Elevated admission microalbuminuria predicts poor myocardial blood flow and 6-month mortality in ST-segment elevation myocardial infarction patients undergoing primary percutaneous coronary intervention

Admission proteinuria predicts the incidence of acute kidney injury among patients with acute ST-segment elevation myocardial infarction: a retrospective cohort study

BACKGROUND

Proteinuria indicates renal dysfunction and is associated with the development of acute kidney injury (AKI) in several conditions, but the association between proteinuria and AKI in patients with ST-segment elevation myocardial infarction (STEMI) remains unclear. This research aims to investigate the predictive value of proteinuria for the development of AKI in STEMI patients.

METHODS

A total of 2735 STEMI patients were enrolled. The present study's endpoint was AKI incidence during hospitalization. AKI is defined according to the Kidney Disease: Improving Global Outcomes criteria. We defined proteinuria, measured with a dipstick, as mild (1+) or heavy (2+ to 4+). Multivariate logistic regression and subgroup analyses were used to testify to the association between proteinuria and AKI.

RESULTS

Overall, proteinuria was observed in 634 (23.2%) patients. Multivariate logistic regression analyses revealed that proteinuria [odds ratio (OR), 1.58; 95% confidence interval (CI), 1.25-2.00; P  < 0.001] was the independent predictive factor for AKI. Severe proteinuria was associated with a higher adjusted risk for AKI compared with the nonproteinuria group (mild proteinuria: OR, 1.35; 95% CI, 1.04-1.75; P  = 0.025; severe proteinuria: OR, 2.50; 95% CI, 1.70-3.68; P  < 0.001). The association was highly consistent across all studied subgroups. (all P for interaction >0.05).

CONCLUSION

Admission proteinuria measured using a urine dipstick is an independent risk factor for the development of AKI in STEMI patients.

Microalbuminuria during acute coronary syndrome: Association with 22-year mortality and causes of death. The ABC-8* study on heart disease. (*ABC is an acronym for Adria, Bassano, Conegliano, and Padova Hospitals)

BACKGROUND

Microalbuminuria is associated with adverse outcomes in acute coronary syndrome (ACS) patients.

METHODS

To evaluate the very long-term association between Microalbuminuria and the overall mortality and causes of death in this clinical setting, we prospectively studied 579 unselected ACS patients admitted to three hospitals. The baseline albumin-to-creatinine ratio (ACR) was measured on days 1, 3, and 7 in 24-h urine samples. Patients were followed for 22 years or until death.

RESULTS

Virtually all patients completed follow-up; 449(78%) had died: 41% due to non-sudden cardiac death (non-SCD), 19% sudden cardiac death (SCD), 40% due to non-cardiac (non-CD) death. Using unadjusted Cox regression analysis, ACR was a significant predictor of all-cause mortality (hazard ratio [HR] 1.26;95%confidence interval [CI] 1.22-1.31; p˂0.0001) and the three causes of death (HR 1.40;95%CI 1.32-1.48; p˂0.0001), (HR 1.22;95%CI 1.12-1.32; p˂0.0001) and (HR 1.16;95%CI 1.09-1.23; p˂0.0001) for non-SCD, SCD and non-CD respectively. Using a fully adjusted model, ACR was a significant independent predictor of all-cause mortality (HR 1.12; 95%CI 1.08-1.16; p˂0.0001) and only non-SCD (HR 1.21; 95%CI 1.14-1.29; p˂0.0001). There was a positive interaction between ACR level and history of AMI (HR 1.15; 95%CI 1.03-1.29; p = 0.01) and the presence of heart failure at admission (HR 1.11; 95%CI 1.01-1.24; p = 0.04), and negative interaction with higher than median LVEF (HR 0.89; 95%CI 0.80-0.99; p = 0.03) for all-cause mortality at the multivariable level.

CONCLUSION

Based on the present analysis, baseline urinary albumin excretion during ACS is a strong independent predictor of the very long-term mortality risk, chiefly due to non-sudden cardiac death.

