjusted HR, 1.83; 95% CI, 1.49-2.26) after a mean follow-up of 2.3 years.

CONCLUSION

Revascularization was associated with a lower risk of all-cause mortality in NSTEMI patients with severe CKD. For non-dialysis-dependent patients who survived to discharge, revascularization was associated with a higher risk of progression to chronic hemodialysis.

Endothelial biomarkers and platelet reactivity on ticagrelor versus clopidogrel in patients after acute coronary syndrome with and without concomitant type 2 diabetes: a preliminary observational study

BACKGROUND

Pleiotropic effects have been implicated in clinical benefits of ticagrelor compared to thienopyridine P2Y₁₂ antagonists. There are conflicting data regarding effects of ticagrelor vs. thienopyridine P2Y₁₂ blockers on endothelial function. Our aim was to compare endothelial biomarkers and their relations with platelet reactivity in real-world patients after acute coronary syndrome (ACS) on maintenance dual antiplatelet therapy (DAPT) with ticagrelor or clopidogrel stratified by diabetes status.

METHODS

Biochemical indices of endothelial dysfunction/activation and platelet reactivity by multiple electrode aggregometry were compared in 126 stable post-ACS subjects (mean age: 65 ± 10 years, 92 men and 34 women), including patients with (n = 61) or without (n = 65) coexistent type 2 diabetes (T2DM) on uneventful maintenance DAPT with either ticagrelor (90 mg b.d.) or clopidogrel (75 mg o.d.) in addition to low-dose aspirin. Exclusion criteria included a complicated in-hospital course, symptomatic heart failure, left ventricular ejection fraction < 40% and relevant coexistent diseases except for well-controlled diabetes, mild renal insufficiency or hypertension.

RESULTS

Clinical characteristics were similar in patients on ticagrelor (n = 62) and clopidogrel (n = 64). The adenosine diphosphate-induced platelet aggregation and circulating soluble P-selectin (sP-selectin) were decreased in ticagrelor users irrespective of T2DM status (p < 0.001 and p < 0.01 for platelet reactivity and sP-selectin, respectively). Plasma levels of soluble vascular cell adhesion molecule-1 (sVCAM-1) were lower in T2DM subjects on ticagrelor vs. clopidogrel (758 ± 162 vs. 913 ± 217 µg/L, p < 0.01). In contrast, plasma sVCAM-1 was similar in non-diabetic patients on ticagrelor and clopidogrel (872 ± 203 vs. 821 ± 210 µg/L, p > 0.7). The concentrations of sE-selectin, monocyte chemoattractant protein-1 and asymmetric dimethylarginine did not differ according to the type of P2Y₁₂ antagonist regardless of T2DM status. Platelet reactivity was unrelated to any endothelial biomarker in subjects with or without T2DM.

CONCLUSIONS

Our preliminary findings may suggest an association of ticagrelor-based maintenance DAPT with favorable endothelial effects compared to clopidogrel users in stable post-ACS patients with T2DM. If proven, this could contribute to more pronounced clinical benefits of ticagrelor in diabetic subjects.

Association of secondary prevention medication use after myocardial infarction with mortality in hemodialysis patients

BACKGROUND

Mortality after myocardial infarction (MI) among patients undergoing dialysis is high. However, studies investigating the use of secondary prevention medications after MI and clinical outcomes in dialysis patients are lacking. This study aimed to examine the association of the number of guideline-recommended medications (antiplatelets, β-blockers, statins and renin-angiotensin-aldosterone system inhibitors) with all-cause mortality after MI in hemodialysis (HD) patients.

METHODS

We conducted a nationwide cohort study of incident HD patients who were admitted for MI between 1 January 2010 and 31 December 2014 and were followed up until 31 December 2015, using Taiwan's national health insurance research database.

RESULTS

Of 1471 patients (mean age 68 years, 41.9% women) included in the analysis, 281 (19.1%) were treated with one cardioprotective medication, 406 (27.6%) with two, 490 (33.3%) with three and 294 (20%) with four. During a median follow-up of 1.0 years, 458 (31.1%) patients died. In a multivariable Cox model, each additional use of guideline-recommended therapies was associated with a significant 12% reduction in the risk of mortality {hazard ratio [HR] 0.88 [95% confidence interval (CI) 0.80-0.97]}. Similar results were obtained in the analysis with the inverse probability of treatment weighting [HR 0.84 (95% CI 0.77-0.92)] and in the propensity score-matched subcohort [HR 0.87 (95% CI 0.77-0.98)]. The decreased mortality risk was consistently observed across all subgroups.

