# How are treatment decisions for myocardial infarction made in the presence of advanced kidney disease? A qualitative study in the UK

## TL;DR

This study explores how doctors and patients with kidney disease make treatment decisions for heart attacks in the UK, finding that clinicians often avoid aggressive treatments due to fears of harm.

## Contribution

The study reveals how clinicians' reluctance to follow guidelines and limited patient involvement affect treatment decisions for heart attacks in patients with kidney disease.

## Key findings

- Patients with CKD reported minimal involvement in treatment decisions despite having strong health priorities.
- Clinicians often avoided active treatment due to concerns about causing harm, relying on personal experiences over guidelines.
- Improved teamworking and clinical safety-nets may help increase treatment access for MI in CKD patients.

## Abstract

To understand why patients with chronic kidney disease (CKD) may not be treated according to international guidelines for myocardial infarction (MI).

Multicentre qualitative interview study. Interviews were analysed using reflexive thematic analysis approach as outlined by Braun and Clarke to generate themes associated with MI treatment decision-making for, and by, patients with CKD.

Four National Health Service hospital centres in the UK (February 2022 to July 2024).

A purposive sample of 46 participants (patients and clinicians). Clinicians (n=32) were senior doctors-in-training or consultants in cardiology, nephrology, acute or emergency care or cardiac surgery. Patient participants (n=14) had CKD, defined as an estimated glomerular filtration rate <60 mL/min/1.73 m2, or receipt of kidney replacement therapy (KRT).

Despite expressing strong views regarding their health priorities, patients reported minimal involvement in treatment decision-making. Decision-making by clinicians was driven by the desire to avoid causing harm to patients by ‘active’ treatment initiation. In general, despite the concept of evidence-based medicine being widely accepted, there remained scepticism of guidelines or epidemiological data, especially in the light of personal adverse experiences or anecdotes. Clinicians described how, in the absence of collaborative decision-making and a clinical safety-net for managing treatment complications, they tended to make conservative treatment decisions for patients with CKD.

Interventions to foster teamworking between specialists and ensure adequately resourced specialist clinical service safety-nets may improve access to treatments for MI for people with CKD. Intervention development and evaluation should follow to determine if outcomes for people with CKD and MI can be improved.