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Early Angiography in Patients with Chronic Kidney Disease: A Collaborative Systematic Review

David M. Charytan^*, Lars Wallentin, Bo Lagerqvist, Rudolf Spacek, Robbert J. De Winter^||, Noam M. Stern^*, Eugene Braunwald^¶, Christopher P. Cannon^¶, and Niteesh K. Choudhry^**

^* Renal Division and Clinical Biometrics, ^¶ Cardiovascular Division, and ^** Division of Pharmacoepidemiology and Pharmacoeconomics and Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Uppsala Clinical Research Center and Cardiothoracic Center, University Hospital, Uppsala, Sweden; ^|| Department of Cardiology, Academic Medical Center, Amsterdam, Netherlands; and Cardiocenter, University Hospital Kralovske Vinohrady, Third Medical School of Charles University Prague, Prague, Czech Republic

Correspondence: Dr. David Charytan, Renal Division and Clinical Biometrics, Brigham and Women's Hospital, 1620 Tremont Street, 3rd Floor, Boston, MA 02120. Phone: 617-525-7718; Fax: 617-525-7752; E-mail: dcharytan{at}partners.org

Background and objectives: In the general population, an early invasive strategy of routine coronary angiography is superior to a conservative strategy of selective angiography in patients who are admitted with unstable angina or non–ST segment elevation myocardial infarction (MI), but the effectiveness of this strategy in individuals with chronic kidney disease (CKD) is uncertain.

Design, setting, participants, & measurements: We conducted a collaborative meta-analysis with data provided by the main authors of identified trials to estimate the effectiveness of early angiography in patients with CKD. The Cochrane, Medline, and EMBASE databases were searched to identify randomized trials that compared invasive and conservative strategies in patients with unstable angina or non-ST MI. Pooled risks ratios were estimated using data from enrolled patients with estimated GFR <60 ml/min per 1.73 m².

Results: Five randomized trials that enrolled 1453 patients with CKD were included. An early invasive strategy was associated with nonsignificant reductions in all-cause mortality, nonfatal MI, and a composite of death or nonfatal MI. The invasive strategy significantly reduced rehospitalization.

Conclusions: This collaborative study suggests that the benefits of an early invasive strategy are preserved in patients with CKD and that an early invasive approach reduces the risk for rehospitalization and is associated with trends of reduction in the risk for death and nonfatal re-infarction in patients with CKD. Coronary angiography should be considered for patients who have CKD and are admitted with non–ST elevation acute coronary syndromes.

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				C. P. Cannon Should We Manage Patients With Non-ST Segment Elevation Myocardial Infarction With Renal Failure With an Invasive Strategy? Circulation, September 8, 2009; 120(10): 828 - 830. [Full Text] [PDF]