Baylor University Medical Center Proceedings October 2017 - 400

Percutaneous coronary intervention and inpatient mortality
in patients with advanced chronic kidney disease presenting
with acute coronary syndrome
Brijesh Patel, DO, Mahek Shah, MD, Raman Dusaj, MD, Sharon Maynard, MD, and Nainesh Patel, MD

Chronic kidney disease (CKD) is an important risk factor for coronary
artery disease, yet patients with CKD are less likely to undergo coronary
angiography and percutaneous coronary intervention (PCI). We retrospectively analyzed the 2006-2012 National Inpatient Sample Database to
examine the temporal trends in coronary angiography and PCI among
patients without CKD, with advanced CKD (CKD III-V), and with end-stage
renal disease (ESRD) presenting with unstable angina/non-ST elevation
myocardial infarction (NSTE-ACS) and ST-elevation myocardial infarction
(STEMI). A total of 579,747 admissions for NSTE-ACS and 293,950 admissions for STEMI were studied. Patients with NSTE-ACS were less likely
to undergo coronary angiography/PCI than those with STEMI, irrespective
of CKD. Between 2006 and 2012, performance of PCI saw an uptrend
across all CKD groups with NSTE-ACS (no CKD, 29.9%-36.8%; CKD III-V,
18.2%-21.5%; ESRD, 19.8%-27.5%; all Ptrends < 0.01) and STEMI (no
CKD, 57.0%-76.0%; CKD III-V, 33.0%-52.6%; ESRD, 29.9%-42.9%;
Ptrends < 0.01). Multivariate analyses revealed that PCI was associated
with a lower risk of hospital mortality across all degrees of CKD in both
NSTE-ACS (adjusted odds ratios: no CKD, 0.44; CKD III-V, 0.48; ESRD,
0.46; P < 0.01) and STEMI (no CKD, 0.35; CKD III-V, 0.50; ESRD, 0.52;
P < 0.01). Performance of PCI increased over time among patients
presenting with NSTE-ACS and STEMI in the presence of advanced CKD
and independently predicted lower in-hospital mortality.

C

hronic kidney disease (CKD) is associated with an increased risk for development of complex coronary artery
disease. At the same time, coronary angiography (CAG)
carries a high risk of contrast-induced nephropathy
(CIN) in this population. Patients with CKD experience higher
rates of bleeding, drug-related adverse events, strokes, and need
for dialysis, as well as longer hospital stays and increased mortality following coronary revascularization when compared to
patients with normal kidney function (1). The objective of our
study was to examine temporal trends in performance of CAG
and percutaneous coronary intervention (PCI) among patients
presenting with acute coronary syndrome (ACS) according to
their baseline renal function.
METHODS
We queried the unweighted 2006-2012 National Inpatient
Sample (2) to identify patients aged ≥18 years with a primary

400

diagnosis of acute myocardial infarction (AMI) (ICD-9CM
codes 410x and 411.1). Patients were separated into three categories depending on baseline renal function: no CKD, CKD
stage III-V, and end-stage renal disease (ESRD) on chronic
dialysis (ICD-9CM codes: 585.3-6, 585.9). A chi-square test
was used to compare categorical variables. Trend analysis was
performed using the Mantel-Haenszel linear test of trend. We
created separate multivariable logistic regression models based
on the degree of CKD (no CKD, CKD III-V, ESRD) within
the group of patients presenting with non-ST elevation myocardial infarction (NSTE)-ACS and ST-elevation myocardial
infarction (STEMI) to evaluate the relationship between performance of PCI and in-hospital mortality. Within these models,
we adjusted for several risk factors, including patient characteristics (demographics, comorbidities), hospital characteristics (bed
size, location, and teaching status), admission characteristics
(year, weekend), and primary insurance payer.
RESULTS
A total of 579,747 admissions for NSTE-ACS and 293,950
admissions for STEMI were studied. Patients with advanced
stages of CKD had higher proportions of women and comorbidities, but lesser proportions of Caucasians, compared to patients
with normal baseline renal function in both the NSTE-ACS
and STEMI groups (Tables 1 and 2). As shown in Figure 1, use
of both CAG and PCI increased for NSTE-ACS and STEMI
during the study duration, irrespective of CKD status. However,
patients with CKD and ESRD were less likely to undergo CAG/
PCI than those without CKD. By the year 2012, two-thirds of
patients with CKD or ESRD underwent CAG. Interestingly,
patients with CKD III-V were less likely to undergo CAG than
ESRD patients when presenting with NSTE-ACS (45.7% vs.
56.4%) in 2012. For any given year, NSTE-ACS patients were
less likely to undergo CAG/PCI than patients with STEMI, regardless of CKD status. Even though two-thirds of NSTE-ACS
From the Departments of Cardiology (Patel, Shah, Dusaj, Patel) and Nephrology
(Maynard), Lehigh Valley Hospital, Allentown, Pennsylvania.
The study was supported by Dorothy Rider Pool Trust Fund Grant #1573-007
(Lehigh Valley Hospital, Allentown, PA).
Corresponding author: Brijesh Patel, DO, Lehigh Valley Hospital, 1250 S. Cedar
Crest Blvd., Ste. 301, Allentown, PA 18103 (e-mail: b2patel@gmail.com).
Proc (Bayl Univ Med Cent) 2017;30(4):400-403



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