Impact of an Early Invasive Strategy versus Conservative Strategy for Unstable Angina and Non-ST Elevation Acute Coronary Syndrome in Patients with Chronic Kidney Disease: A Systematic Review.

Catriona Shaw,Jasmine Lee,Damian Fogarty,Dorothea Nitsch,Claire C Sharpe,Carmine Pizzi

doi:10.1371/journal.pone.0153478

Abstract

BackgroundClinical practice guidelines support an early invasive approach after NSTE-ACS in patients with chronic kidney disease (CKD). There is no direct randomised controlled trial evidence in the CKD population, and whether the benefit of an early invasive approach is maintained across the spectrum of severity of CKD remains controversial.MethodsWe conducted a systematic review to evaluate the association between an early invasive approach and all-cause mortality in patients with CKD. We searched MEDLINE and EMBASE (1990-May 2015) and article reference lists. Data describing study design, participants, invasive management strategies, renal function, all-cause mortality and risk of bias were extracted.Results3,861 potentially relevant studies were identified. Ten studies, representing data on 147,908 individuals with NSTE-ACS met the inclusion criteria. Qualitative heterogeneity in the definitions of early invasive approach, comparison groups and renal dysfunction existed. Meta-analysis of the RCT derived and observational data were generally supportive of an early invasive approach in CKD (RR0.76 (95% CI 0.49–1.17) and RR0.50 (95%CI 0.42–0.59) respectively). Meta-analysis of the observational studies demonstrated a large degree of heterogeneity (I2 79%) driven in part by study size and heterogeneity across various kidney function levels.ConclusionsThe observational data support that an early invasive approach after NSTE-ACS confers a survival benefit in those with early-moderate CKD. Local opportunities for quality improvement should be sought. Those with severe CKD and the dialysis population are high risk and under-studied. Novel and inclusive approaches for CKD and dialysis patients in cardiovascular clinical trials are needed.

Highlights

In non ST elevation acute coronary syndrome (NSTE-ACS) an early invasive approach is the recommended strategy in patients with hemodynamic instability, refractory angina, electrical instability, or an elevated risk for clinical events [1]
The observational data support that an early invasive approach after NSTE-ACS confers a survival benefit in those with early-moderate chronic kidney disease (CKD)
All the cohort studies that reported multivariable adjusted results reported a survival benefit associated with an early invasive strategy compared to a conservative strategy in those with CKD (Table 1 and Fig 2) [4, 8,9,10, 12,13,14]

Summary

Introduction

In non ST elevation acute coronary syndrome (NSTE-ACS) an early invasive approach (coronary angiography followed by revascularisation if appropriate) is the recommended strategy in patients with hemodynamic instability, refractory angina, electrical instability, or an elevated risk for clinical events [1]. Patients with chronic kidney disease (CKD) are recognised as high risk for poor outcomes after NSTE-ACS, analyses of real world cohorts have consistently suggested that they are less likely to undergo angiography or revascularisation than those with normal kidney function [2,3,4]. The reasons behind these practice patterns are complex. Clinical practice guidelines support an early invasive approach after NSTE-ACS in patients with chronic kidney disease (CKD). There is no direct randomised controlled trial evidence in the CKD population, and whether the benefit of an early invasive approach is maintained across the spectrum of severity of CKD remains controversial

Methods

Results

Conclusion