Vol 31, No 2 (2024)
Original Article
Published online: 2023-05-26

open access

Page views 846
Article views/downloads 362
Get Citation

Connect on Social Media

Connect on Social Media

Effect of delayed hospitalization on 3-year clinical outcomes according to renal function in patients with non-ST-segment elevation myocardial infarction

Yong Hoon Kim1, Ae-Young Her1, Seung-Woon Rha2, Cheol Ung Choi2, Byoung-Geol Choi3, JI Bak Kim2, Soohyung Park2, Dong Oh Kang2, Ji Young Park4, Sang-Ho Park5, Myung Ho Jeong6
Pubmed: 37246457
Cardiol J 2024;31(2):271-284.


Background: We evaluated the effect of delayed hospitalization (symptom-to-door time [STD] ≥ 24 h) on 3-year clinical outcomes according to renal function in patients with non-ST-segment elevation myocardial infarction (NSTEMI) undergoing new-generation drug-eluting stent (DES) implantation. Methods: A total of 4513 patients with NSTEMI were classified into chronic kidney disease (CKD) (estimated glomerular filtration rate [eGFR] < 60 mL/min/1.73 m2, n = 1118) and non-CKD (eGFR ≥ 60 mL/min/1.73 m2, n = 3395) groups. They were further sub-classified into groups with (STD ≥ 24 h) and without (STD < 24 h) delayed hospitalization. The primary outcome was the occurrence of major adverse cardiac and cerebrovascular events (MACCE), defined as all-cause death, recurrent myocardial infarction, any repeat coronary revascularization, and stroke. The secondary outcome was stent thrombosis (ST). Results: After multivariable-adjusted and propensity score analyses, the primary and secondary clinical outcomes were similar in patients with or without delayed hospitalization in both CKD and non-CKD groups. However, in both the STD < 24 h and STD ≥ 24 h groups, MACCE (p < 0.001 and p < 0.006, respectively) and mortality rates were significantly higher in the CKD group than in the non-CKD group. However, ST rates were similar between the CKD and non-CKD groups and between the STD < 24 h and STD ≥ 24 h groups. Conclusions: Chronic kidney disease appears to be a much more important determinant of MACCE and mortality rates than STD in patients with NSTEMI.

