Key result
Modern STEMI therapies are linked to ~70% fewer ischemic events but increased bleeding in advanced CKD.
Why the study?
Data on the efficacy and safety of modern interventional therapies and medications in patients with advanced CKD are limited because they are often excluded or underrepresented in randomized trials.
How have treatment strategies and 1-year clinical outcomes changed over time for STEMI patients with advanced CKD?
Observational (n=9,605)
No
How have treatment strategies and 1-year clinical outcomes changed over time for STEMI patients with advanced CKD?
Odds Ratio: 0.3 (95% CI 0.1–0.7)
Absolute Event Rate: 3.1% vs 10.8%
p-value: p=<0.01
Increased use of primary PCI, newer P2Y12 inhibitors, and drug-eluting stents in STEMI patients with advanced CKD has reduced ischemic events but increased bleeding, without improving overall 1-year mortality.
Requires balancing ischemic gains vs bleeding risk in advanced CKD STEMI; leaves net benefit and optimal strategies open.
BACKGROUND: Although the detrimental effects of advanced chronic kidney disease (CKD) on prognosis in coronary artery disease is known, there are few data on the efficacy and safety of modern interventional therapies and medications in patients with advanced CKD, because this special patient cohort is often excluded or underrepresented in randomized trials. METHODS: In the present study all patients admitted with ST-elevation myocardial infarctions (STEMI) from the region of Bremen/Germany treated between 2006 and 2019 were analyzed. Advanced CKD was defined as glomerular filtration rate < 45 ml/min. RESULTS: Of 9605 STEMI-patients, 1018 (10.6%) had advanced CKD with a serum creatinine of 2.22 ± 4.2 mg/dl at admission and with lower rates of primary percutaneous coronary intervention (pPCI) (84.1 vs. 94.1%, p < 0.01) and higher all-cause-mortality (44.4 vs. 3.6%, p < 0.01). Over time, advanced CKD-patients were more likely to be treated with pPCI (2015-2019: 90.3% vs. 2006-2010:75.8%, p < 0.01) and with ticagrelor/prasugrel (59.6% vs. 1.7%, p < 0.01) and drug eluting stents (90.7% vs. 1.3%, p < 0.01). During the study period a decline in adverse ischemic events (OR 0.3, 95% CI 0.1-0.7) and an increase in bleedings (OR 2.2, 95% CI 1.3-3.8) within 1 year after the index event could be observed in patients with advanced CKD while 1-year-mortality (OR 1.0, 95% CI 0.7-1.4) and rates of acute kidney injury (OR 1.2, 95% CI 0.8-1.7) did not change in a multivariate model. Both, ticagrelor/prasugrel (OR 0.48, 95% CI 0.2-0.98) and DES (OR 0.38, 95% CI 0.2-0.8) were associated with a decrease in ischemic events at 1 year. CONCLUSIONS: During the observed time period STEMI-patients with advanced CKD were more likely to be treated with primary PCI, ticagrelor or prasugrel and DE-stents. 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.
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Schmucker et al. (2022) conducted an observational in ST-elevation myocardial infarction (STEMI) and advanced chronic kidney disease (CKD) (n=9,605). Modern interventional therapies (primary PCI, DES, ticagrelor/prasugrel) vs. Historical treatment strategies (2006-2010) was evaluated on Adverse ischemic events (in-stent-thrombosis, myocardial reinfarction, and repeat target lesion revascularization) at 1 year (OR 0.3, 95% CI 0.1-0.7, p=<0.01). In STEMI patients with advanced chronic kidney disease, the adoption of modern interventional therapies over a 14-year period was associated with a significant reduction in 1-year adverse ischemic events (OR 0.3) but an increase in bleeding (OR 2.2).
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