What is the clinical evidence from this study?

Study design: Cohort. Population: Acute myocardial infarction (AMI) (n=5835). Intervention: Severe kidney impairment (eGFR 0-29 mL/min/1.73m2) vs. Preserved kidney function (eGFR 60-120 mL/min/1.73m2). Primary outcome: All-cause death during index AMI hospitalisation (OR 1.80, 95% CI 1.37-2.38).

November 2, 2023Open Access

Management and outcomes of myocardial infarction in people with impaired kidney function in England

Key Result

Severe kidney impairment (eGFR 0-29) was associated with significantly increased odds of in-hospital mortality (OR 1.80) compared to preserved kidney function following acute myocardial infarction.

Study Design

Type

Cohort (n=5,835)

Multicenter

Yes

Structured PICO

Does reduced eGFR worsen mortality and reduce the likelihood of receiving invasive management in patients hospitalized for acute myocardial infarction?

Population

5,835 adults with chronic kidney disease or risk factors hospitalized for acute myocardial infarction in England, followed for a mean of 2.4 years.

Exposure

Reduced estimated glomerular filtration rate (eGFR categories 3a, 3b, and 4-5)

Comparator

Preserved kidney function (eGFR category 1-2, ≥60 mL/min/1.73m2)

Outcome

All-cause death during the index AMI hospitalization, and all-cause death during follow-up for those who survived the index AMI hospitalization (mean follow-up 2.4 years)hard clinical

Patients with reduced eGFR hospitalized for AMI are less likely to receive invasive management and have significantly higher in-hospital and post-discharge mortality compared to those with preserved eGFR.

Main Result

Odds Ratio: 1.8 (95% CI 1.37–2.38)

Absolute Event Rate: 27% vs 11%

Limitations

Unable to exclude type two AMIs from analyses
Potential misclassification of eGFR categories due to acute kidney injury prior to or at admission
Unable to risk stratify the AMI cohort
Competing risk of death may bias effect estimates for invasive management
Residual confounding from severity of comorbidities and pharmacological management
Study population selected from 10% of GPs in England, which may not be fully representative
Potential overestimation of baseline kidney function due to the median one-year gap between creatinine test and AMI

Abstract

BACKGROUND: Acute myocardial infarction (AMI) causes significant mortality and morbidity in people with impaired kidney function. Previous observational research has demonstrated reduced use of invasive management strategies and inferior outcomes in this population. Studies from the USA have suggested that disparities in care have reduced over time. It is unclear whether these findings extend to Europe and the UK. METHODS: Linked data from four national healthcare datasets were used to investigate management and outcomes of AMI by estimated glomerular filtration rate (eGFR) category in England. Multivariable logistic and Cox regression models compared management strategies and outcomes by eGFR category among people with kidney impairment hospitalised for AMI between 2015-2017. RESULTS: compared with people with eGFR ≥ 60 when hospitalised for non-ST segment elevation MI (NSTEMI). The association between eGFR and odds of invasive management for ST-elevation MI (STEMI) varied depending on the availability of percutaneous coronary intervention. A graded association between mortality and eGFR category was demonstrated both in-hospital and after discharge for all people. CONCLUSIONS: In England, patients with reduced eGFR are less likely to receive invasive management compared to those with preserved eGFR. Disparities in care may however be decreasing over time, with the least difference seen in patients with STEMI managed via the primary percutaneous coronary intervention pathway. Reduced eGFR continues to be associated with worse outcomes after AMI.

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