CONCLUSIONS

The use of more evidence-based medications for secondary prevention after MI was associated with a lower risk of all-cause mortality in HD patients.

Additional effect of hemodialysis on mortality estimated from renal function in ischemic heart disease

Aim: The present study examined whether hemodialysis in patients with ischemic heart disease increases mortality more than the estimated mortality from renal function. Patients & methods: A total of 1621 patients with angina pectoris (n = 815), ST-elevation myocardial infarction (n = 421) or non-ST-elevation acute coronary syndrome (n = 385) were examined. An estimated mortality curve according to the estimated glomerular filtration rate was drawn using the marginal effect from the logit model. The probability of mortality in patients with hemodialysis was plotted on these curves. Results: The probability of mortality in patients undergoing hemodialysis crossed the estimated mortality curves at the estimated glomerular filtration rate of 5.7 ml/min/1.73 m² in angina pectoris, 31.3 ml/min/1.73 m² in STEMI and 45.9 ml/min/1.73 m² in non-ST-elevation acute coronary syndrome. Conclusion: Hemodialysis does not have an additional adverse impact on the estimated mortality.

Room for improvement: diagnosing and managing acute coronary syndromes in persons with reduced eGFR

Cardiovascular events are the leading cause of death in chronic kidney disease. A recent analysis from the High-Sensitivity Troponin in the Evaluation of Patients With Suspected Acute Coronary Syndrome trial focused on results in those with reduced estimated glomerular filtration rate. This commentary discusses aspects of acute coronary syndrome diagnosis in this group and the differential approach to acute coronary syndrome management that was observed between those with normal and reduced kidney function.

Radiographic Contrast Media and the Kidney

AKI is a potential complication of intravascular iodinated contrast exposure. Contrast-associated AKI, which typically manifests as small and transient decrements in kidney function that develop within several days of contrast administration, is associated with serious adverse outcomes, including progressive kidney dysfunction and death. However, a causal link between the small increases in serum creatinine that characteristically occur with contrast-associated AKI and serious adverse outcomes remains unproven. This is important given mounting evidence that clinically indicated, potentially lifesaving radiographic procedures are underutilized in patients with CKD. This has been hypothesized to be related to provider concern about precipitating contrast-associated AKI. Intravascular gadolinium-based contrast, an alternative to iodinated contrast that is administered with magnetic resonance imaging, has also been linked with potential serious adverse events, notably the development of nephrogenic systemic fibrosis in patients with severe impairment in kidney function. Patients hospitalized in the intensive care unit frequently have clinical indications for diagnostic and therapeutic procedures that involve the intravascular administration of contrast media. Accordingly, critical care providers and others treating critically ill patients should possess a sound understanding of the risk factors for and incidence of such outcomes, the ability to perform evidence-based risk-benefit assessments regarding intravascular contrast administration, and knowledge of empirical data on the prevention of these iatrogenic complications.

Invasive Versus Medical Management in Patients With Chronic Kidney Disease and Non-ST-Segment-Elevation Myocardial Infarction

