Non–ST‐Segment–Elevation Myocardial Infarction Among Patients With Chronic Kidney Disease: A Propensity Score–Matched Comparison of Percutaneous Coronary Intervention Versus Conservative Management

Abstract

BackgroundChronic kidney disease (CKD) remains an independent predictor of cardiovascular morbidity and mortality. CKD complicates referral for percutaneous coronary intervention (PCI) in non–ST‐segment–elevation myocardial infarction (NSTEMI) patients because of the risk for acute kidney injury and the need for dialysis, with American College of Cardiology/American Heart Association guidelines underscoring the limited data on these patients.Methods and ResultsUsing the National Inpatient Sample to analyze hospitalizations in the United States from 2004 to 2014, we sought to assess PCI utilization and in‐hospital outcomes in NSTEMI admissions with CKD. NSTEMI admissions were identified by International Classification of Diseases, Ninth Edition, Clinical Modification (ICD‐9‐CM) code 410.7. CKD admissions were identified by ICD‐9‐CM code 585. Propensity score–matched cohorts of patients with NSTEMI were matched for age, sex, comorbidities, race, median household income, primary payer status, and hospital characteristics. Of 4 488 795 hospitalizations for NSTEMI, 31% underwent PCI. Overall, 89% of admissions had no CKD. In addition, 32% of NSTEMI admissions with no CKD and 23%, 14%, and 22% with CKD stages 3, 4, and 5 underwent PCI, respectively. Hospitalized NSTEMI patients with CKD stages 4 and 5 had 41% and 20% less likelihood, respectively, of undergoing PCI compared with those with no CKD. Among hospitalized NSTEMI patients with no CKD or CKD stage 3, 4, or 5, PCI‐treated groups had 63%, 57%, 39%, and 59% lower likelihood, respectively, of all‐cause, in‐hospital mortality compared with propensity score–matched medically managed groups.Conclusions PCI use decreased among hospitalized NSTEMI patients as CKD severity increased, and all‐cause, in‐hospital mortality was greater for NSTEMI patients admitted with more severe CKD regardless of treatment strategy.

Contemporary National Outcomes of Acute Myocardial Infarction-Cardiogenic Shock in Patients with Prior Chronic Kidney Disease and End-Stage Renal Disease

“…We observed that in non-ST-segment elevation AMI admissions with CKD stages 4 and 5 had 41% and 20% less likelihood, respectively, of undergoing PCI compared with those with no CKD. The cohort treated with PCI had lower in-hospital mortality compared to those managed medically across all CKD stages [8]. Similarly, this current study confirms what prior studies have shown that patients with CKD/ESRD tend to receive less coronary angiography, PCI and MCS.…”

“…Using the HCUP-NIS data from 2005–2016, a retrospective cohort study of admissions with AMI in the primary diagnosis field (International Classification of Diseases 9.0 Clinical Modification [ICD-9CM] 410.x and ICD-10CM I21.x-22.x) and a secondary diagnosis of CS (ICD-9CM 785.51, ICD-10CM R57.0) were identified [ 24 ]. Similar to prior literature, prior CKD/ESRD was identified using ICD-9CM 585.x and ICD-10CM N18.x codes [ 8 ]. The use of chronic dialysis was identified using ICD-9CM 39.95/ICD-10CM 5A1D70Z, 5A1D80Z, 5A1D90Z (hemodialysis) and ICD-9CM 54.98/ICD-10CM 3E1M39Z (peritoneal dialysis) in the absence of a concomitant diagnosis of AKI [ 5 , 7 ].…”

“…CKD/ESRD are known predisposing factors for accelerated atherosclerosis and therefore, these patients often present with a higher risk profile and comorbidities, making them more susceptible to acute organ failure, including acute kidney injury (AKI) and mortality [ 3 , 5 , 6 , 7 ]. The risk of AKI is increased with an increase in the CKD stage, and AKI itself has been associated with high in-hospital mortality [ 2 , 3 , 8 ]. As such, it is not surprising that some studies have shown that these patients tend to receive less invasive treatments, including coronary angiography, percutaneous coronary interventions (PCI) and mechanical circulatory support (MCS), mainly due to concerns relating to contrast-associated AKI, worsening kidney function and need for potential acute renal replacement therapy [ 2 , 5 ].…”

Value of the high-sensitivity troponin T assay for diagnosis of acute myocardial infarction in patients with and without renal insufficiency

“…Chronic kidney disease (CKD) is an independent risk factor for AMI and the risk increases with advanced renal insufficiency [2,3]. Additionally, AMI patients comorbid with CKD are not ideal patients for coronary angiography and percutaneous coronary intervention, therefore having higher mortality rates than AMI patients without CKD [2,[4][5][6][7][8]. Furthermore, AMI patients comorbid with advanced CKD have a higher rate of long-term adverse cardiac events than those with normal kidney function [9].…”

The progress in outcomes of the management of patients with non-ST-segment elevation myocardial infarction between 2005 and 2014 in Poland – a propensity score matching analysis from the PL-ACS registry

“…On the contrary, percentage of smoking habit significantly decreased recently. Additionally, in the years 2005-2014 numerous changes in the clinical profile (mean age, gender, comorbidities and Killip class on admission) that might have impact on prognosis were noted[9][10][11][12][13].…”