Despite underrepresentation in clinical trials of acute coronary syndrome treatments, a recent study suggests treatment strategies and outcomes in chronic kidney disease patients with ST-elevation myocardial infarctions (STEMI) have improved over time.
Advanced chronic kidney disease (CKD) is known to negatively impact prognosis in patients with coronary artery disease (CAD) and cardiovascular disease (CVD), but there are limited data on the efficacy and safety of treatments for acute coronary syndromes (ACS) in patients with CKD. A recent study assessed temporal treatment practices in patients presenting with ST-elevation myocardial infarctions (STEMI) to gauge their safety and efficacy in this patient population.
Patients with CKD are at an increased risk of developing CAD or CVD, with a glomerular filtration rate (GFR) of less than 60 ml/min generally indicating a significantly greater risk relative to others. CAD and CVD are the leading causes of mortality and morbidity in patients with CKD when present, and CKD is associated with atypical symptoms and complications related to ACS.
Despite the known associations, patients with advanced CKD are often excluded from or underrepresented in randomized clinical trials of ACS treatments, in part due to increased bleeding rates reported in patients with CKD, study authors noted.
In the current study, which was published in BMC Cardiovascular Disorders, data from a real-world clinical registry were used to assess the treatment of patients with advanced CKD and STEMI over 14 years in the Bremen region of Germany. Data from 2006 to 2019 were analyzed, and advanced CKD was defined as a GFR of less than 45 ml/min.
There were 9605 patients with recorded STEMI in the registry, 1018 of whom (10.6%) had advanced CKD with mean (SD) creatinine levels of 2.22 (4.2) mg/dl at admission. The rate of primary percutaneous coronary intervention (pPCI) was 84.1% in patients with advanced CKD versus 94.1% in other STEMI patients, and all-cause mortality at 1 year post-STEMI was 44.4% in patients with advanced CKD versus 3.6% in those without it.
Between 2015-2019, patients with CKD were more likely to be treated with pPCI (90.3%) versus in 2006-2010 (75.8%). They were also more likely to be treated with P2Y12 inhibitors ticagrelor or prasugrel in the more recent time frame (59.6%) versus in 2006-2010 (1.7%). The same trend was seen in treatment of advanced CKD patients with drug-eluting stents (DES) (90.7% in 2015-2019 versus 1.3% in 2006-2020).
Over the 14-year study period, a multivariate model showed a decline in adverse ischemic events, although there was an increase in rates of cumulative bleedings over the course of the observation period. However, both P2Y12 inhibitor treatment and DES use were associated with a decrease in ischemic events at 1 year after STEMI. Rates of mortality at 1 year and acute kidney injury did not significantly change over the course of the study period.
The study’s limitations included the lack of assessment of causal relationships given its observational nature, as well as the definition of kidney disease, which was estimated with the reported initial renal function and may not truly reflect renal function prior to the index STEMI.
Overall, study authors concluded that in recent years, patients presenting with CKD and STEMI were more likely receive DES treatment and more potent P2Y12 inhibition than in years prior.
“These changes probably have contributed to the decline in ischemic events and the increase in bleedings within 1 year after STEMI while overall mortality at 1 year remained unchanged for this high-risk patient group,” study authors wrote. While mortality remained high throughout the study period, they concluded that new therapeutic strategies in STEMI patients can be safe and effective in the subgroup of patients with advanced CKD.
Schmucker J, Fach A, Osteresch R, et al. Temporal trends in treatment strategies and clinical outcomes among patients with advanced chronic kidney disease and ST-elevation myocardial infarctions: results from the Bremen STEMI registry. BMC Cardiovasc Disord. 2022;22(1):142. doi:10.1186/s12872-022-02573-1