Article available in PDF format

View PDF Download PDF file


  1. Rakowski T, Dudek D, Dziewierz A, et al. Impact of infarct-related artery patency before primary PCI on outcome in patients with ST-segment elevation myocardial infarction: the HORIZONS-AMI trial. EuroIntervention. 2013; 8(11): 1307–1314.
  2. Collet JP, Thiele H, Barbato E, et al. ESC Scientific Document Group. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J. 2021; 42(14): 1289–1367.
  3. Lawton JS, Tamis-Holland JE, Bangalore S, et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2022; 79(2): e21–e2e129.
  4. Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC Guideline for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014; 64(24): e139–e228.
  5. Eggers KM, James SK, Jernberg T, et al. Timing of coronary angiography in patients with non-ST-elevation acute coronary syndrome: long-term clinical outcomes from the nationwide SWEDEHEART registry. EuroIntervention. 2022; 18(7): 582–589.
  6. Badings EA, Hermanides RS, Van Der Sluis A, et al. Use, timing and outcome of coronary angiography in patients with high-risk non-ST-segment elevation acute coronary syndrome in daily clinical practice: insights from a 'real world' prospective registry. Neth Heart J. 2019; 27(2): 73–80.
  7. Hoedemaker NPG, Damman P, Woudstra P, et al. Early invasive versus selective strategy for non-ST-segment elevation acute coronary syndrome: the ICTUS trial. J Am Coll Cardiol. 2017; 69(15): 1883–1893.
  8. Meisel SR, Kleiner-Shochat M, Abu-Fanne R, et al. Direct admission of patients with st-segment-elevation myocardial infarction to the catheterization laboratory shortens pain-to-balloon and door-to-balloon time intervals but only the pain-to-balloon interval impacts short- and long-term mortality. J Am Heart Assoc. 2021; 10(1): e018343.
  9. Denktas AE, Anderson HV, McCarthy J, et al. Total ischemic time: the correct focus of attention for optimal ST-segment elevation myocardial infarction care. JACC Cardiovasc Interv. 2011; 4(6): 599–604.
  10. Cha JJ, Bae S, Park DW, et al. Clinical outcomes in patients with delayed hospitalization for non-ST-segment elevation myocardial infarction. J Am Coll Cardiol. 2022; 79(4): 311–323.
  11. Anavekar NS, McMurray JJV, Velazquez EJ, et al. Relation between renal dysfunction and cardiovascular outcomes after myocardial infarction. N Engl J Med. 2004; 351(13): 1285–1295.
  12. Washam JB, Herzog CA, Beitelshees AL, et al. American Heart Association Clinical Pharmacology Committee of the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, Council on Functional Genomics and Translational Biology, Council on the Kidney in Cardiovascular Disease, and Council on Quality of Care and Outcomes Research. Pharmacotherapy in chronic kidney disease patients presenting with acute coronary syndrome: a scientific statement from the American Heart Association. Circulation. 2015; 131(12): 1123–1149.
  13. Majmundar M, Ibarra G, Kumar A, et al. Invasive versus medical management in patients with chronic kidney disease and non-ST-segment-elevation myocardial infarction. J Am Heart Assoc. 2022 [Epub ahead of print]; 11(12): e025205.
  14. Szummer K, Lundman P, Jacobson SH, et al. Relation between renal function, presentation, use of therapies and in-hospital complications in acute coronary syndrome: data from the SWEDEHEART register. J Intern Med. 2010; 268(1): 40–49.
  15. Neumann FJ, Sousa-Uva M, Ahlsson A, et al. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J. 2019; 40(2): 87–165.
  16. Kim JH, Chae SC, Oh DJ, et al. Korea Acute Myocardial Infarction-National Institutes of Health Registry Investigators. Multicenter Cohort Study of Acute Myocardial Infarction in Korea - Interim Analysis of the Korea Acute Myocardial Infarction Registry-National Institutes of Health Registry. Circ J. 2016; 80(6): 1427–1436.
  17. Grech ED. ABC of interventional cardiology: percutaneous coronary intervention. II: the procedure. BMJ. 2003; 326(7399): 1137–1140.
  18. Levey AS, Stevens LA, Schmid CH, et al. CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration). A new equation to estimate glomerular filtration rate. Ann Intern Med. 2009; 150(9): 604–612.
  19. Eknoyan G. National Kidney Foundation. K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Am J Kidney Dis. 2002; 39(2 Suppl 1): S1–S266.
  20. Pieper KS, Gore JM, FitzGerald G, et al. Global Registry of Acute Coronary Events (GRACE) Investigators. Validity of a risk-prediction tool for hospital mortality: the Global Registry of Acute Coronary Events. Am Heart J. 2009; 157(6): 1097–1105.
  21. Oh S, Hyun DY, Cho KH, et al. Long-term outcomes in ST-elevation myocardial infarction patients treated according to hospital visit time. Korean J Intern Med. 2022; 37(3): 605–617.
