Brief report

Effects of renal insufficiency on early invasive management in patients with acute coronary syndromes (The TACTICS-TIMI 18 Trial)

Patients with chronic kidney disease (CKD) have traditionally been excluded from randomized trials. We aimed to compare percutaneous coronary intervention versus conservative management, and early intervention (EI; within 24 hours of admission) versus delayed intervention (DI; after 24 to 72 hours of admission) in patients with non–ST-segment elevation myocardial infarction (NSTEMI) and concomitant CKD. An electronic literature search was performed to search for studies comparing invasive management to conservative management or EI versus DI in patients with NSTEMI with CKD. The primary outcome was all-cause mortality; secondary outcomes were acute kidney injury (AKI) or dialysis, major bleeding, and recurrent MI. Hazard ratios (HRs) for the primary outcome and odds ratios for secondary outcomes were pooled in random-effects meta-analyses. Eleven studies (140,544 patients) were analyzed. Invasive management was associated with lower mortality than conservative management (HR 0.62, 95% confidence interval 0.57 to 0.67, p <0.001, I² = 47%), with consistent benefit across all CKD stages, except CKD 5. There was no significant mortality difference between EI and DI, but subgroup analyses showed significant benefit for EI in stage 1 to 2 CKD (HR 0.75, 95% confidence interval 0.58 to 0.97, p = 0.03, I² = 0%), with no significant difference in stage 3 and 4 to 5 CKD. Invasive strategy was associated with higher odds of AKI or dialysis and major bleeding, but lower odds of recurrent MI compared with conservative management. In conclusion, in patients with NSTEMI and CKD, an invasive strategy is associated with significant mortality benefit over conservative management in most patients with CKD, but at the expense of higher risk of AKI and bleeding. EI appears to benefit those with early stages of CKD. Trial Registration: PROSPERO CRD42023405491.

The guideline for coronary artery revascularization replaces the 2011 coronary artery bypass graft surgery and the 2011 and 2015 percutaneous coronary intervention guidelines, providing a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization as well as the supporting documentation to encourage their use.

A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered.

Coronary artery disease remains a leading cause of morbidity and mortality globally. Coronary revascularization is an important therapeutic option when managing patients with coronary artery disease. The 2021 coronary artery revascularization guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with coronary artery disease who are being considered for coronary revascularization, with the intent to improve quality of care and align with patients’ interests.

Prophylactic hemodialysis after coronary angiography in patients with chronic kidney disease (CKD) prevents contrast nephropathy; however, the one-year outcomes are unclear. This study aimed to investigate the one-year outcomes of prophylactic hemodialysis against standard treatment in patients with CKD who underwent coronary angiography.

A cohort study of 359 patients with CKD, coronary artery disease (CAD), and serum creatinine levels of 176.8–530.4 μmol/L, who were referred for elective coronary angiography was conducted. Propensity score matching identified 118 patient pairs for outcome comparisons. The hemodialysis group underwent prophylactic hemodialysis after coronary angiography, whereas the control group received standard treatment. The study's primary outcome was free from dialysis was considered the primary outcome, whereas the secondary outcome was overall survival. Unadjusted estimates of the probability of free from dialysis and overall survival were computed using Kaplan–Meier survival curves and log-rank tests. Cox proportional-hazards regression models were used in determining the risk factors associated with ESRD and mortality.

During a mean 9.3 months follow-up duration, the hemodialysis group had significantly better free from dialysis (85.6% vs. 64.4%; P = 0.002) and overall survival (85.4% vs. 78.5%; P = 0.008) rates than the control group. Cox proportional-hazards regression analyses of the propensity score-matched patients showed that the hemodialysis group had reduced risks for ESRD and mortality (hazard ratios, 0.32 and 0.48, respectively).

Prophylactic Hemodialysis following coronary angiography was associated with reduced ESRD and mortality risks in CKD patients with CAD, who did not routinely undergo dialysis.

The efficacy and safety of pharmacoinvasive strategy following fibrinolysis for ST-elevation myocardial infarction (STEMI) in relation to renal function have not been established.

Using patient-level data from 4 randomized controlled trials, we examined the efficacy and safety of pharmacoinvasive versus standard treatment after fibrinolysis for STEMI. Patients were stratified based on the estimated glomerular filtration rate (eGFR) on presentation (<60 mL/min/1.73 m² vs ≥60 mL/min/1.73 m²). The primary outcome was the composite of death or reinfarction at 30 days.

Of 2,029 patients, 457 (23%) had an eGFR< 60 mL/min/1.73 m². Patients with eGFR< 60 mL/min/1.73 m² were older and had higher Thrombolysis in Myocardial Infarction risk scores. Compared with patients with eGFR ≥ 60 mL/min/1.73 m², patients with renal dysfunction had higher rates of the primary outcome (5.3% vs 11.8%, respectively; P < .001). There was no significant heterogeneity in the treatment effect of pharmacoinvasive strategy on the primary outcome (P heterogeneity = .73) or the rate of death or reinfarction at 1 year (P heterogeneity = .64) in relation to eGFR. Patients with renal dysfunction had higher rates of in-hospital major bleeding compared with patients with eGFR ≥60 mL/min/1.73 m² (7.7% vs 4.3%, respectively; P = .004); however, there was no difference in bleeding events between treatment arms in the overall cohort or in relation to eGFR (P heterogeneity = .67).

Renal impairment is associated with increased rates of adverse events in STEMI patients treated with fibrinolysis. However, the safety and efficacy of pharmacoinvasive strategy are preserved in patients with renal impairment on presentation.

Ischemic heart disease remains a major cause of mortality and morbidity worldwide. Over the past three decades, advances in prevention, diagnosis, and pharmacotherapy coupled with increased rates of revascularization have substantially improved outcomes in patients with acute coronary syndromes (ACS). These trends have led to the emergence of non-ST elevation ACS (NSTE-ACS) with increasingly heterogeneous risk profiles as the predominant presentation of ACS in contemporary cohorts. Accurate early risk assessment of ACS patients represents an ongoing clinical challenge, with underappreciation of risk posing a major barrier to the optimal use of evidence-based therapies. Following a survey of the evolution of NSTE-ACS outcomes over the past three decades, this article will review the prognostic value of individual clinical indicators generally available to physicians at initial presentation, compare validated bedside clinical risk prediction tools, and consider the role of further testing during hospitalization.