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Treatment Effect of Percutaneous Coronary Intervention in Dialysis Patients With ST-Elevation Myocardial Infarction.

RATIONALE & OBJECTIVE
Patients receiving maintenance dialysis have higher mortality following primary percutaneous coronary intervention (pPCI) than patients not receiving dialysis. Whether pPCI confers a similar benefit to patients receiving dialysis remains unknown. We compared the effect of pPCI on in-hospital outcomes among patients hospitalized for STEMI and receiving maintenance dialysis to the effect among patients hospitalized for STEMI but not receiving dialysis.


STUDY DESIGN
Retrospective cohort study.


SETTING & PARTICIPANTS
We used the National-Inpatient-Sample (2016-2018) and included all adult hospitalizations with a primary diagnosis of STEMI.


PREDICTORS
Primary exposure was PCI. Confounders included dialysis status, demographics, insurance, household income, comorbidities, and the elective nature of the admission.


OUTCOMES
In-hospital mortality, stroke, AKI, new dialysis requirements, vascular complications, gastrointestinal bleeding, blood transfusion, mechanical ventilation, palliative care, and discharge destination.


ANALYTICAL APPROACH
The average treatment effect [ATE] of pPCI was estimated using propensity score matching within ESRD and non-ESRD groups independently to explore if the effect is modified by ESRD status. Additionally, the average marginal effect [AME] was calculated accounting for the clustering within hospitals.


RESULTS
4,220 (1.07%) out of 413,500 hospitalizations were for patients receiving dialysis. The dialysis cohort was older (65.2±12.2 vs. 63.4±13.1, p<0.001), had more females (42.4% vs. 30.6%, p<0.001) and more comorbidities, but fewer White patients (41.1% vs. 71.7%, p<0.001). Patients receiving dialysis underwent less angiography (73.1% vs. 85.4%, p<0.001) or pPCI (57.5% vs. 79.8%, p<0.001). pPCI was associated with lower mortality in patients receiving dialysis (15.7% vs. 27.1%, p<0.001) as well as in those who were not (5.0% vs. 17.4%, p<0.001). The ATE on mortality did not differ significantly between patients receiving dialysis (-8.6% [-15.6%, -1.6%], p=0.02) and those who were not (-8.2% [-8.8%, -7.5%], p<0.001 (p-interaction=0.9). The AME method showed similar results (-9.4% [-14.8%, -4.0%], p<0.001) among patients receiving dialysis and those who were not (-7.9% [-8.5%, -7.4%], p<0.001) (p-interaction=0.59). Both the ATE and AME were comparable for other in-hospital outcomes in both groups.


LIMITATIONS
Administrative data, lack of pharmacotherapy and long-term outcome data, and residual confounding.


CONCLUSION
Compared with conservative management, pPCI for STEMI was associated with comparable reductions in short-term mortality among patients irrespective of their receipt of maintenance dialysis.