Clinically indicated invasive cardiac care for acute coronary syndrome is delivered less frequently to veterans with vs without stage 3-4 chronic kidney disease (CKD), and the underuse is associated with premature death, a new study finds.

In a retrospective study of 64,695 mostly male US veterans hospitalized during 2013-2017 with acute coronary syndrome (ACS), 34,430 patients (53%) had GRACE scores that predicted 5% or greater mortality at 6 months. Of these, 18,780 (55%) had stage 3-4 CKD (an estimated glomerular filtration rate of 15 to 59.9 mL/min/1.73 m2) and 15,650 (45%) did not have CKD.

The CKD group had a smaller proportion of patients undergoing clinically indicated invasive cardiac care compared with the non-CKD group (49.5% vs 61.0%), Steven D. Weisbord, MD, MSc, of the VA Pittsburgh Healthcare System in Pennsylvania, and colleagues reported in the Journal of the American Society of Nephrology. In adjusted analyses, the CKD group had significant 32% decreased odds of receiving that care. Separate analyses of patients with ST elevation myocardial infarction (STEMI) and non-ST elevation ACS (NSTE-ACS) yielded similar results.

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As CKD stage increased from 3A to 4, the odds of invasive care decreased. Invasive cardiac care included coronary angiography with or without percutaneous coronary intervention and/or coronary artery bypass graft surgery (PCI and CABG).

Among patients with CKD, nonreceipt of invasive care was associated with a 6% increase in the absolute risk of dying from any cause within 6 months (21.5% vs 15.5%), the investigators reported.

There was no difference in the rate of acute kidney injury among patients who did and did not receive invasive care. Nonuse of invasive cardiac care was significantly associated with a 2.0-fold increased risk of dying within 30 days.

Clinical practice guidelines from the American Heart Association/American College of Cardiology recommend emergent PCI to treat STEMI and angiography with revascularization to treat NSTE-ACS, including in moderate CKD, Dr Weisbord’s team noted. They believe the growing body of evidence supporting a survival benefit of these interventions in patients with moderate CKD may increase appropriate use.

For shared decision-making, “it is important that providers employ empirical data to estimate the potential risks and benefits of invasive care and use such data to inform patients of the treatment approach that optimizes the likelihood of a favorable outcome,” Dr Weisbord’s team wrote.

Disclosure: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.


Weisbord S, Mor MK, Hochheiser H, et al. Utilization and outcomes of clinically indicated invasive cardiac care in veterans with acute coronary syndrome and chronic kidney disease. J Am Soc Nephrol. Published online January 5, 2023. doi:10.1097/ASN.0000000000000067