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.
Insights
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.
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.
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