Early angiography in patients with chronic kidney disease: a collaborative systematic review

Abstract

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 m(2).

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.

Figure 1.

Results of search strategy.

Figure 2.

(A through D) Comparison of invasive and noninvasive strategies with respect to the likelihood of death at 1 yr (A), myocardial infarction (MI) at 1 yr (B), the composite end point of death or nonfatal MI (C), or rehospitalization during the year after randomization (D). For the ICTUS trial, only cardiovascular hospitalizations were recorded. Data presented as the study-specific and composite risk ratio (RR) estimates comparing early invasive and conservative therapy groups. RR <1 indicates that the routine angiography strategy was superior to selective strategy. The filled boxes represent the RR from the individual trials, with the size of the box reflecting the sample sizes of the trials. The horizontal bars extending from the box represent the 95% confidence intervals (CI) for the RR. The open diamonds represent the cumulative RR with or without the inclusion. The size of the diamond represents the 95% CI for the RR.