Many randomized studies and systematic revisions have shown that an early invasive approach (within 24hrs. after diagnosis) will not reduce mortality across the non-ST elevation acute coronary syndrome (NST-ACS) population, hence the relevance of NST-ACS; patients with a GRACE score higher than 140 were the ones showing improved outcomes.
Roughly 40% of NST-ACS patients have chronic kidney disease (CKD) at varying stages. However, the latest guidelines of the European Society of Cardiology have yet to define a specific treatment for these patients. In some cases, postponing the coronary angiogram might be an opportunity to increase hydration and therefore improve prior preparation.
The aim of this study was to find out the association between an early invasive strategy and mortality in a cohort of patient with CKD and NST-ACS.
A retrospective study of all NST-ACS patients undergoing early invasive strategy at the Sheba Medical Center (Israel) was carried out. Primary end point was all cause mortality.
Of 7107 NST-ACS patients, 50% was treated with an early approach (3259 patients). Mean age was 66±11, and 77% were men. 1837 patients (52%) received a coronary angiogram within 24 hours.
Read also: Spontaneous Coronary Artery Dissection: Treatment and Prognosis.
Early invasive strategy patients were younger, had fewer comorbidities, better kidney function and higher troponin levels. They also had lower rate of multivessel/ left main disease (33% vs 40%; P<0.001).
At mean 4-year followup, 15% of these patients died and 30-day mortality was higher in patients with CKD in both groups. During followup, the lowest rates of kidney disease were associated with worse survival rate; patients with moderate to severe CKD had 66% more chances of dying, vs the population with mild or no CKD (CI 95% 1.3-2.1; P<0.001). Patients with severe CKD had 4 times more chances of dying (CI 95% 3.0-5.3; P <0.001).
After Inverse probability weighting treatment (IPWT), the early invasive strategy was associated to 30% lower mortality (CI 95% 0.56-0.85; P<0.001). This benefit was compromised by CKD, and there was no significant difference in patients with moderate to severe disease (glomerular filtration <44ml/min).
Conclusion
The association between early invasive strategy and long-term survival varies according to kidney function: the more dysfunctional (GF <44), the lower the benefit of an early intervention, as regards mortality.
Dr. Omar Tupayachi.
Member of the Editorial Board of SOLACI.org.
Original Title: Early Invasive Strategy and Outcome of Non–ST-Segment Elevation Myocardial Infarction Patients With Chronic Kidney Disease.
Source: Sharon A, Massalha E, Fishman B, Fefer P, Barbash IM, Segev A, Matetzky S, Guetta V, Grossman E, Maor E. Early Invasive Strategy and Outcome of Non-ST-Segment Elevation Myocardial Infarction Patients With Chronic Kidney Disease. JACC Cardiovasc Interv. 2022 Oct 10;15(19):1977-1988. doi: 10.1016/j.jcin.2022.08.008. PMID: 36202565.
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