Background The role of invasive management compared with medical management in patients with non-ST-segment-elevation myocardial infarction (NSTEMI) and advanced chronic kidney disease (CKD) is uncertain, given the increased risk of procedural complications in patients with CKD. We aimed to compare clinical outcomes of invasive management with medical management in patients with NSTEMI-CKD. Methods and Results We identified NSTEMI and CKD stages 3, 4, 5, and end-stage renal disease admissions using International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes from the Nationwide Readmission Database 2016 to 2018. Patients were stratified into invasive and medical management. Primary outcome was mortality (in-hospital and 6 months after discharge). Secondary outcomes were in-hospital postprocedural complications (acute kidney injury requiring dialysis, major bleeding) and postdischarge 6-month safety and major adverse cardiovascular events. Out of 141 052 patients with NSTEMI-CKD, 85 875 (60.9%) were treated with invasive management, whereas 55 177 (39.1%) patients were managed medically. In propensity-score matched cohorts, invasive strategy was associated with lower in-hospital (CKD 3: odds ratio [OR], 0.47 [95% CI, 0.43-0.51]; P<0.001; CKD 4: OR, 0.79 [95% CI, 0.69-0.89]; P<0.001; CKD 5: OR, 0.72 [95% CI, 0.49-1.06]; P=0.096; end-stage renal disease: OR, 0.51 [95% CI, 0.46-0.56]; P<0.001) and 6-month mortality. Invasive management was associated with higher in-hospital postprocedural complications but no difference in postdischarge safety outcomes. Invasive management was associated with a lower hazard of major adverse cardiovascular events at 6 months in all CKD groups compared with medical management. Conclusions Invasive management was associated with lower mortality and major adverse cardiovascular events but minimal increased in-hospital complications in patients with NSTEMI-CKD compared with medical management, suggesting patients with NSTEMI-CKD should be offered invasive management.

Patients with end-stage renal disease requiring hemodialysis benefit from percutaneous coronary intervention after non-ST-segment elevation myocardial infarction

Percutaneous coronary intervention (PCI) treatment significantly improves outcomes after acute myocardial infarction (AMI). It remains unclear whether the benefits of PCI exist in patients with end-stage renal disease (ESRD) and non-ST-segment elevation myocardial infarction (NSTEMI). The present study was designed to investigate the effects of PCI on the short- and long-term prognosis of patients with ESRD and NSTEMI. We conducted a retrospective study from 1 January 2015 to 1 January 2020, which includes 148 consecutive patients with ESRD and NSTEMI. All patients were estimated glomerular filtration rate (eGFR) < 15 mL/min/1.73 m² and had received regular hemodialysis treatment before hospitalization. Logistic regression analyses were used to identify the risk factors for in-hospital mortality. Cox proportional hazard model was used to identify independent predictors of 1-year major adverse cardiac events (MACE). In this study, 62 patients received PCI treatment. Univariable logistic regression analysis showed that PCI treatment was associated with the trend of reduction in the risk of in-hospital mortality (11.3% vs 43%, P = 0.022), but was not independently related to lower in-hospital mortality risk after multivariable logistic regression analysis (P = 0.131). After a 1-year follow-up, Kaplan-Meier survival analysis demonstrated that MACE rate was significantly lower in patients with ESRD and NSTEMI who had received PCI treatment during hospitalization (P < 0.001). After multivariate Cox proportional hazard analysis, no PCI treatment was independently associated with 1-year MACE (hazard ratios 3.217, 95% CI 2.03-8.489, P = 0.003). PCI treatment during hospitalization is associated with reduced 1-year MACE in patients with ESRD and NSTEMI, which suggests that more aggressive therapies may be beneficial for this special higher risk population.

External validation of the GRACE risk score and the risk-treatment paradox in patients with acute coronary syndrome

Objectives

To validate the Global Registry of Acute Coronary Events (GRACE) risk score and examine the extent and impact of the risk–treatment paradox in contemporary patients with acute coronary syndrome (ACS).

Methods

Data from 5015 patients with ACS enrolled in the FORCE-ACS registry between January 2015 and December 2019 were used for model validation. The performance of the GRACE risk score for predicting in-hospital and 1-year mortality was evaluated based on indices of model discrimination and calibration. Differences in the delivery of guideline-recommended care among patients who survived hospitalisation (n=4911) per GRACE risk stratum were assessed and the association with postdischarge mortality was examined.

Results

Discriminative power of the GRACE risk score was good for predicting in-hospital (c-statistic: 0.86; 95% CI: 0.83 to 0.90) and 1-year mortality (c-statistic: 0.82; 95% CI: 0.79 to 0.84). However, the GRACE risk score overestimated the absolute in-hospital and 1-year mortality risk (Hosmer-Lemeshow goodness-of-fit test p<0.01). Intermediate-risk and high-risk patients were 12% and 29% less likely to receive optimal guideline-recommended care compared with low-risk patients, respectively. Optimal guideline-recommended care was associated with lower mortality in intermediate- and high-risk patients.

Conclusions

The GRACE risk score identified patients at higher risk for in-hospital and 1-year mortality, but overestimated absolute risk levels in contemporary patients. Optimal guideline-recommended care was associated with lower mortality in intermediate-risk and high-risk patients, but was less likely to be delivered with increasing mortality risk.