Low serum albumin: A neglected predictor in patients with cardiovascular disease

Albumin, the most abundant circulating protein in blood, is an essential protein which binds and transports various drugs and substances, maintains the oncotic pressure of blood and influences the physiological function of the circulatory system. Albumin also has anti-inflammatory, antioxidant, and antithrombotic properties. Evidence supports albumin's role as a strong predictor of cardiovascular (CV) risk in several patient groups. Its protective role extends to those with coronary artery disease, heart failure, hypertension, atrial fibrillation, peripheral artery disease or ischemic stroke, as well as those undergoing revascularization procedures or with aortic stenosis undergoing transcatheter aortic valve replacement, and patients with congenital heart disease and/or endocarditis. Hypoalbuminemia is a strong prognosticator of increased all-cause and CV mortality according to several cohort studies and meta-analyses in hospitalized and non-hospitalized patients with or without comorbidities. Normalization of albumin levels before discharge lowers mortality risk, compared with hypoalbuminemia before discharge. Modified forms of albumin, such as ischemia modified albumin, also has prognostic value in patients with coronary or peripheral artery disease. When albumin is combined with other risk factors, such as uric acid or C-reactive protein, the prognostic value is enhanced. Although albumin supplementation may be a plausible approach, its efficacy has not been established and in patients with hypoalbuminemia, priority is focused on diagnosing and managing the underlying condition. The CV effects of hypoalbuminemia and relevant issues are considered in this review. Large cohort studies and meta-analyses are tabulated and the physiologic effects of albumin and the deleterious effects of low albumin are pictorially illustrated.

Long-Term Variation in Kidney Function and Its Impact After Acute Myocardial Infarction

Kidney disease (KD) in patients with acute myocardial infarction (AMI) is associated with major cardiovascular events (MACE). We sought to compare the long-term variation in KD in patients with AMI versus controls and its value as a risk factor for MACE in patients with AMI. A cohort of 300 outpatients with AMI, recruited between 2014 and 2016 in Barcelona, Spain, were compared with a control cohort matched 1:1 based on age and several risk factors for developing KD. Annual estimated glomerular filtration rate (eGFR) using MDRD-4 formula and albuminuria were collected and patients were followed up for the occurrence of MACE (death, heart failure hospitalization, AMI, or stroke). After a median follow-up of 5.3 years, the decline in eGFR was more pronounced in patients with AMI (-1.15 ml/min/1.73 m²/ per year in patients with AMI vs -0.81 ml/min/1.73 m² per year in controls, p = 0.018 between the ß coefficients of both regression slopes). In patients with AMI, those with the greatest eGFR decline during follow-up had more MACE (hazard ratio [HR] for first vs fourth quartiles = 3.33, p <0.001). In multivariate analysis, after excluding patients with baseline KD, a newly diagnosed eGFR <60 ml/min/1.73 m² during follow-up was associated with MACE (HR = 3.21, p <0.001), as well as new onset albuminuria >30 mg/g (HR = 6.93, p <0.001) and the combination of both (HR 5.63, p <0.001). In conclusion, the decline in eGFR after AMI is more pronounced than in the general population. A longitudinal drop in eGFR and newly diagnosed albuminuria during follow-up are associated with MACE and can be useful tools to reclassify the risk profile after AMI.

Urinary Alpha1-Microglobulin: A New Predictor for In-Hospital Mortality in Patients with ST-Segment Elevation Myocardial Infarction

