Impact of chronic kidney disease in early invasive versus early conservative revascularization strategies in non-ST-segment elevation acute coronary syndromes: a population-based study from NHIRD of Taiwan.

BACKGROUND: Patients with chronic kidney disease (CKD) sustaining a non-ST-segment elevation acute coronary syndrome (NSTE-ACS) are considered high risk and an early invasive strategy (EIS) is often recommended. However, the impact of CKD on patients receiving an EIS or an early conservative strategy (ECS) is unclear in real-world practice.

METHODS: Data were analyzed from the 2005-2008 National Health Insurance Research Database (NHIRD) in Taiwan. The diagnosis of CKD was based on the International Classification of Disease-9 codes recorded by physicians. EIS was defined as coronary angiography with intent to revascularization performed within 72 h of symptom onset. The primary endpoint was time to first major adverse cardiac event (MACE) comprising cardiovascular death, myocardial infarction (MI) and stroke. The secondary endpoints included major bleeding (MB), heart failure (HF) and dialysis during admission (DDA).

RESULTS: 834 patients (466 EIS and 368 ECS) were enrolled and age was 64.3 ± 12.6 years. Mean follow-up time was 1,163.96 ± 19.99 days. In the whole population an EIS was associated with a reduction in MACE (HR 0.69; 95% CI 0.50-0.95, p = 0.024) but not in the CKD population (HR 1.08; 95% CI 0.66-1.78, p = 0.76). Kaplan-Meier curves showed CKD subjects receiving an EIS had the highest MACE, HF and DDA rate (all p < 0.019) and CKD subjects receiving an ECS had the highest MB rate (p = 0.018). Cox regression analysis showed CKD predicted higher HF and DDA in those receiving an EIS and higher DDA and MB in those receiving an ECS.

CONCLUSION: An EIS reduced MACE in the overall population, and CKD was a poor outcome predictor for both revascularization strategies in NSTE-ACS.