Chronic Renal Failure and Cardiovascular Disease: A Comprehensive Appraisal

Coronary artery disease is highly prevalent in patients with chronic kidney disease. The concomitant renal disease often poses a major challenge in decision making as symptoms, cardiac biomarkers and noninvasive studies for evaluation of myocardial ischemia have different sensitivity and specificity thresholds in this specific population. Moreover, the effectiveness and safety of intervention and medical treatment in those patients is of great doubt as most clinical studies exclude patients with advance CKD. In the present paper, we discuss and review the literature in the diagnosis, treatment and prevention of CAD in the acute and chronic setting, in patients with CKD.

Effect of Procedural Volume on In-Hospital Outcomes After Percutaneous Coronary Intervention in Patients With Chronic Kidney Disease (from the Japanese National Clinical Data [J-PCI Registry])

Chronic kidney disease (CKD) increases the risk of death and other poor outcomes in patients with cardiovascular diseases. This study investigated the relation between the institutional CKD percutaneous coronary intervention (PCI) volume and in-hospital clinical outcomes in patients with CKD. Among 1,199,901 patients who underwent PCI in 2014 to 2018 from the Japanese nationwide registry, we analyzed 220,509 patients with CKD. Patients were classified into quartiles (Q) according to the mean annual institutional CKD-PCI volume (Q1 <42 PCIs/year, Q2 <74 PCIs/year, Q3 <124 PCIs/year, Q4 ≥125 PCIs/year). The primary outcome was a composite of in-hospital death and periprocedural complications. The mean age of patients was 73 ± 10 years, and 36% (n = 78,332) were on dialysis. PCI was more likely to be performed with rotational atherectomy devices in high-volume institutions. Contrast volume was lower, the rate of radial access PCI was higher, and door-to-balloon time (for ST-elevation myocardial infarction) was shorter in the highest quartile institutions. Primary outcomes were observed in 6,539 patients (3.0%). The crude rate of the primary outcome was lowest in institutions with the highest PCI volume (Q1 3.4%, Q2 3.0%, Q3 3.0%, Q4 2.4%, p <0.001); higher PCI volume was associated with reduced frequency of the primary outcome (odds ratio [95% confidence interval] relative to Q1:Q2, 0.89 [0.83 to 0.96]; Q3 0.90 [0.84 to 0.97]; and Q4 0.76 [0.84 to 0.97]). In conclusion, the procedural characteristics and outcomes of PCI differed significantly by institutional volume in patients with CKD. When considering revascularization among these patients, institutional CKD-PCI volume needs to be incorporated in decision-making.

Revascularization vs. Conservative Medical Treatment in Patients With Chronic Kidney Disease and Coronary Artery Disease: A Meta-Analysis

Background

As a strong risk factor for coronary artery disease (CAD), chronic kidney disease (CKD) indicates higher mortality in patients with CAD. However, the optimal treatment for the patients with two coexisting diseases is still not well defined.

Methods

To conduct a meta-analysis, PubMed, Embase, and the Cochrane database were searched for studies comparing medical treatment (MT) and revascularization [percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG)] in adults with CAD and CKD. Long-term all-cause mortality was evaluated, and subgroup analyses were performed.

Results

A total of 13 trials met our selection criteria. Long-term (with at least a 1-year follow-up) mortality was significantly lower in the revascularization arm [relative risk (RR) = 0.66; 95% CI = 0.60–0.72] by either PCI (RR = 0.61; 95% CI = 0.55–0.68) or CABG (RR = 0.62; 95% CI = 0.46–0.84). The results were consistent in dialysis patients (RR = 0.68; 95% CI = 0.59–0.79), patients with stable CAD (RR = 0.75; 95% CI = 0.61–0.92), patients with acute coronary syndrome (RR = 0.62; 95% CI = 0.58–0.66), and geriatric patients (RR = 0.57; 95% CI = 0.54–0.61).

Conclusion

In patients with CKD and CAD, revascularization is more effective in reducing mortality than MT alone. This observed benefit is consistent in patients with stable CAD and elderly patients. However, future randomized controlled trials (RCTs) are required to confirm these findings.

