The aim of this study was to compare clinical outcomes among early invasive (EI),
deferred invasive (DI), and conservative strategies in patients with acute non–ST-segment
elevation myocardial infarction (NSTEMI) and chronic kidney disease (CKD). High-risk
patients with NSTEMI are believed to fare better with an EI strategy, but the optimal
treatment for patients with NSTEMI and CKD is not known. In total 5,185 patients with
acute NSTEMI were enrolled from the Korea Acute Myocardial Infarction Registry and
followed for 1 year. Patients were divided into EI, DI, and conservative treatment
groups and classified into 4 stages using references from the National Kidney Foundation.
The invasive EI and DI groups were compared to the conservative groups, and the EI
and DI groups were compared according to each renal function stage. At 1-year follow-up,
mortality rates in the conservative group were significantly higher than in the invasive
groups except for the severe CKD group. The benefit of the EI over the DI strategy,
although there were no significant differences between the 2 groups, tended to decrease
as renal function decreased. In conclusion, in the management of NSTEMI, an invasive
strategy decreased mortality compared to a conservative strategy except for severe
CKD. In the timing of an invasive strategy, the EI strategy was observed to be superior
to the DI strategy in patients with mild CKD; however, this tendency reversed as renal
function decreased. When patients with NSTEMI have severe CKD, a conservative or DI
strategy with prescription of cardioprotective medications and prevention of further
deterioration in renal function should be considered.
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References
- Clinical outcomes and therapeutic strategy in patients with acute myocardial infarction according to renal function: data from the Korean Acute Myocardial Infarction Registry.Circ J. 2008; 72: 1410-1418
- Acute myocardial infarction and renal dysfunction: a high-risk combination.Ann Intern Med. 2002; 137: 563-570
- Influence of renal function on the effects of early revascularization in non–ST-elevation myocardial infarction: data from the Swedish Web-System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies (SWEDEHEART).Circulation. 2009; 120: 851-858
- Effects of renal insufficiency on early invasive management in patients with acute coronary syndromes (the TACTICS-TIMI 18 Trial).Am J Cardiol. 2002; 90: 1246-1249
- Early invasive treatment benefits patients with renal dysfunction in unstable coronary artery disease.Am Heart J. 2006; 152: 1052-1058
- Current management of acute myocardial infarction: Experience from the Korea Acute Myocardial Infarction Registry.J Cardiol. 2010; 56: 1-7
- ACC/AHA 2007 guidelines for the management of patients with unstable angina/non ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non ST-Elevation Myocardial Infarction): developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons: endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine.Circulation. 2007; 116: e148-e304
- Guidelines for the diagnosis and treatment of non–ST-segment elevation acute coronary syndromes.Eur Heart J. 2007; 28: 1598-1660
- Evaluation of prolonged antithrombotic pretreatment (“cooling-off” strategy) before intervention in patients with unstable coronary syndromes: A randomized controlled trial.JAMA. 2003; 290: 1593-1599
- Invasive compared with non-invasive treatment in unstable coronary-artery disease: FRISC II prospective randomised multicentre study.Lancet. 1999; 354: 708-715
- Interventional versus conservative treatment for patients with unstable angina or non–ST-elevation myocardial infarction: the British Heart Foundation RITA 3 randomised trial.Lancet. 2002; 360: 743-751
- Comparison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor tirofiban.N Engl J Med. 2001; 344: 1879-1887
- Value of first day angiography/angioplasty in evolving non-ST segment elevation myocardial infarction: an open multicenter randomized trial.Eur Heart J. 2002; 23: 230-238
- 5-Year outcome of an interventional strategy in non-ST-elevation acute coronary syndrome: the British Heart Foundation RITA 3 randomised trial.Lancet. 2005; 366: 914-920
- K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification.Am J Kidney Dis. 2002; 39: S1-S266
- Revised equations for estimated GFR from serum creatinine in Japan.Am J Kidney Dis. 2009; 53: 982-992
- The TIMI risk score for unstable angina/non-ST elevation MI: a method for prognostication and therapeutic decision making.JAMA. 2000; 284: 835-842
- Validity of a risk-prediction tool for hospital mortality: the Global Registry of Acute Coronary Events.Am Heart J. 2009; 157: 1097-1105
- Early invasive versus selectively invasive management for acute coronary syndromes.N Engl J Med. 2005; 353: 1095-1104
- Routine vs selective invasive strategies in patients with acute coronary syndromes: a collaborative meta-analysis of randomized trials.JAMA. 2005; 293: 2908-2917
- Benefit of early invasive therapy in acute coronary syndromes: a meta-analysis of contemporary randomized clinical trials.J Am Coll Cardiol. 2006; 48: 1319-1325
- Long-term outcome of a routine versus selective invasive strategy in patients with non–ST-segment elevation acute coronary syndrome a meta-analysis of individual patient data.J Am Coll Cardiol. 2010; 55: 2435-2445
- Creatinine clearance and adverse hospital outcomes in patients with acute coronary syndromes: findings from the Global Registry of Acute Coronary Events (GRACE).Heart. 2003; 89: 1003-1008
- Optimal timing of intervention in non–ST-segment elevation acute coronary syndromes: insights from the CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA guidelines) Registry.Circulation. 2005; 112: 3049-3057
- Relation of timing of cardiac catheterization to outcomes in patients with non–ST-segment elevation myocardial infarction or unstable angina pectoris enrolled in the multinational global registry of acute coronary events.Am J Cardiol. 2005; 95: 1397-1403
- Time to coronary angiography and outcomes among patients with high-risk non ST-segment elevation acute coronary syndromes: results from the SYNERGY trial.Circulation. 2007; 116: 2669-2677
- Early versus delayed invasive intervention in acute coronary syndromes.N Engl J Med. 2009; 360: 2165-2175
- Association of renal insufficiency with treatment and outcomes after myocardial infarction in elderly patients.Ann Intern Med. 2002; 137: 555-562
- Acute renal failure after coronary intervention: incidence, risk factors, and relationship to mortality.Am J Med. 1997; 103: 368-375
- Impact of end-stage renal disease on clinical and angiographic outcomes after coronary stenting.Am J Cardiol. 2000; 86: 485-489
Article Info
Publication History
Accepted:
March 9,
2011
Received in revised form:
March 9,
2011
Received:
January 2,
2011
Footnotes
This study was performed with the support of the Korean Society of Circulation, Seoul, Republic of Korea, in honor of its 50th anniversary and Grant A084869 from the Korea Healthcare Technology R&D Project, Ministry for Health, Welfare & Family Affairs , Seoul, Republic of Korea.
Identification
Copyright
© 2011 Elsevier Inc. Published by Elsevier Inc. All rights reserved.
