Cardiol Res

Cardiology Research, ISSN 1923-2829 print, 1923-2837 online, Open Access

Article copyright, the authors; Journal compilation copyright, Cardiol Res and Elmer Press Inc

Journal website https://cr.elmerpub.com

Original Article

Volume 15, Number 6, December 2024, pages 425-438

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

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.

**Table 1.** Characteristics of Included Studies
	Study design, country	Hospital PCI capability	N	Dates	Definition of impaired CKD function	Definition of control group	ACS type(s)	Age range	Crude figures	Effect estimates, OR (95% CI)
PCI: percutaneous coronary intervention; ACS: acute coronary syndrome; CKD: chronic kidney disease; eGFR: estimated glomerular filtration rate; ICD: international classification of diseases; NSTE-ACS: non-ST-elevation acute coronary syndrome; NSTEMI; non-ST-elevation myocardial infarction; OR: odds ratio; CI: confidence interval; STEMI: ST-elevation myocardial infarction; UA: unstable angina; PD: peritoneal dialysis; HD: hemodialysis; ESRD: end-stage renal disease; ICD-9 CM: International Classification of Diseases, Ninth Revision, Clinical Modification.
Alushi et al, 2021 [29]	Prospective, Germany	All	438	2012 - 2017	eGFR < 30 or dialysis duration > 30days at the time of MI	eGFR > 90	NSTEMI, UA	Not specified	NSTE-ACS 25/222 CKD vs. 18/216 non-CKD	Crude OR NSTE-ACS 1.36 (0.75 - 2.46)
										Adjusted OR NSTE-ACS 3.20 (1.28 - 8.00)
Bagai et al, 2018 [7]	Retrospective, USA	All	615,425	2007 - 2015	eGFR < 60	eGFR ≥ 60	NSTEMI, STEMI	Not specified	All ACS 21,191/171,140 CKD vs. 49,707/444,285 non-CKD	Crude OR all ACS 1.12 (1.10 - 1.14)
									NSTE-ACS 16,344/91,021 CKD vs. 37,087/216,244 non-CKD	Crude OR NSTE-ACS 1.12 (1.10 - 1.14)
									STEMI 4,847/80,119 CKD vs. 37,087/228,041 non-CKD	Crude OR STEMI 1.10 (1.06 - 1.14)
Blicher et al, 2013 [28]	Retrospective, Denmark	Mixed	34,722	2000 - 2009	Code for CKD/dialysis [4]	No CKD code [5]	NSTEMI, STEMI [2]	> 25 years	All MI 239/904 CKD vs. 6,337/33,818 non-CKD	Crude OR all ACS 1.56 (1.34 - 1.81)
Kawsara et al, 2022 [33]	Retrospective, USA	Mixed	69,281	2016 - 2019	Dialysis code	No dialysis code	STEMI	≥ 18 years	STEMI 37/522 CKD vs. 3,438/68,759 non-CKD	Crude OR STEMI 1.45 (1.04 - 2.03)
