Re: Renal outcomes associated with invasive versus conservative management of acute coronary syndrome: propensity matched cohort study
James MT, et al’s paper is timely important in delineating the association of early invasive management of acute coronary syndrome with adverse renal outcomes and survival, and determining whether the risks or benefits of early invasive management differ in people with pre-existing chronic kidney disease.1 Early invasive management was associated with an increased risk of acute kidney injury, but no difference in the risk of acute kidney injury requiring dialysis. Over a median follow-up of 2.5 years, the risk of progression to end stage renal disease did not differ between the groups; however, early invasive management was associated with reduced long term mortality. These associations were consistent among people with pre-existing reduced estimated glomerular filtration rate and with alternate definitions for early invasive management.
Pre-existing reduced estimated glomerular filtration rate and end stage renal disease are independent risk factors for cardiovascular disease and further these conditions increase complications such as contrast-dye induced nephropathy following invasive coronary procedures.2,3 Therefore, in a real world, invasive coronary procedures are often delayed or underused in these patients despite of the benefits on randomized clinical trials4,5 and current guidelines recommending early invasive management for high risk patients with non-ST elevation acute coronary syndrome.6 One of the reasons is some studies suggest that people with acute kidney injury are at a higher risk of chronic kidney disease progression and end stage renal disease.7,8
.
In this point, the current study provides an important clinical implication. Thus, there is a strong scientific rationale for recommending that early invasive management should be performed in patients with non-ST elevation acute coronary syndrome regardless of pre-existing chronic kidney disease.
Funding: None, Disclosures: None
REFERENCES
1. James MT, Tonelli M, Ghali WA, Knudtson ML, Faris P, Manns BJ, et al; Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) and Alberta Kidney Disease Network Investigators. Renal outcomes associated with invasive versus conservative management of acute coronary syndrome: propensity matched cohort study. BMJ 2013;347:f4151.
2. Nikolsky E, Mehran R, Turcot D, Aymong ED, Mintz GS, Lasic Z, et al. Impact of chronic kidney disease on prognosis of patients with diabetes mellitus treated with percutaneous coronary intervention. Am J Cardiol 2004;94:300-5.
3. Papafaklis MI, Naka KK, Papamichael ND, Kolios G, Sioros L, Sclerou V, et al. The impact of renal function on the long-term clinical course of patients who underwent percutaneous coronary intervention. Catheter Cardiovasc Interv 2007;69:189-97.
4. Fox K, Poole-Wilson P, Clayton T, Henderson R, Shaw T, Wheatley D, et al. 5-year
outcome of an interventional strategy in non-ST-elevation acute coronary syndrome: the
British Heart Foundation RITA 3 randomised trial. Lancet 2005;366:914-20.
5. Damman P, van Geloven N, Wallentin L, Lagerqvist B, Fox KA, Clayton T, et al. Timing of angiography with a routine invasive strategy and long-term outcomes in non-ST-segment elevation acute coronary syndrome: a collaborative analysis of individual patient data from the FRISC II (Fragmin and Fast Revascularization During Instability in Coronary Artery Disease), ICTUS (Invasive Versus Conservative Treatment in Unstable Coronary Syndromes), and RITA-3 (Intervention Versus Conservative Treatment Strategy in Patients With Unstable Angina or Non-ST Elevation Myocardial Infarction) Trials. JACC Cardiovasc Interv 2012;5:191-9.
6. Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction-executive summary. J Am Coll Cardiol 2007;50:652-726.
7. Goldberg A, Kogan E, Hammerman H, Markiewicz W, Aronson D. The impact of transient and persistent acute kidney injury on long-term outcomes after acute myocardial infarction. Kidney Int 2009;76:900-6.
8. Bruetto RG, Rodrigues FB, Torres US, Otaviano AP, Zanetta DM, Burdmann EA. Renal function at hospital admission and mortality due to acute kidney injury after myocardial infarction. PLoS One 2012;7:e35496.
