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Published on: May 28, 2019
Treatment Effect of Percutaneous Coronary Intervention in Dialysis Patients With ST-Elevation Myocardial Infarction
Akram Kawsara1, Samian Sulaiman1, Mohamed Mohamed2
1Division of Cardiology, West Virginia University, Morgantown, West Virginia.
Insights
Primary percutaneous coronary intervention (pPCI) offers similar mortality benefits for patients with ST-elevation myocardial infarction (STEMI) undergoing maintenance dialysis as for those not on dialysis. This indicates pPCI is a valuable treatment option regardless of dialysis status.
Area of Science:
- Cardiology
- Nephrology
- Health Services Research
Background:
- Patients on maintenance dialysis face higher mortality risks following primary percutaneous coronary intervention (pPCI) for ST-elevation myocardial infarction (STEMI).
- The comparative benefit of pPCI in dialysis patients versus non-dialysis patients with STEMI remains incompletely understood.
Purpose of the Study:
- To compare the in-hospital outcomes of pPCI for STEMI between patients receiving maintenance dialysis and those not receiving dialysis.
- To determine if the effectiveness of pPCI in reducing mortality and other adverse events differs based on dialysis status.
Main Methods:
- A retrospective cohort study utilizing the National Inpatient Sample (2016-2018) of adult STEMI hospitalizations.
- Propensity score matching was employed to estimate the average treatment effect (ATE) of pPCI within dialysis and non-dialysis groups.
- Average marginal effect (AME) analysis was conducted, accounting for hospital clustering, to assess in-hospital outcomes.
Main Results:
- The dialysis cohort was older, had more comorbidities, and was less likely to receive pPCI compared to the non-dialysis cohort.
- pPCI was associated with significantly lower in-hospital mortality in both dialysis (15.7% vs 27.1%) and non-dialysis patients (5.0% vs 17.4%).
- The reduction in mortality attributed to pPCI was comparable between patients receiving dialysis (-8.6% ATE) and those not receiving dialysis (-8.2% ATE), with no significant interaction (P=0.9).
Conclusions:
- Primary percutaneous coronary intervention (pPCI) for ST-elevation myocardial infarction (STEMI) is associated with comparable short-term mortality reductions in patients with and without maintenance dialysis.
- The findings suggest that pPCI is a beneficial intervention for STEMI patients, regardless of their dialysis status, challenging previous assumptions about higher risk.
- Further research into long-term outcomes and pharmacotherapy is warranted given the study's reliance on administrative data.
Rationale & Objective:
Patients receiving maintenance dialysis have higher mortality after primary percutaneous coronary intervention (pPCI) than patients not receiving dialysis. Whether pPCI confers a benefit to patients receiving dialysis that is similar to that which occurs in lower-risk groups remains unknown. We compared the effect of pPCI on in-hospital outcomes among patients hospitalized for ST-elevation myocardial infarction (STEMI) and receiving maintenance dialysis with the effect among patients hospitalized for STEMI but not receiving dialysis.
Study Design:
Retrospective cohort study.
Setting & Participants:
We used the National Inpatient Sample (2016-2018) and included all adult hospitalizations with a primary diagnosis of STEMI.
Predictors:
Primary exposure was PCI. Confounders included dialysis status, demographics, insurance, household income, comorbidities, and the elective nature of the admission.
Outcome:
In-hospital mortality, stroke, acute kidney injury, new dialysis requirement, vascular complications, gastrointestinal bleeding, blood transfusion, mechanical ventilation, palliative care, and discharge destination.
Analytical Approach:
The average treatment effect (ATE) of pPCI was estimated using propensity score matching independently within the group receiving dialysis and the group not receiving dialysis to explore whether the effect is modified by dialysis status. Additionally, the average marginal effect (AME) was calculated accounting for the clustering within hospitals.
Results:
Among hospitalizations, 4,220 (1.07%) out of 413,500 were for patients receiving dialysis. The dialysis cohort was older (65.2 ± 12.2 vs 63.4 ± 13.1, P < 0.001), had a higher proportion of women (42.4% vs 30.6%, P < 0.001) and more comorbidities, and had a lower proportion of White patients (41.1% vs 71.7%, P < 0.001). Patients receiving dialysis were less likely to undergo angiography (73.1% vs 85.4%, P < 0.001) or pPCI (57.5% vs 79.8%, P < 0.001). Primary PCI was associated with lower mortality in patients receiving dialysis (15.7% vs 27.1%, P < 0.001) as well as in those who were not (5.0% vs 17.4%, P < 0.001). The ATE on mortality did not differ significantly (P interaction = 0.9) between patients receiving dialysis (-8.6% [95% CI, -15.6% to -1.6%], P = 0.02) and those who were not (-8.2% [95% CI, -8.8% to -7.5%], P < 0.001). The AME method showed similar results among patients receiving dialysis (-9.4% [95% CI, -14.8% to -4.0%], P < 0.001) and those who were not (-7.9% [95% CI, -8.5% to -7.4%], P < 0.001) (P interaction = 0.6). Both the ATE and AME were comparable for other in-hospital outcomes in both groups.
Limitations:
Administrative data, lack of pharmacotherapy and long-term outcome data, and residual confounding.
Conclusions:
Compared with conservative management, pPCI for STEMI was associated with comparable reductions in short-term mortality among patients irrespective of their receipt of maintenance dialysis.
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