Risk Factors of Cardiac Death for Elderly Patients with Severe Chronic Kidney Disease after Percutaneous Coronary Intervention

Aims: To identify risk factors for cardiac death of elderly and severe chronic kidney disease (CKD) patients with coronary atherosclerotic heart disease (CAHD) after percutaneous coronary intervention (PCI). Methods: 1010 CAHD-CKD patients over 60 years old who had CKD stage 3 or above and underwent PCI were followed up for at least 3 years. Cases of cardiac death were divided into groups. After univariate analysis of all variables, the variables with P < .2 were selected for further logistic regression. Results: For logistic regression single-vessel disease (SVD) PCI OR = 0.612, 95%CI: 0.416–0.899, P = .012, it is the protective factor. There are four risk factors, stable angina pectoris (SAP) OR = 4.723, 95%CI: 1.098∼20.322, P = .037, combined with lower extremity arteriosclerosis obliterans (LEASO) OR = 2.631, 95%CI: 1.272∼5.440, P = .009, K > 4.285 mmol/L OR = 1.44, 95%CI: 1.002∼2.069, P = .049, without statins OR = 2.015, 95%CI: 1.072∼3.789, P = .030. Conclusion: In elderly and serious CAHD-CKD patients after PCI, SVD PCI was a protective factor against cardiac death. However, SAP, CAHD-CKD combined with LEASO, K > 4.285 mmol/L, and no statins were independent risk factors of cardiac death for elderly patients with severe CKD after PCI.

Impact of Renal Insufficiency on Prognosis of Patients with Acute Coronary Syndrome

Purpose

Chronic kidney disease (CKD) is common in patients admitted with acute coronary syndrome (ACS), and it is associated with poor outcomes. However, data are limited. Hence, we examined the long-term prognostic significance of estimated glomerular filtration rate (eGFR) among Chinese patients hospitalized with ACS.

Patients and Methods

This is a multicenter, observational study that included 1860 ACS patients enrolled between March 2014 and June 2019 from 11 hospitals in Chengdu. CKD-EPI equation was used to calculate the baseline eGFR. Patients were divided into three groups: eGFR ≥ 90 mL/min (normal renal function), eGFR 60 to <90 mL/min (mild impaired renal function), and eGFR < 60 mL/min (moderate or severe renal dysfunction). The endpoint was all-cause death during follow-up.

Results

At baseline, 714 patients had normal renal function, while 746 patients had mild impaired renal function, and 400 patients had moderate or severe renal dysfunction. In the follow-up of 15 months (10 months, 22 months), 261 (14.0%) patients died;, 139 (34.8%) in the moderate or severe renal dysfunction group, 94 (12.6%) in the mild impaired renal function group, and 28 (3.9%) in the normal renal function group (log-rank p-value from Kaplan–Meier analysis <0.001). In multivariable Cox Proportional hazard analysis, age, systolic blood pressure (SBP), heart rate, eGFR, ST-elevation myocardial infarction (STEMI), and percutaneous coronary intervention (PCI) were independent predictors of all-cause death.

Conclusion

In this study, among Chinese patients with ACS, renal insufficiency was associated with unfavorable long-term prognosis. Age, SBP, heart rate, eGFR, STEMI, and PCI could identify those at risk.

Outcome of early versus delayed invasive strategy in patients with non-ST-segment elevation myocardial infarction and chronic kidney disease not on dialysis

BACKGROUND AND AIMS

Because of paucity of published data, we evaluated the 2-year major clinical outcomes between early invasive (EI) and delayed invasive (DI) strategies according to the stage of chronic kidney disease (CKD) in patients with non-ST-segment elevation myocardial infarction (NSTEMI), who underwent a successful newer-generation drug-eluting stent (DES) implantation.

METHODS

A total of 8241 NSTEMI patients were recruited from the Korea Acute Myocardial Infarction Registry (KAMIR). Based on baseline estimated glomerular filtration rate (eGFR; ≥90, 60-89, 30-59, and <30 mL/min/1.73 m²), the patients were classified into groups A (n = 3498), B (n = 3109), C (n = 1178), and D (n = 1178). Thereafter, these 4 groups were sub-classified into the EI and DI groups. Major adverse cardiac events (MACE), defined as all-cause death, recurrent MI (re-MI), and any repeat revascularization, were evaluated.

