title: Inpatient coronary angiography and revascularisation following non-ST-elevation acute coronary syndrome in patients with renal impairment: a cohort study using the Myocardial Ischaemia National Audit Project.
abstract: BACKGROUND
  International guidelines support an early invasive management strategy (including early coronary angiography and revascularisation) for non-ST-elevation acute coronary syndrome (NSTE-ACS) in patients with renal impairment. However, evidence from outside the UK suggests that this approach is underutilised. We aimed to describe practice within the NHS, and to determine whether the severity of renal dysfunction influenced the provision of angiography and modified the association between early revascularisation and survival.
  
  
  METHODS
  We performed a cohort study, using multivariable logistic regression and propensity score analyses, of data from the Myocardial Ischaemia National Audit Project for patients presenting with NSTE-ACS to English or Welsh hospitals between 2008 and 2010.
  
  
  RESULTS
  Of 35 881 patients diagnosed with NSTE-ACS, eGFR of <60 ml/minute/1.73 m(2) was present in 15 680 (43.7%). There was a stepwise decline in the odds of undergoing inpatient angiography with worsening renal dysfunction. Compared with an eGFR>90 ml/minute/1.73 m(2), patients with an eGFR between 45-59 ml/minute/1.73 m(2) were 33% less likely to undergo angiography (adjusted OR 0.67, 95% CI 0.55-0.81); those with an eGFR<30/minute/1.73 m(2) had a 64% reduction in odds of undergoing angiography (adjusted OR 0.36, 95%CI 0.29-0.43). Of 16 646 patients who had inpatient coronary angiography, 58.5% underwent inpatient revascularisation. After adjusting for co-variables, inpatient revascularisation was associated with approximately a 30% reduction in death within 1 year compared with those managed medically after coronary angiography (adjusted OR 0.66, 95%CI 0.57-0.77), with no evidence of modification by renal function (p(interaction) = 0.744).
  
  
  CONCLUSIONS
  Early revascularisation may offer a similar survival benefit in patients with and without renal dysfunction, yet renal impairment is an important determinant of the provision of coronary angiography following NSTE-ACS. A randomised controlled trial is needed to evaluate the efficacy of an early invasive approach in patients with severe renal dysfunction to ensure that all patients who may benefit are offered this treatment option.
authors.affiliation: UK Renal Registry, Southmead Hospital, Bristol, United Kingdom; Department of Renal Sciences, Division of Transplantation Immunology and Mucosal Biology, Kings College London, London, United Kingdom.
authors.forename: Catriona
authors.initials: C
authors.lastname: Shaw
authors.affiliation: London School of Hygiene and Tropical Medicine, London, United Kingdom.
authors.forename: Dorothea
authors.initials: D
authors.lastname: Nitsch
authors.affiliation: UK Renal Registry, Southmead Hospital, Bristol, United Kingdom.
authors.forename: Retha
authors.initials: R
authors.lastname: Steenkamp
authors.affiliation: Department of Epidemiology and Public Health, University College London, London, United Kingdom.
authors.forename: Cornelia
authors.initials: C
authors.lastname: Junghans
authors.affiliation: Department of Renal Medicine, Kings College Hospital, London, United Kingdom.
authors.forename: Sapna
authors.initials: S
authors.lastname: Shah
authors.affiliation: Department of Renal Medicine, Salford Royal NHS Foundation Trust, Salford, United Kingdom.
authors.forename: Donal
authors.initials: D
authors.lastname: O'Donoghue
authors.affiliation: Department of Renal Medicine, Belfast Health and Social Care Trust, Belfast, Northern Ireland, United Kingdom.
authors.forename: Damian
authors.initials: D
authors.lastname: Fogarty
authors.affiliation: Myocardial Ischaemia National Audit Project, College of Medicine, Swansea University, Swansea, Wales, United Kingdom.
authors.forename: Clive
authors.initials: C
authors.lastname: Weston
authors.affiliation: Department of Renal Sciences, Division of Transplantation Immunology and Mucosal Biology, Kings College London, London, United Kingdom.
authors.forename: Claire C
authors.initials: CC
authors.lastname: Sharpe
mesh_terms: D054058:Acute Coronary Syndrome / Q000000981:diagnostic imaging / Q000401:mortality* / Q000503:physiopathology / Q000601:surgery; D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D017023:Coronary Angiography; D005260:Female; D005919:Glomerular Filtration Rate; D006801:Humans; D007297:Inpatients; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D017202:Myocardial Ischemia / Q000401:mortality* / Q000503:physiopathology / Q000601:surgery; D062645:Percutaneous Coronary Intervention; D057216:Propensity Score; D051437:Renal Insufficiency / Q000401:mortality* / Q000503:physiopathology; D016896:Treatment Outcome