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Inpatient coronary angiography and revascularisation following non-ST-elevation acute coronary syndrome in patients with renal impairment: a cohort study using the Myocardial Ischaemia National Audit Project.

Shaw C, Nitsch D, Steenkamp R, Junghans C, Shah S, O'Donoghue D, Fogarty D, Weston C, Sharpe CC - PLoS ONE (2014)

Bottom Line: Of 35 881 patients diagnosed with NSTE-ACS, eGFR of <60 ml/minute/1.73 m(2) was present in 15 680 (43.7%).Compared with an eGFR>90 ml/minute/1.73 m(2), patients with an eGFR between 45-59 ml/minute/1.73 m(2) were 33% less likely to undergo angiography (adjusted OR 0.67, 95% CI 0.55-0.81); those with an eGFR<30/minute/1.73 m(2) had a 64% reduction in odds of undergoing angiography (adjusted OR 0.36, 95%CI 0.29-0.43).After adjusting for co-variables, inpatient revascularisation was associated with approximately a 30% reduction in death within 1 year compared with those managed medically after coronary angiography (adjusted OR 0.66, 95%CI 0.57-0.77), with no evidence of modification by renal function (p(interaction) = 0.744).

View Article: PubMed Central - PubMed

Affiliation: UK Renal Registry, Southmead Hospital, Bristol, United Kingdom; Department of Renal Sciences, Division of Transplantation Immunology and Mucosal Biology, Kings College London, London, United Kingdom.

ABSTRACT

Background: International guidelines support an early invasive management strategy (including early coronary angiography and revascularisation) for non-ST-elevation acute coronary syndrome (NSTE-ACS) in patients with renal impairment. However, evidence from outside the UK suggests that this approach is underutilised. We aimed to describe practice within the NHS, and to determine whether the severity of renal dysfunction influenced the provision of angiography and modified the association between early revascularisation and survival.

Methods: We performed a cohort study, using multivariable logistic regression and propensity score analyses, of data from the Myocardial Ischaemia National Audit Project for patients presenting with NSTE-ACS to English or Welsh hospitals between 2008 and 2010.

Findings: Of 35 881 patients diagnosed with NSTE-ACS, eGFR of <60 ml/minute/1.73 m(2) was present in 15 680 (43.7%). There was a stepwise decline in the odds of undergoing inpatient angiography with worsening renal dysfunction. Compared with an eGFR>90 ml/minute/1.73 m(2), patients with an eGFR between 45-59 ml/minute/1.73 m(2) were 33% less likely to undergo angiography (adjusted OR 0.67, 95% CI 0.55-0.81); those with an eGFR<30/minute/1.73 m(2) had a 64% reduction in odds of undergoing angiography (adjusted OR 0.36, 95%CI 0.29-0.43). Of 16 646 patients who had inpatient coronary angiography, 58.5% underwent inpatient revascularisation. After adjusting for co-variables, inpatient revascularisation was associated with approximately a 30% reduction in death within 1 year compared with those managed medically after coronary angiography (adjusted OR 0.66, 95%CI 0.57-0.77), with no evidence of modification by renal function (p(interaction) = 0.744).

Interpretation: Early revascularisation may offer a similar survival benefit in patients with and without renal dysfunction, yet renal impairment is an important determinant of the provision of coronary angiography following NSTE-ACS. A randomised controlled trial is needed to evaluate the efficacy of an early invasive approach in patients with severe renal dysfunction to ensure that all patients who may benefit are offered this treatment option.

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Number of patients in the complete case analysis contributing to various stages of the analysis.
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pone-0099925-g002: Number of patients in the complete case analysis contributing to various stages of the analysis.

Mentions: Of 16 646 patients who had inpatient coronary angiography, 9 732 (58.5%) underwent inpatient revascularisation (Figure 2). On the basis of the propensity score, there was good overlap in the distribution of baseline characteristics between the group that underwent inpatient revascularisation and those who underwent angiography only (Appendix S1). Only 16% of patients with severe renal dysfunction at presentation (eGFR<30 ml/min/1.73 m2) underwent inpatient coronary angiography and could be considered for early revascularisation. However, of the 502 patients in this renal category that did have diagnostic angiography, nearly 50% underwent subsequent inpatient revascularisation (Table 5). The adjusted odds of undergoing inpatient revascularisation did not vary depending on eGFR category (data not shown).