Khan et al, 2020 [34]	Retrospective, USA	Mixed	149,983	2012 - 2017	ICD-9 CM code for ESRD	Other	STEMI	≥ 18 years	STEMI 251/1,753 CKD vs. 63,675/12,735/148,230 non-CKD	STEMI OR 1.78 (1.55 - 1.03)
Kotwal et al, 2017 [35]	Retrospective, Australia	Mixed	12,662	2004 - 2008	ICD-10 code for CKD	No CKD code	NSTEMI, STEMI	≥ 18 years	All ACS 272/811 CKD vs. 1,741/11,851 non-CKD	All ACS OR 2.93 (2.51 - 3.42)
Lin et al, 2022 [13]	Retrospective, Taiwan	Mixed	67,534	2001 - 2013	Code for CKD/dialysis	No code for CKD or dialysis	NSTEMI, STEMI	≥ 20 years	All ACS 2,433/16,477 CKD vs. 4,894/51,057 non-CKD	All ACS OR 1.62 (1.55 - 1.72)
Murray et al, 2018 [36]	Retrospective, USA	Mixed	236,284	2001 - 2012	ICD-9 code for CKD1-5 or dialysis	No code for CKD or dialysis	NSTEMI	≥ 18 years	NSTE-ACS 7,227/22,891 CKD vs. 47,517/208,293 non-CKD	NSTE-ACS OR 1.18 (1.14 - 1.21)
Panchal et al, 2021 [37]	Retrospective, USA	Mixed	87,883	2012 - 2014	ICD-9 code for CKD1 - 5, unspecified CKD, or dialysis	No code for CKD or dialysis	STEMI	Not specified	STEMI 838/7,476 CKD vs. 5,734/80,407 non-CKD	STEMI OR 1.67 (1.55 - 1.81)
Sakhuja et al, 2016 [38]	Retrospective, USA	Mixed	141,838	2006 - 2010	ICD-9 code for ESRD or OPCS codes for PD or HD, without a code for CKD	No ESRD/PD/HD code	STEMI	≥ 20 years	STEMI 292/1,248 CKD vs. 13,746/140,590 non-CKD	STEMI OR 1.67 (1.43 - 1.95)
Sanchis et al, 2021 [32]	Retrospective, Spain	Not specified	7,211 (total study size)	2002 - 2017	eGFR < 60 calculated from admission creatinine	Admission eGFR ≥ 60	NSTEMI, UA	≥ 70 years	Crude figures not available	Crude OR NSTE-ACS 0.85 (0.70 - 1.03)
										Adjusted OR NSTE-ACS 1.11 (0.92 - 1.35)
Shaw et al, 2014 [6]	Retrospective, England & Wales	Mixed	9,732	2008 - 2010	eGFR < 60 calculated from admission creatinine	Admission eGFR ≥ 60	NSTEMI, UA	Not specified	NSTE-ACS 274/2,318 CKD vs. 679/7,414 non-CKD	Crude OR NSTE-ACS 1.32 (1.15 - 1.54)
Smilowitz et al, 2017 [19]	Retrospective, USA	Mixed	388,592	2007 - 2012	ICD9 codes for CKD3 - 5 or HD	No code for CKD3 - 5 or HD	NSTEMI, STEMI	Not specified	All ACS 9,775/43,242 CKD vs. 55,389/345,350 non-CKD	Crude OR all ACS 1.53 (1.49 - 1.57)
									NSTE-ACS 7,783/30,657 CKD vs. 38,324/175,921 non-CKD	Adjusted OR all ACS 1.06 (1.03 - 1.09)
									STEMI 1,992/12,585 vs. 17,065/169,429 non-CKD	Crude OR NSTE-ACS 1.22 (1.19 - 1.26)
										Adjusted OR NSTE-ACS 1.02 (0.99 - 1.06)
										Crude OR STEMI 1.69 (1.60 - 1.77)
										Adjusted OR STEMI 1.21 (1.14 - 1.28)

