Sharon Amir, Massalha Eias, Fishman Boris, Fefer Paul, Barbash Israel M, Segev Amit, Matetzky Shlomi, Guetta Victor, Grossman Ehud, Maor Elad
Chaim Sheba Medical Center, Tel Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
JACC Cardiovasc Interv. 2022 Oct 10;15(19):1977-1988. doi: 10.1016/j.jcin.2022.08.008.
Current guidelines suggest that an early invasive strategy should be considered for the treatment of non-ST-segment elevation myocardial infarction (NSTEMI). Although chronic kidney disease (CKD) is common among NSTEMI patients, these patients are under-represented in clinical trials, and data regarding their management are limited.
The authors sought to evaluate the association between early invasive strategy and long-term survival among patients with NSTEMI and CKD.
This was a retrospective analysis of 7,107 consecutive NSTEMI patients between 2008 and 2021. Patients were dichotomized into early (≤24 hours) and delayed invasive groups and stratified by kidney function. Inverse probability treatment weighting was used to adjust for differences in baseline characteristics. The primary outcome was all-cause mortality.
The final study population comprised 3,529 invasively treated patients with a median age of 66 years (IQR: 58-74 years), 1,837 (52%) of whom were treated early. There were 483 (14%) patients with at least moderate CKD (estimated glomerular filtration rate [eGFR] <45 mL/min/1.73 m). During a median follow-up of 4 years (IQR: 2-6 years), 527 (15%) patients died. After inverse probability treatment weighting, an early invasive strategy was associated with a significant 30% lower mortality compared with a delayed strategy (HR: 0.7; 95% CI: 0.56-0.85). The association between early invasive strategy and mortality was modified by eGFR (P < 0.001) and declined with lower renal function, with no difference in mortality among patients with eGFR <45 mL/min/1.73 m (HR: 0.89; 95% CI: 0.64-1.24).
Among NSTEMI patients, the association of early invasive strategy with long-term survival is modified by CKD and was not observed in patients with eGFR <45 mL/min/1.73 m.
当前指南建议，对于非ST段抬高型心肌梗死（NSTEMI）的治疗应考虑早期侵入性策略。尽管慢性肾脏病（CKD）在NSTEMI患者中很常见，但这些患者在临床试验中的代表性不足，关于其治疗管理的数据有限。
作者试图评估早期侵入性策略与NSTEMI合并CKD患者长期生存之间的关联。
这是一项对2008年至2021年间连续纳入的7107例NSTEMI患者的回顾性分析。患者被分为早期（≤24小时）侵入组和延迟侵入组，并按肾功能分层。采用逆概率治疗加权法来调整基线特征的差异。主要结局是全因死亡率。
最终研究人群包括3529例接受侵入性治疗的患者，中位年龄为66岁（四分位间距：58 - 74岁），其中1837例（52%）接受了早期治疗。有483例（14%）患者至少患有中度CKD（估计肾小球滤过率[eGFR]<45 mL/min/1.73 m²）。在中位随访4年（四分位间距：2 - 6年）期间，527例（15%）患者死亡。经过逆概率治疗加权后，与延迟策略相比，早期侵入性策略与死亡率显著降低30%相关（风险比：0.7；95%置信区间：0.56 - 0.85）。早期侵入性策略与死亡率之间的关联因eGFR而改变（P<0.001），且随着肾功能降低而下降，eGFR<45 mL/min/1.73 m²的患者死亡率无差异（风险比：0.89；95%置信区间：0.64 - 1.24）。
在NSTEMI患者中，早期侵入性策略与长期生存之间的关联因CKD而改变，在eGFR<45 mL/min/1.73 m²的患者中未观察到这种关联。