Rapid Response:
Re: Renal outcomes associated with invasive versus conservative management of acute coronary syndrome: propensity matched cohort study
James MT, et al’s paper is timely important in delineating the association of early invasive management of acute coronary syndrome with adverse renal outcomes and survival, and determining whether the risks or benefits of early invasive management differ in people with pre-existing chronic kidney disease.1 Early invasive management was associated with an increased risk of acute kidney injury, but no difference in the risk of acute kidney injury requiring dialysis. Over a median follow-up of 2.5 years, the risk of progression to end stage renal disease did not differ between the groups; however, early invasive management was associated with reduced long term mortality. These associations were consistent among people with pre-existing reduced estimated glomerular filtration rate and with alternate definitions for early invasive management.
Pre-existing reduced estimated glomerular filtration rate and end stage renal disease are independent risk factors for cardiovascular disease and further these conditions increase complications such as contrast-dye induced nephropathy following invasive coronary procedures.2,3 Therefore, in a real world, invasive coronary procedures are often delayed or underused in these patients despite of the benefits on randomized clinical trials4,5 and current guidelines recommending early invasive management for high risk patients with non-ST elevation acute coronary syndrome.6 One of the reasons is some studies suggest that people with acute kidney injury are at a higher risk of chronic kidney disease progression and end stage renal disease.7,8
.
In this point, the current study provides an important clinical implication. Thus, there is a strong scientific rationale for recommending that early invasive management should be performed in patients with non-ST elevation acute coronary syndrome regardless of pre-existing chronic kidney disease.
Funding: None, Disclosures: None
REFERENCES
1. James MT, Tonelli M, Ghali WA, Knudtson ML, Faris P, Manns BJ, et al; Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) and Alberta Kidney Disease Network Investigators. Renal outcomes associated with invasive versus conservative management of acute coronary syndrome: propensity matched cohort study. BMJ 2013;347:f4151.
2. Nikolsky E, Mehran R, Turcot D, Aymong ED, Mintz GS, Lasic Z, et al. Impact of chronic kidney disease on prognosis of patients with diabetes mellitus treated with percutaneous coronary intervention. Am J Cardiol 2004;94:300-5.
3. Papafaklis MI, Naka KK, Papamichael ND, Kolios G, Sioros L, Sclerou V, et al. The impact of renal function on the long-term clinical course of patients who underwent percutaneous coronary intervention. Catheter Cardiovasc Interv 2007;69:189-97.
4. Fox K, Poole-Wilson P, Clayton T, Henderson R, Shaw T, Wheatley D, et al. 5-year
outcome of an interventional strategy in non-ST-elevation acute coronary syndrome: the
British Heart Foundation RITA 3 randomised trial. Lancet 2005;366:914-20.
5. Damman P, van Geloven N, Wallentin L, Lagerqvist B, Fox KA, Clayton T, et al. Timing of angiography with a routine invasive strategy and long-term outcomes in non-ST-segment elevation acute coronary syndrome: a collaborative analysis of individual patient data from the FRISC II (Fragmin and Fast Revascularization During Instability in Coronary Artery Disease), ICTUS (Invasive Versus Conservative Treatment in Unstable Coronary Syndromes), and RITA-3 (Intervention Versus Conservative Treatment Strategy in Patients With Unstable Angina or Non-ST Elevation Myocardial Infarction) Trials. JACC Cardiovasc Interv 2012;5:191-9.
6. Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction-executive summary. J Am Coll Cardiol 2007;50:652-726.
7. Goldberg A, Kogan E, Hammerman H, Markiewicz W, Aronson D. The impact of transient and persistent acute kidney injury on long-term outcomes after acute myocardial infarction. Kidney Int 2009;76:900-6.
8. Bruetto RG, Rodrigues FB, Torres US, Otaviano AP, Zanetta DM, Burdmann EA. Renal function at hospital admission and mortality due to acute kidney injury after myocardial infarction. PLoS One 2012;7:e35496.
Competing interests: No competing interests