RESULTS

After multivariable-adjusted and propensity score-adjusted analyses, the cumulative incidence of MACE (group A, p = 0.139 and p = 0.103, respectively; group B, p = 0.968 and p = 0.608, respectively; group C, p = 0.111 and p = 0.196, respectively; group D, p = 0.882 and p = 0.571, respectively), all-cause death, re-MI, and any repeat revascularization was similar between the EI and DI groups in the 4 different renal function groups.

CONCLUSIONS

In the era of newer-generation DES, EI and DI strategies showed comparable major clinical outcomes in patients with NSTEMI and CKD during a 2-year follow-up period. However, to confirm these results, further randomized, large-scale, long-term follow-up studies are needed.

High-Sensitivity Cardiac Troponin T in Patients with Severe Chronic Kidney Disease and Suspected Acute Coronary Syndrome

(1) Background: Patients with severe chronic kidney disease (CKD G4-G5) often have chronically elevated high-sensitivity cardiac troponin T (hs-cTnT) values above the 99th percentile of the upper reference limit. In these patients, optimal cutoff levels for diagnosing non-ST-elevation acute coronary syndrome (NSTE-ACS) requiring revascularization remain undefined. (2) Methods: Of 11,912 patients undergoing coronary angiography from 2012 to 2017 for suspected NSTE-ACS, 325 (3%) had severe CKD. Of these, 290 with available serial hs-cTnT measurements were included, and 300 matched patients with normal renal function were selected as a control cohort. (3) Results: In the CKD cohort, 222 patients (76%) had NSTE-ACS with indication for coronary revascularization. Diagnostic performance was high at presentation and similar to that of the control population (AUC, 95% CI: 0.81, 0.75-0.87 versus 0.85, 0.80-0.89, p = 0.68), and the ROC-derived cutoff value was 4 times higher compared to the conventional 99th percentile. Combining the ROC-derived cutoff levels for hs-cTnT at presentation and absolute 3 h changes, sensitivity increased to 98%, and PPV and NPV improved up to 93% and 86%, respectively. (4) Conclusions: In patients with severe CKD and suspected ACS, the diagnostic accuracy of hs-cTnT for the diagnosis of NSTE-ACS requiring revascularization is improved by using higher assay-specific cutoff levels combined with early absolute changes.

Management and outcome across the spectrum of high-risk patients with myocardial infarction according to the thrmobolysis in myocardial infarction (TIMI) risk-score for secondary prevention

Background

Patients with myocardial infarction (MI) are at increased risk for recurrent cardiovascular events, yet some patients, such as the elderly and those with prior comorbidities, are particularly at the highest risk. Whether these patients benefit from contemporary management is not fully elucidated.

Methods

Included were consecutive patients with MI who underwent percutaneous coronary intervention (PCI) in a large tertiary medical center. Patients were stratified according to the thrombolysis in myocardial infarction (TIMI) risk score for secondary prevention (TRS2°P) to high (TRS2°P = 3), very high (TRS2°P = 4), or extremely high‐risk (TRS2°P = 5–9). Excluded were low and intermediate‐risk patients (TRS2°P < 3). Outcomes included 30‐day/1‐year major adverse cardiac events (MACE) and 1‐year mortality. Temporal trends were examined in the early (2004–2010) and late (2011–2016) time‐periods.

Results

Among 2053 patients, 50% were high‐risk, 30% very high‐risk and 20% extremely high‐risk. Extremely high‐risk patients were older (age 74 ± 10 year) and had significant comorbidities (chronic kidney disease 68%, prior CABG 40%, heart failure 78%, peripheral artery disease 29%). Drug‐eluting stents and potent antiplatelets were more commonly used over time in all risk‐strata. Over time, 30‐day MACE rates have decreased, mainly attributed to the very high (11.3% to 5.1%, p = .006) and extremely high‐risk groups (15.9% to 8.0%, p = .016), but not the high‐risk group, with similar quantitative results for 1‐year MACE. The rates of 1‐year mortality remained unchanged in either group.

Conclusion

Within a particularly high‐risk cohort of MI patients who underwent PCI, the implementation of guideline‐recommended therapies has improved over time, with the highest‐risk groups demonstrating the greatest benefit in outcomes.