Inpatient coronary angiography and revascularisation following non-ST-elevation acute coronary syndrome in patients with renal impairment: a cohort study using the Myocardial Ischaemia National Audit Project.

Shaw C, Nitsch D, Steenkamp R, Junghans C, Shah S, O'Donoghue D, Fogarty D, Weston C, Sharpe CC - PLoS ONE (2014)

Number of patients in the complete case analysis contributing to various stages of the analysis.
© Copyright Policy
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4061061&req=5

pone-0099925-g002: Number of patients in the complete case analysis contributing to various stages of the analysis.
Mentions: Of 16 646 patients who had inpatient coronary angiography, 9 732 (58.5%) underwent inpatient revascularisation (Figure 2). On the basis of the propensity score, there was good overlap in the distribution of baseline characteristics between the group that underwent inpatient revascularisation and those who underwent angiography only (Appendix S1). Only 16% of patients with severe renal dysfunction at presentation (eGFR<30 ml/min/1.73 m2) underwent inpatient coronary angiography and could be considered for early revascularisation. However, of the 502 patients in this renal category that did have diagnostic angiography, nearly 50% underwent subsequent inpatient revascularisation (Table 5). The adjusted odds of undergoing inpatient revascularisation did not vary depending on eGFR category (data not shown).

Bottom Line: Of 35 881 patients diagnosed with NSTE-ACS, eGFR of <60 ml/minute/1.73 m(2) was present in 15 680 (43.7%).Compared with an eGFR>90 ml/minute/1.73 m(2), patients with an eGFR between 45-59 ml/minute/1.73 m(2) were 33% less likely to undergo angiography (adjusted OR 0.67, 95% CI 0.55-0.81); those with an eGFR<30/minute/1.73 m(2) had a 64% reduction in odds of undergoing angiography (adjusted OR 0.36, 95%CI 0.29-0.43).After adjusting for co-variables, inpatient revascularisation was associated with approximately a 30% reduction in death within 1 year compared with those managed medically after coronary angiography (adjusted OR 0.66, 95%CI 0.57-0.77), with no evidence of modification by renal function (p(interaction) = 0.744).

View Article: PubMed Central - PubMed

Affiliation: UK Renal Registry, Southmead Hospital, Bristol, United Kingdom; Department of Renal Sciences, Division of Transplantation Immunology and Mucosal Biology, Kings College London, London, United Kingdom.

ABSTRACT

Background: International guidelines support an early invasive management strategy (including early coronary angiography and revascularisation) for non-ST-elevation acute coronary syndrome (NSTE-ACS) in patients with renal impairment. However, evidence from outside the UK suggests that this approach is underutilised. We aimed to describe practice within the NHS, and to determine whether the severity of renal dysfunction influenced the provision of angiography and modified the association between early revascularisation and survival.

Methods: We performed a cohort study, using multivariable logistic regression and propensity score analyses, of data from the Myocardial Ischaemia National Audit Project for patients presenting with NSTE-ACS to English or Welsh hospitals between 2008 and 2010.

Findings: Of 35 881 patients diagnosed with NSTE-ACS, eGFR of <60 ml/minute/1.73 m(2) was present in 15 680 (43.7%). There was a stepwise decline in the odds of undergoing inpatient angiography with worsening renal dysfunction. Compared with an eGFR>90 ml/minute/1.73 m(2), patients with an eGFR between 45-59 ml/minute/1.73 m(2) were 33% less likely to undergo angiography (adjusted OR 0.67, 95% CI 0.55-0.81); those with an eGFR<30/minute/1.73 m(2) had a 64% reduction in odds of undergoing angiography (adjusted OR 0.36, 95%CI 0.29-0.43). Of 16 646 patients who had inpatient coronary angiography, 58.5% underwent inpatient revascularisation. After adjusting for co-variables, inpatient revascularisation was associated with approximately a 30% reduction in death within 1 year compared with those managed medically after coronary angiography (adjusted OR 0.66, 95%CI 0.57-0.77), with no evidence of modification by renal function (p(interaction) = 0.744).

Interpretation: Early revascularisation may offer a similar survival benefit in patients with and without renal dysfunction, yet renal impairment is an important determinant of the provision of coronary angiography following NSTE-ACS. A randomised controlled trial is needed to evaluate the efficacy of an early invasive approach in patients with severe renal dysfunction to ensure that all patients who may benefit are offered this treatment option.

Show MeSH
Related in: MedlinePlus