Study Sample Characteristics
Overall, 19,029 STEMI and 30,462 NSTEMI patients were included in the present analysis; 30.5% and 42.9% of patients with STEMI and NSTEMI, respectively, had CKD of stage 3 or greater (). Each stage of CKD (3b, 4, 5, dialysis) was more prevalent in patients with NSTEMI than those with STEMI, with the exception of Stage 3a (). With progressively increasing CKD stage, patients were more likely to have hypertension, diabetes mellitus, and prior MI, CHF, and stroke. Additionally, patients with CKD were less likely to be current smokers and had lower BMI levels ().
Prevalence of CKD and Stages 3a, 3b, 4, and 5 (no dialysis), and dialysis presenting with STEMI and NSTEMI. The “no CKD” category is limited by lack of information on albuminuria.
Presenting characteristics by CKD Stage
Short-term outcomes by CKD Stage
Overall, the risk of mortality increased with CKD stage (). Among patients who presented with STEMI, 2.3% of those without CKD died, compared to 8.8%, 17.9%, 27.3%, and 31.8% of those with Stage 3a, 3b, 4, and 5 CKD, respectively. In general, a similar trend was observed for NSTEMI, although the absolute event rates were substantially lower. For STEMI, the odds ratio for Stage 3a, 3b, 4, and 5 CKD relative to no CKD was 2.5, 3.7, 4.8, and 8.0 (p-value (trend) <0.0001). For NSTEMI, the odds ratios were 1.8, 2.4, 3.5, and 4.1 (p-value (trend)<0.0001). However, there was a greater relative increase in death for patients with STEMI with advancing CKD stage than was seen in NSTEMI (p-value (interaction) <0.0001). Also, patients with CKD were at higher risk for CHF than no CKD ().
Figure 2 Crude rates and adjusted odds ratios for death by CKD stages among those presenting with STEMI and NSTEMI; p-values(trend); p-value(interaction) test for STEMI vs. NSTEMI by CKD stages. The “no CKD” category is limited by lack of information (more ...)
Crude rates and adjusted odds ratios for in-hospital outcomes and in-hospital procedures by CKD Stage**; n represents the number of events
Acute Therapy and In-hospital Procedures
Among patients presenting with STEMI, the odds ratio for any reperfusion therapy was significantly lower with worsening CKD stage (p-value (trend)=0.0005, ) after adjustment for baseline features. However, the use of primary PCI (p-value (trend)=0.75, ) and thrombolytics (p-value (trend)=0.65) was similar after accounting for baseline differences. Among those presenting with NSTEMI, patients with CKD were less likely to undergo early invasive therapy (p-value (trend)<0.0001) or any revascularization (p-value (trend)<0.0001; ).
Patients presenting with either STEMI or NSTEMI also had higher rates of major bleeding () with advancing CKD stage; notably, rates were similar among those with Stage 4 and Stage 5 CKD. CKD patients presenting with either STEMI or NSTEMI had excess dosing of Glycoprotein IIb/IIIa inhibitors (GPI, p-value<0.0001 for trend). For patients presenting with STEMI, those without CKD had a 2.2% rate of Glycoprotein IIb/IIIa inhibitors (GPI) overdosing, compared with 55.6% among those with Stage 5 CKD (p-value (trend)<0.0001; ). For patients with NSTEMI, the rate of GPI overdosing ranged from 2.2% among patients without CKD to 40.9% among patients with Stage 5 CKD (p-value (trend)<0.0001; ).
Crude rates and adjusted odds ratios in-hospital adverse outcomes by CKD Stage**; n represents the number of events
Acute In-hospital and Discharge Cardio-Protective Medications and Counseling
Rates of acute (within 24-hours) in-hospital aspirin use were substantially lower among those with more advanced CKD (p-value (trend)<0.001 for STEMI and NSTEMI, ). Similarly, use of clopidogrel, beta blockers, and statins were generally lower among patients with more advanced CKD (all p-value (trend)<0.0001). In general, similar observations were made for discharge medications. Rates of smoking cessation, dietary and exercise counseling and referral to cardiac rehabilitation were generally lower for patients with more advanced CKD stage ().
Figure 3 Crude rates of acute in-hospital medications (within 24-hours), discharge medications, and discharge counseling by CKD status. All p-values test for trend across CKD stage <0.001 except for Aspirin as a discharge medication and referral to cardiac (more ...)