Optimal treatment strategies for coronary artery disease in patients with advanced kidney disease: a meta-analysis

Background:

Coronary artery disease (CAD) is the leading cause of death in advanced kidney disease. However, its best treatment has not been determined.

Methods:

We searched PubMed and Cochrane databases and scanned references to related articles. Studies comparing the different treatments for patients with CAD and advanced CKD (estimated glomerular filtration rate <30 ml/min/1.73 m² or dialysis) were selected. The primary result was all-cause death, classified according to the follow-up time: short-term (<1 month), medium-term (1 month-1 year), and long-term (>1 year).

Results:

A total of 32 studies were selected to enroll 84,498 patients with advanced kidney disease. Compared with medical therapy (MT) alone, percutaneous coronary intervention (PCI) was associated with low risk of short-, medium-term and long-term all-cause death (more than 3 years). For AMI patients, compared with MT, PCI was not associated with low risk of short- and medium-term all-cause death. For non-AMI patients, compared with MT, PCI was associated with low risk of long-term mortality (more than 3 years). Compared with MT, coronary artery bypass surgery (CABG) had no significant advantages in each follow-up period of all-cause death. Compared with PCI, CABG was associated with a high risk of short-term death, but low risk of long-term death: 1–3 years; more than 3 years. CABG could also reduce the risk of long-term risk of cardiac death, major adverse cardiovascular events (MACEs), myocardial infarction (MI), and repeat revascularization.

Conclusions:

In patients with advanced kidney disease and CAD, PCI reduced the risk of short-, medium- and long- term (more than 3 years) all-cause death compared with MT. Compared with PCI, CABG was associated with a high risk of short-term death and a low risk of long-term death and adverse events.

Long-Term Antithrombotic Therapy and Clinical Outcomes in Patients with Acute Coronary Syndrome and Renal Impairment: Insights from EPICOR and EPICOR Asia

BACKGROUND

Information is lacking on long-term management of patients with acute coronary syndrome (ACS) and chronic kidney disease (CKD) (estimated glomerular filtration rate [eGFR] < 60 mL/min/1.73 m²).

OBJECTIVES

Our objectives were to describe antithrombotic management patterns and outcomes in patients with ACS with varying renal function from the EPICOR (long-tErm follow-uP of antithrombotic management patterns In acute CORonary syndrome patients; NCT01171404) and EPICOR Asia (NCT01361386) studies.

METHODS

EPICOR and EPICOR Asia were prospective observational studies of patients who survived hospitalization for ACS and were enrolled at discharge in 28 countries across Europe, Latin America, and Asia. The studies were conducted from 2010 to 2013 and from 2011 to 2014, respectively. This analysis evaluated patient characteristics and oral antithrombotic management patterns and outcomes up to 2 years post-discharge according to admission eGFR: ≥ 90, 60-89, 30-59, or < 30 mL/min/1.73 m².

RESULTS

Among 22,380 patients with available data, eGFR < 60 mL/min/1.73 m² was observed in 16.7%. Patients with poorer renal function were older, were at greater cardiovascular risk, and had more prior cardiovascular disease and bleeding. Patients with CKD underwent fewer cardiovascular interventions and had more in-hospital cardiovascular and bleeding events. Dual antiplatelet therapy was less likely at discharge in patients with eGFR < 30 (82.3%) than in those with ≥ 90 (91.3%) mL/min/1.73 m² and declined more sharply during follow-up in patients with low eGFR (p < 0.0001). An adjusted proportional hazards model showed that patients with lower eGFR levels had a higher risk of cardiovascular events and bleeding.

CONCLUSIONS

The presence of CKD in patients with ACS was associated with less aggressive cardiovascular management and an increased risk of cardiovascular events.

