Does Chronic Kidney Disease Influence Revascularization Strategy After Acute Coronary Syndrome? A Systematic Review and Meta-Analysis

Abstract

Background: Coronary artery bypass grafting (CABG) provides superior long-term outcomes to percutaneous coronary intervention (PCI) for complex multivessel coronary artery disease (CAD). People with chronic kidney disease (CKD) have increased prevalence of multivessel CAD, but also increased surgical risk. We investigated whether CKD predicted real-world use of CABG, versus PCI, in patients revascularized for acute coronary syndrome (ACS).

Methods: Embase, MEDLINE, Scopus and CENTRAL were searched to identify articles referring to ACS and invasive coronary intervention in high-income countries (2012 - 2023). Articles were included if CABG rates were reported in ACS patients with and without CKD receiving revascularization. CKD was defined as an estimated glomerular filtration rate < 60 mL/min/1.73 m²; proxy definitions were accepted. Random effect meta-analyses were used to determine the average effect of CKD on odds of CABG, stratified by ACS type and dialysis use.

Results: Searches generated 15,138 articles, of which 13 observational studies were included (n = 1,682,207). Amongst revascularized ACS patients, those with CKD were more likely to receive CABG than those without (pooled odds ratio (OR) = 1.50 (95% confidence interval (CI) = 1.30 - 1.72). This association was stronger following ST-elevation myocardial infarction (STEMI) than non-ST-elevation ACS (NSTE-ACS) (OR: 1.54 (95% CI: 1.23 - 1.93)) versus 1.16 (1.10 - 1.23), respectively).

Conclusions: In high-income countries, revascularized ACS patients with CKD receive CABG (versus PCI) more frequently than those without kidney disease. However, accounting for lower use of coronary angiography in the CKD population removed this association following NSTE-ACS. Greater use of invasive angiography in those with NSTE-ACS and CKD might therefore increase access to revascularization, and thereby improve outcomes.

Keywords: Chronic kidney disease; Meta-analysis; Revascularization.

Figure 1

Flowchart of study selection.

Figure 2

Forest plot summarizing effect estimates for the receipt of CABG by people revascularized after ACS with versus without CKD. In real-world practice, people with CKD are more likely to receive CABG (versus PCI) if revascularized following ACS, than those without kidney disease. ACS: acute coronary syndrome; CKD: chronic kidney disease; CABG: coronary artery bypass graft; OR: odds ratio; CI: confidence interval.

Figure 3

Forest plot summarizing effect estimates for the receipt of CABG, versus PCI, amongst people revascularized after ACS with versus without CKD, by ACS type. Amongst those revascularized for ACS, people with CKD are more likely to receive CABG (versus PCI) than those without kidney disease, independent of ACS type. However, this association is stronger following STEMI, than NSTE-ACS. ACS: acute coronary syndrome; CABG: coronary artery bypass graft; CKD: chronic kidney disease; NSTE-ACS: non-ST-elevation acute coronary syndrome; OR: odds ratio; STEMI; ST-elevation myocardial infarction.

Figure 4

Flowchart demonstrating the crude proportions of individuals receiving invasive management by ACS type and CKD status. People with CKD are less likely to receive either invasive coronary angiography or revascularization (of any form) following ACS, than those without kidney disease. In this figure, invasive coronary angiography and revascularization are portrayed as distinct steps, however in clinical practice, angiography is typically associated with immediate revascularization in STEMI. ACS: acute coronary syndrome; CABG: coronary artery bypass graft; CKD: chronic kidney disease; NSTE-ACS: non-ST-elevation acute coronary syndrome; PCI: percutaneous coronary intervention; STEMI: ST-elevation myocardial infarction.