782 Acute Coronary Syndrome in Severe Chronic Kidney Disease – Analysis of Management and Outcome

Abstract

Choice of medical therapy alone or invasive revascularisation in patients with severe chronic kidney disease (CKD) presenting with acute coronary syndrome (ACS) is difficult. Clinical trials frequently exclude these patients making optimal management controversial. We assess the management and outcome in Auckland, New Zealand. Patients with advanced CKD (stage 4 or 5) or end stage kidney disease (ESKD) on dialysis who presented to hospital in Auckland between 2012-2019 with ACS were identified from the national ANZACS-QI registry. Clinical details, management and combined endpoint of major adverse cardiovascular events (MACE) of all-cause mortality, stroke, rehospitalisation and heart failure were analysed with a median follow-up of 2.2±1.8 years. 229 patients identified (17% peritoneal, 26% haemodialysis). Mean age 65±11y. Male 80(34.9%). Polynesians 126(55%), Europeans 51(22.3%). STEMI 18% and NSTEACS 82%. Diabetic nephropathy predominates (60%). Over half has prior history of ACS and presents in heart failure. Those on dialysis were more likely to undergo invasive coronary angiography (ICA) (83% vs 65%, p=0.002). Overall rate of ICA is 73%, similar in both STEMI and NSTEACS. Stent revascularisation comprise 30% and coronary artery bypass grafting 17%. Peri-angiographic complications were low (significant bleed 1%, stroke 1%, contrast nephropathy 3.6%, death 1.8%). Patients who underwent ICA had reduced all-cause-mortality (OR 0.55, 95% CI 0.38-0.79, p=0.001) and MACE (OR 0.61, 95% CI 0.43-0.84, p=0.003) compared to medical therapy alone. In the Auckland region, over half of patients with advanced CKD presenting with ACS undergo ICA which appears to reduce mortality and MACE rates compared to medical therapy alone.