Abstract
BackgroundInternational 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.MethodsWe 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.FindingsOf 35 881 patients diagnosed with NSTE-ACS, eGFR of <60 ml/minute/1.73 m2 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 m2, patients with an eGFR between 45–59 ml/minute/1.73 m2 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 m2 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).InterpretationEarly 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.
Highlights
Thirty to forty percent of patients presenting with NSTE-ACS have renal impairment [1]
Data was missing regarding coronary angiography in 4.5%, management strategy in 18.3% and for mortality in,1% of patients. 15.8% of individuals excluded from the complete case analysis due to incomplete data died compared with 19.0% of those included (Appendix S3)
In this study of over 35 000 individuals with NSTE-ACS in England and Wales, admitted to National Health Service (NHS) hospitals between 2008 and 2010, we have demonstrated that renal dysfunction is common and that patients with renal impairment are much less likely to undergo inpatient diagnostic coronary angiography than patients with normal renal function
Summary
Thirty to forty percent of patients presenting with NSTE-ACS have renal impairment [1]. Several reports from outside the UK suggest that patients with renal dysfunction are significantly less likely to undergo angiography or subsequent revascularisation [1,8,9,10]. Reasons for this discrepancy, between guidelines and practice, are likely to be complex. 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. 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
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