Table 1. Characteristics of Included Studies

Study design, country

Hospital PCI capability

Dates

Definition of impaired CKD function

Definition of control group

ACS type(s)

Age range

Crude figures

Effect estimates, OR (95% CI)

PCI: percutaneous coronary intervention; ACS: acute coronary syndrome; CKD: chronic kidney disease; eGFR: estimated glomerular filtration rate; ICD: international classification of diseases; NSTE-ACS: non-ST-elevation acute coronary syndrome; NSTEMI; non-ST-elevation myocardial infarction; OR: odds ratio; CI: confidence interval; STEMI: ST-elevation myocardial infarction; UA: unstable angina; PD: peritoneal dialysis; HD: hemodialysis; ESRD: end-stage renal disease; ICD-9 CM: International Classification of Diseases, Ninth Revision, Clinical Modification.

Alushi et al, 2021 [29]

Prospective, Germany

All

438

2012 - 2017

eGFR < 30 or dialysis duration > 30days at the time of MI

eGFR > 90

NSTEMI, UA

Not specified

NSTE-ACS 25/222 CKD vs. 18/216 non-CKD

Crude OR NSTE-ACS 1.36 (0.75 - 2.46)

Adjusted OR NSTE-ACS 3.20 (1.28 - 8.00)

Bagai et al, 2018 [7]

Retrospective, USA

All

615,425

2007 - 2015

eGFR < 60

eGFR ≥ 60

NSTEMI, STEMI

Not specified

All ACS 21,191/171,140 CKD vs. 49,707/444,285 non-CKD

Crude OR all ACS 1.12 (1.10 - 1.14)

NSTE-ACS 16,344/91,021 CKD vs. 37,087/216,244 non-CKD

Crude OR NSTE-ACS 1.12 (1.10 - 1.14)

STEMI 4,847/80,119 CKD vs. 37,087/228,041 non-CKD

Crude OR STEMI 1.10 (1.06 - 1.14)

Blicher et al, 2013 [28]

Retrospective, Denmark

Mixed

34,722

2000 - 2009

Code for CKD/dialysis [4]

No CKD code [5]

NSTEMI, STEMI [2]

> 25 years

All MI 239/904 CKD vs. 6,337/33,818 non-CKD

Crude OR all ACS 1.56 (1.34 - 1.81)

Kawsara et al, 2022 [33]

Retrospective, USA

Mixed

69,281

2016 - 2019

Dialysis code

No dialysis code

STEMI

≥ 18 years

STEMI 37/522 CKD vs. 3,438/68,759 non-CKD

Crude OR STEMI 1.45 (1.04 - 2.03)

Khan et al, 2020 [34]

Retrospective, USA

Mixed

149,983

2012 - 2017

ICD-9 CM code for ESRD

Other

STEMI

≥ 18 years

STEMI 251/1,753 CKD vs. 63,675/12,735/148,230 non-CKD

STEMI OR 1.78 (1.55 - 1.03)

Kotwal et al, 2017 [35]

Retrospective, Australia

Mixed

12,662

2004 - 2008

ICD-10 code for CKD

No CKD code

NSTEMI, STEMI

≥ 18 years

All ACS 272/811 CKD vs. 1,741/11,851 non-CKD

All ACS OR 2.93 (2.51 - 3.42)

Lin et al, 2022 [13]

Retrospective, Taiwan

Mixed

67,534

2001 - 2013

Code for CKD/dialysis

No code for CKD or dialysis

NSTEMI, STEMI

≥ 20 years

All ACS 2,433/16,477 CKD vs. 4,894/51,057 non-CKD

All ACS OR 1.62 (1.55 - 1.72)

Murray et al, 2018 [36]

Retrospective, USA

Mixed

236,284

2001 - 2012

ICD-9 code for CKD1-5 or dialysis

No code for CKD or dialysis

NSTEMI

≥ 18 years

NSTE-ACS 7,227/22,891 CKD vs. 47,517/208,293 non-CKD

NSTE-ACS OR 1.18 (1.14 - 1.21)

Panchal et al, 2021 [37]

Retrospective, USA

Mixed

87,883

2012 - 2014

ICD-9 code for CKD1 - 5, unspecified CKD, or dialysis

No code for CKD or dialysis

STEMI

Not specified

STEMI 838/7,476 CKD vs. 5,734/80,407 non-CKD

STEMI OR 1.67 (1.55 - 1.81)

Sakhuja et al, 2016 [38]

Retrospective, USA

Mixed

141,838

2006 - 2010

ICD-9 code for ESRD or OPCS codes for PD or HD, without a code for CKD

No ESRD/PD/HD code

STEMI

≥ 20 years

STEMI 292/1,248 CKD vs. 13,746/140,590 non-CKD

STEMI OR 1.67 (1.43 - 1.95)

Sanchis et al, 2021 [32]

Retrospective, Spain

Not specified

7,211 (total study size)

2002 - 2017

eGFR < 60 calculated from admission creatinine

Admission eGFR ≥ 60

NSTEMI, UA

≥ 70 years

Crude figures not available

Crude OR NSTE-ACS 0.85 (0.70 - 1.03)

Adjusted OR NSTE-ACS 1.11 (0.92 - 1.35)

