Invasive Management of ACS: The Kidneys Are All Right.


Despite early increases in acute kidney injury, invasive treatment is associated with better long-term outcomes than conservative management.
Invasive treatment options for acute coronary syndromes (ACS) might be underused in patients at high risk for renal disease because of concerns about contrast-induced renal failure and other complications. However, comparative data on renal outcomes in patients managed invasively versus conservatively are lacking. Therefore, investigators conducted a cohort study involving 10,516 patients presenting with non-ST-segment-elevation ACS in Alberta, Canada, 41% of whom received early invasive management (coronary catheterization within 2 days after hospital admission). Stratification according to baseline estimated glomerular filtration rate and propensity-score matching resulted in a cohort of 6768 participants.

Compared with conservative management, early invasive therapy was associated with an increased risk for acute renal injury (10.3% vs. 8.7%, P=0.019), but treatments did not differ in risk for dialysis (0.4% vs. 0.3%, P=0.670) during the index hospitalization. During a median follow-up of 2.5 years, the risk for progression to end-stage renal disease did not differ between the two groups (0.3 vs. 0.4 events per 100 person-years, P=0.712). Moreover, early invasive treatment was associated with reduced long-term mortality (2.4 vs. 3.4 events per 100 person-years; P<0.001). The relative reduction in mortality risk was consistent across all strata of baseline renal function.

COMMENT

Although early invasive treatment of acute coronary syndromes increased the risk for acute renal injury compared with conservative management, it did not affect risk for dialysis or progression to end-stage renal disease. The improvements in long-term survival at all levels of baseline renal function suggest that invasive therapy should not be withheld for fear of renal complications.

Source: NEJM

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