Aims:
To find out whether we can reduce death after heart attack for people with kidney disease.
Background:
Kidney disease is common. People with kidney disease die, on average, at a younger age than people without kidney disease. One of the most common causes of death is heart attack.
In the UK, 12 people suffer a heart attack every hour. Four out of 12 have kidney disease. New “gold-standard” heart attack treatments means that without kidney disease, nine out of ten people will be alive one year after their heart attack. For people with kidney disease, only five survive this long.
We do not know why people with kidney disease have worse survival after heart attack. Research from outside England shows that people with kidney disease are less likely to receive “gold standard” treatments for heart attack than those without kidney disease. Some evidence suggests that despite increased side effects, people with kidney disease who do receive “gold-standard” treatments do better. Doctors could therefore by accident be underusing treatments that could help people with kidney disease live longer.
Use of “gold-standard” heart attack treatments in people with kidney disease has not yet been studied in England.
Methods:
We will review English GP and hospital data to compare heart attack treatment between people with and without kidney disease and find out whether increased use of “gold-standard” treatments could improve survival in people with kidney disease. This will help me design interventions to improve heart attack treatment for people with kidney disease.
To determine the impact of chronic kidney disease (CKD) on care and outcomes of hospitalised myocardial infarction (MI) in England.
Coronary artery disease causes significant morbidity and mortality in people with CKD; survival is up to 15-fold worse than the general population. Research outside the UK demonstrates that people with CKD are less likely to receive guideline-based MI care than those without CKD. Variation in care may reflect an inappropriate restriction of access to effective treatment.
We will use a retrospective cohort design to determine the impact of CKD (primary exposure), and CKD stage on management and outcomes of hospitalised MI in England. Outcomes will include MI care, mortality and major adverse cardiac and renal events. We will determine the validity of CKD coding in HES-Admitted Patient Care (HES-APC).
Record-linkage between the Clinical Practice Research Datalink (CPRD), HES-APC, Office for National Statistics Death Registration and Patient level Index of Multiple Deprivation will be undertaken. Serum creatinine in CPRD will be used to identify CKD cases. Cases will be matched to controls a) without CKD who have had MI, b) without CKD or MI and c) with CKD but no MI, by age and sex using incidence density sampling.
We will describe MI care for people with and without CKD, and by CKD stage (objective 1) and use Cox regression analyses and Kaplan-Meier survival curves to determine outcomes (objective 2). Propensity-score adjusted multivariable regression and instrumental variable analysis will be employed to investigate equity of access to coronary angiography, a key gatekeeper to revascularisation (objective 3). Receiver Operating Characteristic curves will describe specificity and sensitivity of CKD algorithms in HES (objective 4). Understanding differences in outcomes and access to treatment for people with and without CKD in the UK, will inform future service redesign work to optimise care.
Outcomes: Receipt of preventative cardiovascular care
Prescription of cardioprotective medications and medication dose (antiplatelets, anticoagulants, antihypertensives, diuretics, lipid-lowering agents, nitrates and SGLT2 inhibitors) prior to admission with AMI.
Outcomes: Receipt of AMI care
Admission ward; admission to a coronary care unit; admission under a cardiologist; inter-hospital transfer(s); cardiac imaging during index hospitalisation; percutaneous coronary intervention (PCI, within 30 days of index event); coronary artery bypass graft (CABG, within 30 days of index event); prescription of cardioprotective medications and medication dose (antiplatelets, anticoagulants, antihypertensives, diuretics, lipid-lowering agents, nitrates and SGLT2 inhibitors) systolic blood pressure (12 months after index event); serum cholesterol (12 months after index event); attendance at a cardiac rehabilitation programme (within one year of index event).
Outcomes: Morbidity & mortality
Duration of inpatient admission; discharge to a care home; major adverse cardiac events (hospitalisation for heart failure, non-fatal acute coronary syndrome (ACS), cerebrovascular event (CVE) or cardiac arrhythmia, (further) coronary artery intervention, incident diagnosis of stable angina); major adverse renal events (incident end-stage kidney disease (ESKD) or renal transplant failure, doubling of serum creatinine, drop in estimated glomerular filtration rate (eGFR) of 30 points, death due to end-stage renal disease); bleeding; all-cause mortality; cardiovascular mortality (death from AMI, arrhythmia, heart failure or sudden cardiac death).
Jemima Scott - Chief Investigator - University of Bristol
Jemima Scott - Corresponding Applicant - University of Bristol
Fergus Caskey - Collaborator - University of Bristol
Neil Davies - Collaborator - University of Bristol
Pippa Bailey - Collaborator - University of Bristol
Rachel Johnson - Collaborator - University of Bristol
Yoav Ben-Shlomo - Collaborator - University of Bristol
Yoav Ben-Shlomo - Collaborator - University of Bristol
HES Admitted Patient Care;ONS Death Registration Data;Patient Level Index of Multiple Deprivation