  22. Sacco RL, Kasner SE, Broderick JP, et al. An updated definition of stroke for the 21st century: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013; 44(7): 2064–2089.
  23. Lee JM, Rhee TM, Hahn JY, et al. Multivessel percutaneous coronary intervention in patients with ST-segment elevation myocardial infarction with cardiogenic shock. J Am Coll Cardiol. 2018; 71(8): 844–856.
  24. Cutlip DE, Windecker S, Mehran R, et al. Clinical end points in coronary stent trials: a case for standardized definitions. Circulation. 2007; 115(17): 2344–2351.
  25. Kim YH, Her AY, Jeong MHo, et al. Impact of renin-angiotensin system inhibitors on long-term clinical outcomes in patients with acute myocardial infarction treated with successful percutaneous coronary intervention with drug-eluting stents: Comparison between STEMI and NSTEMI. Atherosclerosis. 2019; 280: 166–173.
  26. Vatcheva KP, Lee M, McCormick JB, et al. Multicollinearity in regression analyses conducted in epidemiologic studies. Epidemiology (Sunnyvale). 2016; 6(2).
  27. Kim JH. Multicollinearity and misleading statistical results. Korean J Anesthesiol. 2019; 72(6): 558–569.
  28. Kalantari S, Khalili D, Asgari S, et al. Predictors of early adulthood hypertension during adolescence: a population-based cohort study. BMC Public Health. 2017; 17(1): 915.
  29. McKee G, Mooney M, O'Donnell S, et al. Multivariate analysis of predictors of pre-hospital delay in acute coronary syndrome. Int J Cardiol. 2013; 168(3): 2706–2713.
  30. Ting HH, Bradley EH, Wang Y, et al. Factors associated with longer time from symptom onset to hospital presentation for patients with ST-elevation myocardial infarction. Arch Intern Med. 2008; 168(9): 959–968.
  31. Kim YH, Her AY, Jeong MH, et al. Impact of stent generation on 2-year clinical outcomes in ST-segment elevation myocardial infarction patients with multivessel disease who underwent culprit-only or multivessel percutaneous coronary intervention. Catheter Cardiovasc Interv. 2020; 95(2): E40–E55.
  32. Kim YH, Her AY, Jeong MHo, et al. Two-year outcomes between ST-elevation and non-ST-elevation myocardial infarction in patients with chronic kidney disease undergoing newer-generation drug-eluting stent implantation. Catheter Cardiovasc Interv. 2022; 99(4): 1022–1037.
  33. Jobs A, Mehta SR, Montalescot G, et al. Optimal timing of an invasive strategy in patients with non-ST-elevation acute coronary syndrome: a meta-analysis of randomised trials. Lancet. 2017; 390(10096): 737–746.
  34. Bonello L, Laine M, Puymirat E, et al. Timing of coronary invasive strategy in non-ST-Segment elevation acute coronary syndromes and clinical outcomes: an updated meta-analysis. JACC Cardiovasc Interv. 2016; 9(22): 2267–2276.
  35. Kim YH, Her AY, Jeong MHo, et al. Outcome of early versus delayed invasive strategy in patients with non-ST-segment elevation myocardial infarction and chronic kidney disease not on dialysis. Atherosclerosis. 2022; 344: 60–70.
  36. Leszek A, Poli L, Zbinden S, et al. Outcomes with revascularization and medical therapy in patients with coronary disease and chronic kidney disease: A meta-analysis. Atherosclerosis. 2022; 351: 41–48.
  37. Kim YH, Her AY, Jeong MHo, et al. Outcomes of different reperfusion strategies of multivessel disease undergoing newer-generation drug-eluting stent implantation in patients with non-ST-elevation myocardial infarction and chronic kidney disease. J Clin Med. 2021; 10(20).
  38. De Luca G, Suryapranata H, Ottervanger JP, et al. Time delay to treatment and mortality in primary angioplasty for acute myocardial infarction: every minute of delay counts. Circulation. 2004; 109(10): 1223–1225.
  39. Savage ML, Hay K, Murdoch DJ, et al. Clinical outcomes in pre-hospital activation and direct cardiac catheterisation laboratory transfer of STEMI for primary PCI. Heart Lung Circ. 2022; 31(7): 974–984.
  40. Bassand JP, Hamm CW, Ardissino D, et al. Guidelines for the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes. Eur Heart J. 2007; 28(13): 1598–1660.
  41. Collins AJ, Li S, Gilbertson DT, et al. Chronic kidney disease and cardiovascular disease in the Medicare population. Kidney Int Suppl. 2003(87): S24–S31.
  42. Basalay MV, Yellon DM, Davidson SM. Targeting myocardial ischaemic injury in the absence of reperfusion. Basic Res Cardiol. 2020; 115(6): 63.
  43. London GM, Guérin AP, Marchais SJ, et al. Arterial media calcification in end-stage renal disease: impact on all-cause and cardiovascular mortality. Nephrol Dial Transplant. 2003; 18(9): 1731–1740.
  44. Tonelli M, Wiebe N, Culleton B, et al. Chronic kidney disease and mortality risk: a systematic review. J Am Soc Nephrol. 2006; 17(7): 2034–2047.