Chronic kidney disease in acute coronary syndromes: real world data of long-term outcomes

Aim: Patients with chronic kidney disease (CKD) are at increased cardiovascular risk. Methods: Patients with acute coronary syndrome were retrospectively allocated to three groups (stage 3A, stage 3B or stage 4) based on the Kidney Disease Improving Global Outcomes classification formulas: the CKD Epidemiology Collaboration (CKD-EPI; N = 401) and the modification of diet in renal disease (n = 355). The primary end point was all-cause mortality (median follow-up time, 32 months [15-70]). Results: Study results showed decreased median survival was associated with poor renal function for both the CKD-EPI (78 vs 61 vs 40 months, p = 0.014) and modification of diet in renal disease groups (68 vs 57 vs 32 months, p = 0.006). After adjustment, age (OR: 1.07; 95% CI: 1.01-1.14) and pulmonary artery systolic pressure (OR: 1.08; 95% CI: 1.03-1.14), but not estimated glomerular filtration rate, were associated with decreased survival. Conclusion: Study results suggest that poor outcomes after an acute coronary syndrome were associated with comorbidities rather than estimated glomerular filtration rate level.

Impact of renal function on patients with acute coronary syndromes: 15,593 patient-years study

Introduction

Coexistence of chronic kidney disease (CKD) in the case of acute coronary syndromes (ACS) significantly worsens the outcomes.

Aim

The aim of our study was to assess renal function impact on mortality among patients with ACS.

Materials and methods

The study was based on records of 21,985 patients hospitalized in the Medical University of Bialystok in 2009–2015. Inclusion criteria were ACS. Exclusion criteria were: death within 24 h of admission, eGFR <15 ml/min/1.73 m², hemodialysis. Mean observation time was 2296 days.

Results

Criteria were met by 2213 patients. CKD occurred in 24.1% (N = 533) and more often affected those with NSTEMI (26.2 (337) vs. 21.2 (196), p = .006). STEMI patients had higher incidence of post-contrast acute kidney injury (PC-AKI) (5 (46) vs. 4.1 (53), p < .001). During the study, 705 people died (31.9%), more often with NSTEMI (33.2% (428) vs. 29.95% (277), p < .001). However, from a group of patients suffering from PC-AKI 57.6% died. The risk of PC-AKI increased with creatinine concentration (RR: 2.990, 95%CI: 1.567–5.721, p < .001), occurrence of diabetes mellitus (RR: 2.143, 95%CI: 1.029–4.463, p = .042), atrial fibrillation (RR: 2.289, 95%CI: 1.056–4.959, p = .036). Risk of death was greater with an increase in postprocedural creatinine concentration (RR: 2.254, 95%CI: 1.481–3.424, p < .001).

Conclusion

PC-AKI is a major complication in patients with ACS, occurs more frequently in STEMI and may be a prognostic marker of long-term mortality in patients undergoing percutaneous coronary intervention (PCI). More attention should be given to the prevention and diagnosis of PC-AKI but necessary PCI should not be withheld in fear of PC-AKI.

Association of renal insufficiency with treatments and outcomes in patients with acute coronary syndrome in China

BACKGROUND

We aimed to analyze the association of estimated glomerular filtration rate (eGFR) levels of hospitalized patients with treatment decisions and clinical outcomes in Chinese patients with acute coronary syndrome (ACS).

METHODS

This was a secondary analysis study from CPACS-2 Program which was a trial of a quality improvement intervention in China and recruited 15,141 patients from 75 hospitals between October 2007 and August 2010. All patients were divided into three groups by the eGFR level on admission. The primary outcomes were several key performance indicators (KPIs) reflecting the management of ACS and the secondary outcomes were clinical outcomes.

RESULTS

A total of 14,437 ACS patients were enrolled in this analysis. Among patients with reduced eGFR levels, fewer patients received appropriate medical therapy (p for trend <0.001) and fewer high-risk patients received coronary angiography (p for trend <0.001) compared to patients with a normal eGFR. Furthermore, 436 cases of death, 357 cases of cardiac death, 686 cases of major adverse cardiovascular events, and 198 cases of major bleeding episodes were reported. Patients with a worse eGFR level had significantly higher rates of death (p for trend <0.001), cardiac death (p for trend <0.001), major adverse cardiovascular events (p for trend <0.001) and major bleeding episodes (p for trend <0.001).

CONCLUSION

Among Chinese ACS patients, those with renal insufficiency have a lower percentage of adherence to guideline-recommended treatments and worse clinical prognosis. Renal insufficiency is an important factor affecting guideline implementation in Chinese ACS patients.

CLINICAL TRIAL REGISTRATION

http://www.anzctr.org.au/default.aspx. Unique identifier: ACTRN12609000491268.