Early Angiography in Patients with Chronic Kidney Disease

Abstract

Background and objectives: In the general population, an early invasive strategy of routine coronary angiography is superior to a conservative strategy of selective angiography in patients who are admitted with unstable angina or non-ST segment elevation myocardial infarction (MI), but the effectiveness of this strategy in individuals with chronic kidney disease (CKD) is uncertain.Design, setting, participants, & measurements: We conducted a collaborative meta-analysis with data provided by the main authors of identified trials to estimate the effectiveness of early angiography in patients with CKD. The Cochrane, Medline, and EMBASE databases were searched to identify randomized trials that compared invasive and conservative strategies in patients with unstable angina or non-ST MI. Pooled risks ratios were estimated using data from enrolled patients with estimated GFR <60 ml/min per 1.73 m 2 . Results: Five randomized trials that enrolled 1453 patients with CKD were included. An early invasive strategy was associated with nonsignificant reductions in all-cause mortality, nonfatal MI, and a composite of death or nonfatal MI. The invasive strategy significantly reduced rehospitalization.Conclusions: This collaborative study suggests that the benefits of an early invasive strategy are preserved in patients with CKD and that an early invasive approach reduces the risk for rehospitalization and is associated with trends of reduction in the risk for death and nonfatal re-infarction in patients with CKD. Coronary angiography should be considered for patients who have CKD and are admitted with non-ST elevation acute coronary syndromes.

Prognostic Significance of Elevated Baseline Troponin in Patients With Acute Coronary Syndromes and Chronic Kidney Disease Treated With Different Antithrombotic Regimens

“…4,20,28 -31 Earlier studies have demonstrated the benefits of an early invasive strategy in ACS patients with CKD. 33 In the present study there were no significant differences in death or MI in patients with ACS, CKD, and elevated troponins treated with bivalirudin versus a heparin plus a GPI as part of an early invasive strategy (although a nonsignificant trend toward greater mortality with bivalirudin was present at 30 days that was absent at 1 year). Conversely, bivalirudin significantly reduced major hemorrhagic complications.…”

Clinical Quantification of Myocardial Blood Flow Using PET: Joint Position Paper of the SNMMI Cardiovascular Council and the ASNC

“…Cardiovascular disease is the leading cause of death among patients with moderate to severe renal dysfunction, 103 and early referral for revascularization may be beneficial in patients with suitable disease. 104 However, patients with underlying renal dysfunction are also at increased risk of complications after angiography and revascularization. [105][106][107] Unfortunately, as with diabetic patients, traditional relative MPI is unable to identify truly low-risk patients.…”

2012 ACCF/AHA Focused Update Incorporated Into the ACCF/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction

“…In the highly validated GRACE risk score, serum creatinine is 1 of the 8 independent predictors of death. 945,969 In recent study, even early CKD constituted a significant risk factor for cardiovascular events and death. 971,972 Chronic kidney disease also predicts an increase in recurrent cardiovascular events.…”