Invasive Versus Medical Management in Patients With Chronic Kidney Disease and Non-ST-Segment-Elevation Myocardial
Monil Majmundar1, Gabriel Ibarra2, Ashish Kumar3
1Department of Cardiology Maimonides Medical Center, Brooklyn New York NY.
Journal of the American Heart Association
|June 17, 2022
Summary
Invasive management for non-ST-segment-elevation myocardial infarction (NSTEMI) with chronic kidney disease (CKD) reduces mortality and major adverse cardiovascular events. While in-hospital complications may slightly increase, the benefits outweigh the risks, suggesting NSTEMI-CKD patients should receive invasive treatment.
Area of Science:
- Cardiology
- Nephrology
- Clinical Outcomes Research
Background:
- The optimal management strategy for patients experiencing non-ST-segment-elevation myocardial infarction (NSTEMI) who also have advanced chronic kidney disease (CKD) remains unclear.
- Patients with CKD face elevated risks of procedural complications, creating uncertainty regarding the benefits of invasive versus conservative medical management for NSTEMI.
Purpose of the Study:
- To compare the clinical outcomes, including mortality and safety, of invasive management versus medical management in patients diagnosed with NSTEMI and varying stages of CKD.
Main Methods:
- Utilized Nationwide Readmission Database (2016-2018) with International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes to identify NSTEMI patients with CKD stages 3-5 and end-stage renal disease (ESRD).
- Stratified patients into invasive and medical management groups.
- Employed propensity-score matching to compare primary outcomes (in-hospital and 6-month mortality) and secondary outcomes (in-hospital postprocedural complications, postdischarge safety, and major adverse cardiovascular events).
Main Results:
- In propensity-score matched cohorts, invasive management was associated with significantly lower in-hospital and 6-month mortality across all CKD stages (including ESRD).
- Invasive management led to a higher incidence of in-hospital postprocedural complications, such as acute kidney injury requiring dialysis and major bleeding.
- No significant differences in postdischarge safety outcomes were observed between the two management strategies. Invasive management demonstrated a reduced hazard of major adverse cardiovascular events at 6 months.
Conclusions:
- Invasive management in patients with NSTEMI and CKD is associated with reduced mortality and major adverse cardiovascular events.
- Despite a slight increase in in-hospital complications, the overall benefits of invasive management suggest it should be considered for patients with NSTEMI-CKD.
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