Temporal trends in treatment strategies and clinical outcomes among patients with advanced chronic kidney disease and ST-elevation myocardial infarctions: results from the Bremen STEMI registry

Abstract

Background Although the detrimental effects of advanced chronic kidney disease (CKD) on prognosis in coronary artery disease is known, there are few data on the efficacy and safety of modern interventional therapies and medications in patients with advanced CKD, because this special patient cohort is often excluded or underrepresented in randomized trials. Methods In the present study all patients admitted with ST-elevation myocardial infarctions (STEMI) from the region of Bremen/Germany treated between 2006 and 2019 were analyzed. Advanced CKD was defined as glomerular filtration rate < 45 ml/min. Results Of 9605 STEMI-patients, 1018 (10.6%) had advanced CKD with a serum creatinine of 2.22 ± 4.2 mg/dl at admission and with lower rates of primary percutaneous coronary intervention (pPCI) (84.1 vs. 94.1%, p < 0.01) and higher all-cause-mortality (44.4 vs. 3.6%, p < 0.01). Over time, advanced CKD-patients were more likely to be treated with pPCI (2015–2019: 90.3% vs. 2006–2010:75.8%, p < 0.01) and with ticagrelor/prasugrel (59.6% vs. 1.7%, p < 0.01) and drug eluting stents (90.7% vs. 1.3%, p < 0.01). During the study period a decline in adverse ischemic events (OR 0.3, 95% CI 0.1–0.7) and an increase in bleedings (OR 2.2, 95% CI 1.3–3.8) within 1 year after the index event could be observed in patients with advanced CKD while 1-year-mortality (OR 1.0, 95% CI 0.7–1.4) and rates of acute kidney injury (OR 1.2, 95% CI 0.8–1.7) did not change in a multivariate model. Both, ticagrelor/prasugrel (OR 0.48, 95% CI 0.2–0.98) and DES (OR 0.38, 95% CI 0.2–0.8) were associated with a decrease in ischemic events at 1 year. Conclusions During the observed time period STEMI-patients with advanced CKD were more likely to be treated with primary PCI, ticagrelor or prasugrel and DE-stents. These changes probably have contributed to the decline in ischemic events and the increase in bleedings within 1 year after STEMI while overall mortality at 1-year remained unchanged for this high-risk patient group.

Contemporary secondary prevention in survivors of ST-elevation myocardial infarction with and without chronic kidney disease: a retrospective analysis

“…Prescription of guideline-directed drugs shortly after an event has increased during the last decades [ 11 , 15 ]. At discharge, the reported rates by others [ 5 , 8 , 10 , 16 ] are in good accordance with our findings.…”

“…Time trends over recent decades have shown increasing prescription rates resulting in decreased mortality and recurrent ischaemic events [ 5 , 6 ], but optimal medical treatment is still insufficient, even in high-income countries [ 7 ]. Analysis of long-term outcome is often limited to 1- or 2-year follow-up periods [ 8 , 9 ] and data on medical treatment and outcome of patients with severe comorbidities like chronic kidney disease (CKD), which has been shown to be a strong cardiovascular risk factor, are scarce [ 10 , 11 ]. It is still unclear whether patients with CKD or patients on dialysis benefit from guideline-directed therapies to a similar extent as patients without CKD.…”

“…Patients with advanced CKD are often excluded from randomized controlled trials [ 12 ]. Data on treatment are mainly collected via registries [ 10 , 11 , 13 ] or real-world studies [ 14 ]. In order to add knowledge regarding medical treatment and long-term outcome of STEMI patients with and without CKD, we analysed health claim data from a large German health insurance with a follow-up period up to 9 years.…”

Current views on antiplatelet therapy in acute coronary syndrome patients: the place of clopidogrel

“…Анализ данных Бременского регистра пациентов с ИМпST показал, что за период с 2006 по 2019 г. у пациентов с ХБП (рСКФ менее 60 мл/мин) существенно увеличилась доля используемых прасугрела и тикагрелора. Эта тенденция ассоциировалась со снижением риска ишемических осложнений, но отчетливой тенденцией к увеличению риска кровотечений после выписки, что реализовалось в отсутствие снижения общей смертности [41]. В крупном когортном исследовании SWEDENHEART, включившем 45 тыс.…”