Association of Coronary Revascularization Modality and Timing With Outcomes of Acute Coronary Syndrome in Kidney Transplant Recipients

Coronary artery disease (CAD) remains a leading cause of morbidity and mortality among renal transplant (RTx) recipients, with non-ST-segment-elevation acute coronary syndrome (NSTE-ACS) representing a disproportionately high burden. However, the optimal revascularization strategy for NSTE-ACS in RTx recipients remains unclear. This retrospective study analyzed the 2016 to 2021 Nationwide Readmissions Database. RTx recipients (≥18 years) undergoing coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) for NSTE-ACS were included. The primary outcome was in-hospital mortality, while perioperative complications, unplanned 30- and 90-day readmissions, repeat revascularization, and renal allograft failure were also considered. Multivariable logistic regression and Royston–Parmar models were used to identify the risk-adjusted association of revascularization modality, timing, and outcomes. Of an estimated 3,323 patients, 20.5% underwent CABG and 79.5% PCI. Following adjustment, CABG was associated with higher perioperative complications (AOR 3.46, 95% CI 2.31 to 5.19) and demonstrated a trend toward increased mortality risk (AOR 1.79, 95% CI 0.76 to 4.18). Royston–Parmar analysis demonstrated no difference in freedom from readmission or renal allograft failure within 90 days of discharge, but CABG was associated with a lower hazard of repeat revascularization (HR 0.24, 95% CI 0.08 to 0.76). Timing analysis revealed stable mortality rates across intervals for both modalities. While PCI complications increased with longer delays to revascularization, CABG demonstrated a more stable pattern. In conclusion, our findings suggest that PCI appears to be associated with lower risks of mortality and complications compared to CABG in RTx recipients with NSTE-ACS. However, CABG may offer benefits of reduced risk of repeat revascularization and greater flexibility in timing without compromising renal allograft function.