Invasive Approach More Beneficial than Medical Management for NSTEMI in Chronic Kidney Disease

Ankur Kalra, MD

Data from the largest study of its kind suggests patients with chronic kidney disease (CKD) experiencing non-ST segment elevation myocardial infarction (NSTEMI) may benefit more from an invasive management strategy rather than medical management.

An analysis of NSTEMI in patients with stages 3-5 CKD and end-stage renal disease from the Nationwide Readmission database, results of the study demonstrate an invasive management strategy, which included coronary angiography either with or without PCI or CABG, was associated with a lower risk of both in-hospital and 6-month mortality across all patient groups, with invasive management also associated with higher in-hospital procedural complications but no difference in postdischarge safety outcomes.

“These findings are important because they show that the benefits of offering invasive therapy to these patients upfront outweigh the risks,” said Ankur Kalra, MD, associate professor of clinical medicine at the Indiana University School of Medicine Department of Medicine and medical director of interventional cardiology quality and innovation at the Cardiovascular Institute, in a statement. “This study will influence decision-making by physicians and the development of treatment guidelines for NSTEMI in this population of patients.”

With patients with CKD at an increased risk of cardiovascular events, knowledge of optimal management strategies among patients with varying levels of disease severity could have a substantial impact on patient outcomes and quality of life. With this in mind, Kalra and a team of colleagues sought to assess how an invasive management strategy compared against medical management might influence patient outcomes.

To do so, investigators designed their study as a retrospective analysis of data from the Nationwide Readmission Database from 2016-2018. Using ICD-10 codes, investigators identified 688,147 patients aged 18 years or older with NSTEMI during that time period. Among these, 141,052 patients had CKD stages 3-5 or end-stage renal disease in the secondary diagnosis field. Of the 141,052 patients with NSTEMI, 57.9% had Stage 3 CKD, 16.9% had Stage 4 CKD, 2.1% had CKD Stage 5, and 23.4% had end-stage renal disease. In CKD 3, 4, 5, and end-stage-renal disease, 64%, 45%, 42%, and 68% underwent invasive management, respectively.

All of the 141,052, which included 85,875 patients managed with an invasive strategy and 55,177 who received medical management, were included in analyses for in-hospital outcomes. For the analyses of post-discharge outcomes, 7410 patients who died during index hospitalization were excluded, leaving an overall cohort of 133,642 for analysis. Of the 133,642 included in the post-discharge outcomes analyses, 83,254 were managed with an invasive strategy ad 50,388 received medical management. Further stratification of those in the invasive strategy group indicated 67% (n=55,762) received coronary angiography with revascularization and 33% (n=27,492) received coronary angiography without revascularization.

For the purpose of analysis, an invasive approach was defined as coronary angiography with or without PCI and/or CABG while medical management was defined as not undergoing coronary angiography, PCI, or CABG. Investigators noted invasive management was further stratified into coronary angiography with revascularization and coronary angiography without revascularization.

The primary outcomes of interest for the investigators’ analysis were in-hospital and postdischarge 6-month mortality during readmission. Secondary outcomes of interest were divided into in-hospital and postdischarge outcomes. In-hospital outcomes included AKI requiring dialysis, major bleeding, and stroke. Postdischarge outcomes included major adverse cardiovascular events (MACE), efficacy, safety, renal safety, myocardial infarction, need for revascularization during readmission, and acute kidney injury within 6 months of discharge.

In propensity score-matched analysis, results demonstrated an invasive management approach was associated with lower likelihood of in-hospital mortality than medical management among patients with stage 3 CKD (OR, 0.47 [95% CI, 0.43-0.51]; P <.001), stage 4 CKD (OR, 0.79 [95% CI, 0.69-0.89]; P <.001), stage 5 CKD (OR, 0.72 [95% CI, 0.49-1.06]; P=.096), and end-stage renal disease (OR, 0.51 [95% CI, 0.46-0.56]; P <.001). Further analysis suggested a similar trend was observed for 6-month mortality. Additionally, investigators pointed out invasive management was associated with an increase in in-hospital postprocedural complications, but no difference was observed for postdischarge safety outcomes.

“This is a challenging population to treat, and individualized care is important,” Kalra added. “But our results suggest that invasive therapy should be offered to all patients in this category.”

This study, “Invasive Versus Medical Management in Patients With Chronic Kidney Disease and Non–ST-Segment–Elevation Myocardial Infarction,” was published in the Journal of the American Heart Association.