Analysis of long-term survival after revascularization in patients with chronic kidney disease presenting with acute coronary syndromes.

Ischemic heart disease is the most common cause of death in patients with chronic kidney disease (CKD). Patients with CKD who develop an acute coronary syndrome (ACS) have a poor prognosis, with >70% mortality at 2 years. Despite this heavy burden of disease, the optimal management of ACS in this patient population is unknown. Our goal was to compare the effect of coronary revascularization or medical therapy alone on the long-term survival of patients with CKD presenting with ACS. From 1990 to 1998, data were prospectively collected on 4,758 patients admitted to a coronary care unit with the diagnosis of ACS. Of these, 3,104 had preserved renal function, and 1,654 had significant renal dysfunction, as defined by the National Kidney Foundation in the Kidney Disease Outcomes Quality Initiative classification of kidney function as an estimated glomerular filtration rate of <60 ml/min/1.73 m(2). Long-term survival was assessed and outcomes were compared according to whether patients were treated with medical therapy alone or if they underwent a percutaneous or surgical revascularization procedure. Follow-up information was available in 99% of the patients up to 8 years after the index hospitalization. Of the 1,654 patients with significant renal dysfunction, 64 underwent coronary artery bypass surgery, 232 underwent percutaneous coronary revascularization, 280 underwent a diagnostic cardiac catheterization and were subsequently treated medically, whereas 1,078 were treated with medical therapy alone. Percutaneous coronary revascularization was associated with superior long-term survival. In conclusion, patients with severe CKD and ACS had improved long-term survival when treated with percutaneous coronary revascularization.