We aim to assess the differential effect of renal impairment across the spectrum of patients with ischaemic heart disease and to study if any established risk factors may modify this risk.

A total of 2013 patients who underwent revascularization for ST-segment elevation myocardial infarction or invasive physiology assessment were included. Renal impairment was defined as glomerular filtration rate less than 60 ml/min/1.73m². Clinical endpoints were prospectively collected, and the primary endpoint was defined as the composite endpoints of death, myocardial infarction, and unplanned revascularization.

593 (30%) presented with ST-segment elevation myocardial infarction, and 1362 (70%) stable patients had invasive ischaemia assessment which resulted in 37% receiving revascularization and 63% being deferred. Renal impairment was associated with increased adverse events in myocardial infarction [HR 1.77 (95% CI 1.15 to 2.74)], but not in the revascularized stable group [(HR 1.14 (95% CI 0.62 to 2.08)] or the deferred group [HR 1.31 (95% CI 0.84 to 2.03)]. There was an exponential increase in the future risk in ST-segment elevation myocardial infarction patients with severe renal dysfunction (glomerular filtration rate < 30) compared to a linear relationship in stable patients. Age and hypertension were the only two factors that had a differential impact across three groups (P<0.05 for interactions), with inconsistent directional effect of hypertension between medically managed and revascularized groups.

The magnitude of risk of renal impairment varies according to the clinical presentation of coronary artery disease with more weighted risk in myocardial infarction compared to stable patients.