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Does Chronic Kidney Disease Influence Revascularization Strategy After Acute Coronary Syndrome? A Systematic Review
Jemima K Scott1,2, Matthew Letts1,2, Wafaa Hajee-Adam3
1Bristol Medical School, Population Health Sciences, University of Bristol, Bristol, UK.
Insights
Patients with chronic kidney disease (CKD) were more likely to receive coronary artery bypass grafting (CABG) over percutaneous coronary intervention (PCI) after acute coronary syndrome (ACS). However, this trend shifted for non-ST-elevation ACS when considering angiography use.
Area of Science:
- Cardiology
- Nephrology
- Public Health
Background:
- Coronary artery bypass grafting (CABG) offers better long-term results than percutaneous coronary intervention (PCI) for complex multivessel coronary artery disease (CAD).
- Patients with chronic kidney disease (CKD) have a higher prevalence of multivessel CAD but face increased surgical risks.
- The study examines if CKD influences the choice between CABG and PCI in patients treated for acute coronary syndrome (ACS).
Purpose of the Study:
- To investigate the association between chronic kidney disease (CKD) and the utilization of coronary artery bypass grafting (CABG) versus percutaneous coronary intervention (PCI) in patients with acute coronary syndrome (ACS).
- To analyze real-world revascularization patterns in ACS patients with and without CKD.
Main Methods:
- A systematic literature search was conducted across Embase, MEDLINE, Scopus, and CENTRAL from 2012 to 2023.
- Included studies reported CABG rates in ACS patients with and without CKD (eGFR < 60 mL/min/1.73 m²).
- Random effects meta-analyses were performed to determine the odds of CABG in CKD patients, stratified by ACS type and dialysis status.
Main Results:
- Analysis of 13 observational studies (n=1,682,207) revealed that CKD patients were more likely to receive CABG than non-CKD patients (OR=1.50, 95% CI: 1.30-1.72).
- The association between CKD and CABG use was stronger in ST-elevation myocardial infarction (STEMI) (OR=1.54) compared to non-ST-elevation ACS (NSTE-ACS) (OR=1.16).
- After adjusting for lower coronary angiography use in CKD patients with NSTE-ACS, the association between CKD and CABG disappeared.
Conclusions:
- In high-income countries, ACS patients with CKD are more frequently treated with CABG compared to PCI.
- The observed higher CABG use in CKD patients with NSTE-ACS was attenuated when accounting for reduced invasive angiography rates.
- Increased access to invasive coronary angiography for NSTE-ACS patients with CKD could potentially improve revascularization rates and patient outcomes.
Background:
Coronary artery bypass grafting (CABG) provides superior long-term outcomes to percutaneous coronary intervention (PCI) for complex multivessel coronary artery disease (CAD). People with chronic kidney disease (CKD) have increased prevalence of multivessel CAD, but also increased surgical risk. We investigated whether CKD predicted real-world use of CABG, versus PCI, in patients revascularized for acute coronary syndrome (ACS).
Methods:
Embase, MEDLINE, Scopus and CENTRAL were searched to identify articles referring to ACS and invasive coronary intervention in high-income countries (2012 - 2023). Articles were included if CABG rates were reported in ACS patients with and without CKD receiving revascularization. CKD was defined as an estimated glomerular filtration rate < 60 mL/min/1.73 m2; proxy definitions were accepted. Random effect meta-analyses were used to determine the average effect of CKD on odds of CABG, stratified by ACS type and dialysis use.
Results:
Searches generated 15,138 articles, of which 13 observational studies were included (n = 1,682,207). Amongst revascularized ACS patients, those with CKD were more likely to receive CABG than those without (pooled odds ratio (OR) = 1.50 (95% confidence interval (CI) = 1.30 - 1.72). This association was stronger following ST-elevation myocardial infarction (STEMI) than non-ST-elevation ACS (NSTE-ACS) (OR: 1.54 (95% CI: 1.23 - 1.93)) versus 1.16 (1.10 - 1.23), respectively).
Conclusions:
In high-income countries, revascularized ACS patients with CKD receive CABG (versus PCI) more frequently than those without kidney disease. However, accounting for lower use of coronary angiography in the CKD population removed this association following NSTE-ACS. Greater use of invasive angiography in those with NSTE-ACS and CKD might therefore increase access to revascularization, and thereby improve outcomes.
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