Management of acute myocardial infarction in chronic kidney disease in Germany: an observational study
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Published on: April 12, 2021
Victor Walendy1, Andreas Stang2,3, Matthias Girndt4
1Department of Internal Medicine II, Universitätsmedizin (Halle), Medical Faculty of the Martin-Luther-University Halle-Wittenberg, Ernst-Grube-Straße 40, 06120, Halle (Saale), Germany. victor.walendy@uk-halle.de.
Insights
Patients with acute myocardial infarction (AMI) and chronic kidney disease (CKD) receive less percutaneous coronary intervention (PCI). However, those on renal replacement therapy (RRT) have higher rates of coronary artery bypass grafting (CABG).
Area of Science:
- Cardiology
- Nephrology
- Public Health
Background:
- Managing acute myocardial infarction (AMI) in patients with chronic kidney disease (CKD) or on renal replacement therapy (RRT) is complex.
- Concerns about contrast-induced nephropathy may lead to underutilization of guideline-directed therapies in this population.
Purpose of the Study:
- To investigate the utilization of percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in AMI patients with and without CKD or RRT.
- To analyze treatment disparities in AMI management for patients with kidney disease.
Main Methods:
- Analysis of German-DRG data from 2016, including 217,514 AMI cases (STEMI/NSTEMI).
- Comparison of PCI and CABG rates between AMI patients with and without CKD or RRT.
- Log-binomial regression models were used to calculate adjusted relative risks (aRR), controlling for confounders.
Main Results:
- AMI patients with CKD received PCI less frequently (46.6%) compared to those without CKD (60.8%).
- AMI patients on RRT showed similar PCI rates (54.5%) but significantly higher CABG rates (aRR: 2.20) compared to non-CKD patients.
- CKD was negatively associated with CABG (aRR: 0.71).
Conclusions:
- Patients with AMI and CKD are less likely to undergo PCI.
- Renal replacement therapy (RRT) does not impact PCI rates but is associated with increased CABG utilization in AMI.
- Treatment patterns for AMI differ significantly based on kidney disease status.
Background:
Managing acute myocardial infarction (AMI) in patients with chronic kidney disease (CKD) or end-stage renal disease on dialysis (renal replacement therapy, RRT) presents challenges due to elevated complication risks. Concerns about contrast-related kidney damage may lead to the omission of guideline-directed therapies like percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in this population.
Methods:
We analysed German-DRG data of 2016 provided by the German Federal Bureau of Statistics (DESTATIS). We included cases with a primary diagnosis of AMI (ST-Elevation Myocardial Infarction (STEMI) or Non-ST-Elevation Myocardial Infarction (NSTEMI) ICD-10: I21 or I22) with and without CKD or RRT. We calculated crude- and age-standardized hospitalization rates (ASR, per 100,000 person years). Furthermore, we calculated log-binominal regression models adjusting for sex, CKD, RRT, comorbidities, and place of residence to estimate adjusted relative-risks (aRR) for receiving treatments of interest in AMI, such as PCI or CABG.
Results:
We identified 217,514 AMI-cases (69,728 STEMI-cases and 147,786 NSTEMI-cases). AMI-cases without CKD had percutaneous coronary intervention (PCI) in 60.8%. In contrast, AMI-cases with CKD or RRT had PCI in 46.6% and 54.5%, respectively. The ASR for AMI-cases amounted to 184.7 (95%CI 183.5-185.8) per 100,000 person years. In regression analysis AMI-cases with CKD were less likely treated with PCI (aRR: 0.89 (95%CI 0.88-0.90)), compared to cases without CKD. AMI-Cases with RRT showed no difference in PCI rates (aRR: 1.0 (95%CI 0.97-1.03)) but were more frequently treated with CABG (aRR: 2.20 (95%CI 2.03-2.39)). Conversely, CKD was negatively associated with CABG (aRR: 0.71, 95%CI 0.67-0.75) when non-CKD cases were used as the reference group.
Conclusion:
We show that AMI-cases with CKD underwent PCI less frequently, while RRT has no discernible impact on PCI utilization in AMI. Furthermore, AMI-cases with RRT exhibited a higher CABG rate.
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