Long-term Care

Rates of coronary angiography are inappropriately low in older cardiac patients who have chronic kidney disease

A new study shows that Medicare patients with chronic kidney disease (CKD) who had a heart attack underwent coronary angiography at one-half the rate of similar individuals with normal or near-normal kidney function. Coronary angiography is an invasive imaging test used to diagnose the extent of heart damage. By conventional criteria, the procedure was just as appropriate for these CKD patients as it was for non-CKD patients. However, physicians are often reluctant to offer the procedure to patients aged 65 and older who have CKD because they perceive these patients to be at higher risk of nephrotoxicity (kidney toxicity that can lead to end-stage kidney disease) due to radiocontrast media that is introduced by catheter into patients during angiographic imaging.

According to the researchers, receipt of coronary angiography by CKD patients who were considered appropriate candidates for the procedure would reduce their odds of death by 42 percent. Thus, concern about the risks of kidney damage should not dissuade doctors from offering appropriate heart attack patients coronary angiography, notes lead investigator Glenn M. Chertow, M.D., M.P.H., of the University of California, San Francisco. The study was supported in part by the Agency for Healthcare Research and Quality (HS06503).

The researchers classified individuals aged 65 and older with heart attack from the Cooperative Cardiovascular Project by the presence or absence of CKD. They compared use of coronary angiography among CKD and non-CKD patients and the effects of the procedure on death.

Mortality was significantly higher for patients with CKD (53 vs. 26 percent). Fewer patients with CKD underwent coronary angiography (25 vs. 47 percent). Yet, the risk of death was reduced by 42 percent for those who underwent the procedure compared with those who did not. The results of this study suggest that the relative use of angiography in individuals with CKD is inappropriately low and probably not justified.

See "`Renalism': Inappropriately low rates of coronary angiography in elderly individuals with renal insufficiency," by Dr. Chertow, Sharon-Lise T. Normand, Ph.D., and Barbara J. McNeil, M.D., Ph.D., in the Journal of the American Society of Nephrology 15, pp. 2462-2468, 2004.

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