Shaw et al, 2014 [6]

Retrospective, England & Wales

Mixed

9,732

2008 - 2010

eGFR < 60 calculated from admission creatinine

Admission eGFR ≥ 60

NSTEMI, UA

Not specified

NSTE-ACS 274/2,318 CKD vs. 679/7,414 non-CKD

Crude OR NSTE-ACS 1.32 (1.15 - 1.54)

Smilowitz et al, 2017 [19]

Retrospective, USA

Mixed

388,592

2007 - 2012

ICD9 codes for CKD3 - 5 or HD

No code for CKD3 - 5 or HD

NSTEMI, STEMI

Not specified

All ACS 9,775/43,242 CKD vs. 55,389/345,350 non-CKD

Crude OR all ACS 1.53 (1.49 - 1.57)

NSTE-ACS 7,783/30,657 CKD vs. 38,324/175,921 non-CKD

Adjusted OR all ACS 1.06 (1.03 - 1.09)

STEMI 1,992/12,585 vs. 17,065/169,429 non-CKD

Crude OR NSTE-ACS 1.22 (1.19 - 1.26)

Adjusted OR NSTE-ACS 1.02 (0.99 - 1.06)

Crude OR STEMI 1.69 (1.60 - 1.77)

Adjusted OR STEMI 1.21 (1.14 - 1.28)

**Table 2.** Summary of Findings
Finding	No. of studies	No. of participants	Average exposure effect (OR (95% CI))	Certainty of evidence
ACS: acute coronary syndrome; CABG: coronary artery bypass graft; CKD: chronic kidney disease; NSTE-ACS: non-ST-elevation acute coronary syndrome; OR: odds ratio; CI: confidence interval; PCI: percutaneous coronary intervention; STEMI: ST-elevation myocardial infarction.
CKD is associated with increased odds of receipt of CABG vs. PCI amongst people revascularized following ACS.	13	1,682,207	1.50 (1.30 - 1.72)	Moderate
CKD is associated with increased odds of receipt of CABG vs. PCI amongst people revascularized following NSTE-ACS.	6	764,636	1.16 (1.10 - 1.23)	Moderate
CKD is associated with increased odds of receipt of CABG vs. PCI amongst people revascularized following STEMI.	6	939,159	1.54 (1.23 - 1.93)	Moderate
CKD is associated with increased odds of receipt of CABG vs. PCI amongst people revascularized following ACS in people who do not receive dialysis.	5	1,020,773	1.44 (1.20 - 1.71)	Low
CKD is associated with increased odds of receipt of CABG vs. PCI amongst people revascularized following ACS in people who receive dialysis.	5	838,935	1.25 (1.12 - 1.40)	Moderate

Table 2. Summary of Findings

Finding

No. of studies

No. of participants

Average exposure effect (OR (95% CI))

Certainty of evidence

ACS: acute coronary syndrome; CABG: coronary artery bypass graft; CKD: chronic kidney disease; NSTE-ACS: non-ST-elevation acute coronary syndrome; OR: odds ratio; CI: confidence interval; PCI: percutaneous coronary intervention; STEMI: ST-elevation myocardial infarction.

CKD is associated with increased odds of receipt of CABG vs. PCI amongst people revascularized following ACS.

1,682,207

1.50 (1.30 - 1.72)

Moderate

CKD is associated with increased odds of receipt of CABG vs. PCI amongst people revascularized following NSTE-ACS.

764,636

1.16 (1.10 - 1.23)

Moderate

CKD is associated with increased odds of receipt of CABG vs. PCI amongst people revascularized following STEMI.

939,159

1.54 (1.23 - 1.93)

Moderate

CKD is associated with increased odds of receipt of CABG vs. PCI amongst people revascularized following ACS in people who do not receive dialysis.

1,020,773

1.44 (1.20 - 1.71)

Low

CKD is associated with increased odds of receipt of CABG vs. PCI amongst people revascularized following ACS in people who receive dialysis.

838,935

1.25 (1.12 - 1.40)

Moderate