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Temporal management patterns and outcomes of non-ST elevation acute coronary syndromes in patients with kidney
Jorge A Wong1, Shaun G Goodman, Raymond T Yan
1Terrence Donnelly Heart Centre, Division of Cardiology, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
Insights
Patients with kidney dysfunction undergoing non-ST elevation acute coronary syndrome (NSTE-ACS) treatment are less likely to receive invasive procedures, leading to worse outcomes. However, revascularization improved survival regardless of kidney function, highlighting the need for further trials.
Area of Science:
- Cardiology
- Nephrology
- Clinical Research
Background:
- Acute coronary syndrome (ACS) management has evolved, but disparities persist, particularly for patients with kidney dysfunction.
- Kidney dysfunction is a significant comorbidity impacting ACS prognosis and treatment strategies.
Purpose of the Study:
- To analyze temporal trends in ACS management patterns.
- To identify reasons for treatment disparities in ACS patients with and without kidney dysfunction.
- To evaluate the association between invasive treatment and outcomes in ACS patients stratified by kidney function.
Main Methods:
- Utilized data from Canadian ACS I, ACS II registries and the Global Registry of Acute Coronary Events (GRACE) (1999-2007).
- Included 11,377 non-ST elevation ACS patients, stratified by estimated glomerular filtration rate (eGFR) using the MDRD equation.
- Examined in-hospital management (coronary angiography, revascularization) and 1-year mortality.
Main Results:
- In-hospital invasive procedures increased over time across all eGFR groups.
- Patients with kidney dysfunction were significantly less likely to receive invasive management.
- In-hospital revascularization was independently associated with reduced 1-year mortality, irrespective of eGFR.
Conclusions:
- Despite advances, ACS patients with kidney dysfunction are undertreated invasively, correlating with poorer outcomes.
- Invasive revascularization improves survival in ACS patients, regardless of kidney function.
- Further randomized controlled trials are essential to determine optimal aggressive treatment strategies for ACS patients with kidney dysfunction.
Aims:
To examine: (i) the temporal changes in the management pattern; (ii) the reasons for any treatment disparities; (iii) the relationship between invasive treatment and outcome, among acute coronary syndrome (ACS) patients with vs. without kidney dysfunction.
Methods And Results:
Canadian ACS I, ACS II registries and Global Registry of Acute Coronary Events (GRACE) were prospective, multi-centre, observational studies of patients with ACS. From 1999 to 2007, non-ST elevation (NSTE) ACS patients were recruited in ACS I (n = 3295; 1999-2001), ACS II (n = 1956; 2002-2003), and GRACE (n = 6491; 2004-2007) in Canada. Using the four-variable Modified Diet in Renal Disease equation, we stratified the study population (n = 11,377) into three groups based on their estimated glomerular filtration rate (eGFR), and examined their treatment and outcome. While in-hospital use of coronary angiography and revascularization increased over time in all groups (P < 0.001), patients with kidney dysfunction were less likely to undergo invasive management (P < 0.001). Unadjusted 1 year mortality was lower among patients receiving in-hospital coronary angiography within all eGFR categories (> or =60 mL/min/1.73 m(2): 2.5 vs. 7.6%, P < 0.001; 30-59 mL/min/1.73 m(2): 8.0 vs. 14.6%, P < 0.001; <30 mL/min/1.73 m(2): 27.5 vs. 41.5%, P = 0.043). In-hospital revascularization was independently associated with lower 1-year mortality (adjusted OR = 0.52, 95% CI 0.36-0.77, P = 0.001), irrespective of eGFR (P for heterogeneity = 0.39). Underestimation of patient risk was the most common barrier to an invasive treatment strategy.
Conclusion:
Despite temporal increases in invasive management of NSTE-ACS, patients with kidney dysfunction are more commonly treated conservatively, with an associated worse outcome. In-hospital revascularization was independently associated with improved survival, irrespective of eGFR. Randomized controlled trials involving patients with kidney dysfunction are needed to confirm whether more aggressive treatment will improve their poor outcome.
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