An invasive management strategy is associated with improved outcomes in high-risk acute coronary syndromes in patients with chronic kidney disease

Introduction: Chronic kidney disease (CKD) is associated with poor outcomes after acute coronary syndromes, yet selection for invasive investigation and management is low. Methods: Patients presenting with ST segment elevation myocardial infarction (STEMI) or intermediate-to high-risk non-ST segment elevation acute coronary syndrome (NSTEACS) (n = 2597) were stratified into groups based on kidney function, defined as normal (glomerular filtration rate (GFR) >= 60 mL/min/1.73 m(2)), moderate CKD (GFR 30-59 mL/min/1.73 m(2)) and severe CKD (GFR < 30 mL/min/1.73 m(2)). Based on these stratums of kidney function, incidence and outcome measures were obtained for: rates of angiography and revascularization; 6-month mortality; and the incidence and outcome of in-hospital acute kidney impairment (AKI). Results: Patients with CKD were less likely to be offered coronary angiography after STEMI/NSTEACS (P < 0.001); however, after selection, revascularization rates were similar (percutaneous coronary intervention (P = 0.8); surgery (P = 0.4)). Six-month mortality rates increased with CKD (GFR >= 60, 2.8%; GFR 30-59, 9.9%; GFR < 30, 16.5%, P <= 0.001), as well as the combined efficacy/safety end-point (GFR >= 60, 9.4%; GFR 30-59, 20.2%; GFR < 30, 27.1%, P <= 0.001). Six-month mortality was lower in patients who had received prior angiography (GFR > 60, 1.5% vs 3.6%, P = 0.001; GFR 30-59, 5.1% vs 12.7%, P < 0.001; GFR < 30, 7.3% vs 18.5%, P = 0.094). Risk of AKI increased with CKD (GFR >= 60, 0.7%; GFR 30-59, 3.4%; GFR < 30, 6.8%, P <= 0.001), and was associated with high 6-month mortality (35.6% vs 4.1%, P < 0.001). Conclusions: In patients with CKD after STEMI/NSTEACS, 6-month mortality and morbidity is high, selection for angiography is lower, yet angiography is associated with a reduced long-term mortality, and with comparable revascularization rates to those without CKD. In-hospital AKI is more common in CKD and predicts a high 6-month mortality.