Patients with severe chronic kidney disease benefit from early revascularization after acute coronary syndrome

BackgroundEarly revascularization is associated with improved outcomes after non-ST-elevation acute coronary syndrome (ACS). It is unclear whether its benefits exist in patients with ACS and advanced chronic kidney disease (CKD), because these patients are often sub-optimally treated and excluded from clinical trials.MethodsWe undertook meta-analyses of short- and long-term mortality outcomes in comparative studies examining the effectiveness of early revascularization in patients with ACS and CKD (as estimated by Glomerular Filtration Rate, eGFR). A literature search between 1995 and 2010 identified 7 published reports enrolling 23,234 patients with at least mild reduction in eGFR (< 90 mL/min/1.73 m2), of whom 6276 and 16,958 patients received early revascularization versus initial medical therapy, respectively. Summary odds ratios (OR) and their 95% Confidence Intervals (CIs) were calculated using the random-effects models. Sensitivity analyses were performed by one-study removal, and publication bias was assessed by the funnel plot analysis.ResultsEarly revascularization was associated with a reduction in 1-year mortality compared to initial medical therapy (OR = 0.46, 95% CI 0.26-0.82, P = 0.008) among ACS patients with eGFR < 60 mL/min/1.73 m2. The mortality reduction with early revascularization occurred upfront (short term mortality OR = 0.69, 95% CI 0.56-0.87, P = 0.001), persisted at 3 years (OR = 0.54, 95% CI 0.31-0.96, P = 0.037), was evident across all CKD stages (including dialysis patients), and was independent of the influence of any single study.ConclusionsEarly revascularization after ACS is associated with reduced mortality in appropriately-selected patients with CKD, including those with severe CKD or receiving dialysis.