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Inpatient Coronary Angiography and Revascularisation following Non-ST-Elevation Acute Coronary Syndrome in Patients with Renal Impairment: A Cohort Study Using the Myocardial Ischaemia National Audit Project
PLoS ONE, Volume: 9, Issue: 6, Start page: e99925
Swansea University Author: Clive Weston
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DOI (Published version): 10.1371/journal.pone.0099925
Guidelines support early invasive management that includes coronary angiography and revascularisation) for non-ST-elevation acute coronary syndrome (NSTE-ACS) in patients with renal impairment. We described NHS practice to determine whether the severity of renal dysfunction influenced the provision...
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Guidelines support early invasive management that includes coronary angiography and revascularisation) for non-ST-elevation acute coronary syndrome (NSTE-ACS) in patients with renal impairment. We described NHS practice to determine whether the severity of renal dysfunction influenced the provision of angiography and modified the association between early revascularisation and survival.We anaylsed a cohort, using multivariable logistic regression and propensity score analyses, from the Myocardial Ischaemia National Audit Project (MINAP) for patients with NSTE-ACS in England or Wales between 2008 and 2010. Of 35 881 patients diagnosed with NSTE-ACS, eGFR of less than 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,of more than 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 less than 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 thosemanaged medically after coronary angiography (adjusted OR 0.66, 95%CI 0.57–0.77), with no evidence of modification byrenal function (p interaction = 0.744).Early revascularisation offers 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.
Acute coronary syndrome; renal impairment; heart attack; outcome
Swansea University Medical School