title: Patients with severe chronic kidney disease benefit from early revascularization after acute coronary syndrome.
abstract: BACKGROUND
  Early revascularization is associated with improved outcomes after non-ST-elevation acute coronary syndrome (ACS). It is unclear whether its benefits exist in patients with ACS and advanced chronic kidney disease (CKD), because these patients are often sub-optimally treated and excluded from clinical trials.
  
  
  METHODS
  We undertook meta-analyses of short- and long-term mortality outcomes in comparative studies examining the effectiveness of early revascularization in patients with ACS and CKD (as estimated by Glomerular Filtration Rate, eGFR). A literature search between 1995 and 2010 identified 7 published reports enrolling 23,234 patients with at least mild reduction in eGFR (<90 mL/min/1.73 m(2)), of whom 6276 and 16,958 patients received early revascularization versus initial medical therapy, respectively. Summary odds ratios (OR) and their 95% Confidence Intervals (CIs) were calculated using the random-effects models. Sensitivity analyses were performed by one-study removal, and publication bias was assessed by the funnel plot analysis.
  
  
  RESULTS
  Early revascularization was associated with a reduction in 1-year mortality compared to initial medical therapy (OR=0.46, 95% CI 0.26-0.82, P=0.008) among ACS patients with eGFR<60 mL/min/1.73 m(2). The mortality reduction with early revascularization occurred upfront (short term mortality OR=0.69, 95% CI 0.56-0.87, P=0.001), persisted at 3 years (OR=0.54, 95% CI 0.31-0.96, P=0.037), was evident across all CKD stages (including dialysis patients), and was independent of the influence of any single study.
  
  
  CONCLUSIONS
  Early revascularization after ACS is associated with reduced mortality in appropriately-selected patients with CKD, including those with severe CKD or receiving dialysis.
authors.affiliation: Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, United States.
authors.forename: Henry D
authors.initials: HD
authors.lastname: Huang
authors.forename: Mahboob
authors.initials: M
authors.lastname: Alam
authors.forename: Ihab
authors.initials: I
authors.lastname: Hamzeh
authors.forename: Salim
authors.initials: S
authors.lastname: Virani
authors.forename: Anita
authors.initials: A
authors.lastname: Deswal
authors.forename: David
authors.initials: D
authors.lastname: Aguilar
authors.forename: Paul
authors.initials: P
authors.lastname: Rogers
authors.forename: Panos
authors.initials: P
authors.lastname: Kougias
authors.forename: Yochai
authors.initials: Y
authors.lastname: Birnbaum
authors.forename: David
authors.initials: D
authors.lastname: Paniagua
authors.forename: Biswajit
authors.initials: B
authors.lastname: Kar
authors.forename: Christie
authors.initials: C
authors.lastname: Ballantyne
authors.forename: Biykem
authors.initials: B
authors.lastname: Bozkurt
authors.forename: Hani
authors.initials: H
authors.lastname: Jneid
mesh_terms: D054058:Acute Coronary Syndrome / Q000175:diagnosis / Q000453:epidemiology / Q000601:surgery*; D005919:Glomerular Filtration Rate / Q000502:physiology; D006801:Humans; D062645:Percutaneous Coronary Intervention / Q000379:methods; D011446:Prospective Studies; D051436:Renal Insufficiency, Chronic / Q000175:diagnosis / Q000453:epidemiology / Q000601:surgery*; D012189:Retrospective Studies; D012720:Severity of Illness Index
keywords: Acute coronary syndrome; Chronic kidney disease; Coronary artery disease; Early invasive strategy; Myocardial infarction; Revascularization