BACKGROUND Alpha1-microglobulin (A1MG) is a small molecular protein related to oxidation and inflammation. It exists in diverse body fluids, including urine. Results from urine tests are sometimes neglected when predicting in-hospital prognosis. It remains unclear whether urinary A1MG (UA1MG) can predict short-term prognosis of ST-elevated myocardial infarction (STEMI). MATERIAL AND METHODS A total of 1854 hospitalized patients with acute STEMI were retrospectively enrolled in our study. Medical records were used to obtain patient demographic and clinical information, UA1MG values (which were used to divide patients into groups of low, medium, or high), and other laboratory parameters. Principal clinical outcomes of interest were all-cause in-hospital deaths, cardiac deaths, and major adverse cardiac events (MACEs). RESULTS Among the 1854 enrolled patients, 43 (2.3%) died in the hospital, of which 33 (1.8%) were cardiac deaths. MACEs were noted in 113 patients (6.1%) during hospitalization. The group with the highest UA1MG value showed a significantly higher frequency of in-hospital deaths, cardiac deaths, and MACEs, compared to those of the lowest UA1MG value group (4.4% vs. 1.0%, P<0.001; 3.1% vs. 0.6%, P<0.005; and 8.6% vs. 4.7%, P=0.007, respectively). Multivariate regression analysis revealed that UA1MG levels (odds ratio 1.109, 95% confidence interval (CI) 1.027-1.197, P=0.008) independently predicted all-cause in-hospital mortality. A UA1MG value of 3.23 mg/dL was considered as an optimal cutoff point in STEMI to predict all-cause mortality after receiver operating characteristic curve analysis (area under the curve 0.73, 95% CI 0.65-0.80, P<0.001). CONCLUSIONS The UA1MG value at hospital admission could be an independent prognostic factor of all-cause in-hospital mortality in patients with STEMI.

Albuminuria as a Predictor of Cardiovascular Outcomes in Patients With Acute Myocardial Infarction

Background In patients with myocardial infarction ( MI ), reduced kidney function is recognized as an important predictor of poor prognosis, but the impact of albuminuria, a representative measure of kidney damage, has not been extensively evaluated. Methods and Results In the SCREAM (Stockholm Creatinine Measurements) project (2006-2012), we identified 2469 patients with incident MI with dipstick proteinuria measured within a year before MI (427 patients also had urine albumin to creatinine ratio [ ACR ] measured concurrently) and obtained estimates for ACR with multiple imputation in participants with data solely on dipstick proteinuria. We quantified the association of ACR with the post- MI composite and individual outcomes of all-cause mortality, cardiovascular mortality, recurrent MI , ischemic stroke, or heart failure using Cox models and then evaluated the improvement in C statistic. During a median follow-up of 1.0 year after MI , 1607 participants (65.1%) developed the post- MI composite outcome. Higher ACR levels were independently associated with all outcomes except for ischemic stroke. Per 8-fold higher ACR (eg, 40 versus 5 mg/g), the hazard ratio of composite outcome was 1.21 (95% CI , 1.08-1.35). The addition of the ACR improved the C statistic of the post- MI composite by 0.040 (95% CI, 0.030-0.051). Largely similar results were obtained regardless of diabetic status and when ACR or dipstick was separately analyzed without imputation. Conclusions In patients with MI , albuminuria was a potent predictor of subsequent outcomes, suggesting the importance of paying attention to the information on albuminuria, in addition to kidney function, in this high-risk population.

Cardiovascular Disease and Type 2 Diabetes: Has the Dawn of a New Era Arrived?

Hyperglycemia is the major risk factor for microvascular complications in patients with type 2 diabetes (T2D). However, cardiovascular disease (CVD) is the principal cause of death, and lowering HbA1c has only a modest effect on reducing CVD risk and mortality. The recently published LEADER and SUSTAIN-6 trials demonstrate that, in T2D patients with high CVD risk, the glucagon-like peptide 1 receptor agonists liraglutide and semaglutide reduce the primary major adverse cardiac events (MACE) end point (cardiovascular death, nonfatal myocardial infarction, nonfatal stroke) by 13% and 24%, respectively. The EMPA-REG OUTCOME, IRIS (subjects without diabetes), and PROactive (second principal end point) studies also demonstrated a significant reduction in cardiovascular events in T2D patients treated with empagliflozin and pioglitazone. However, the benefit of these four antidiabetes agents (liraglutide, semaglutide, empagliflozin, and pioglitazone) on the three individual MACE end points differed, suggesting that different underlying mechanisms were responsible for the reduction in cardiovascular events. Since liraglutide, semaglutide, pioglitazone, and empagliflozin similarly lower the plasma glucose concentration but appear to reduce CVD risk by different mechanisms, there emerges the intriguing possibility that, if used in combination, the effects of these antidiabetes agents may be additive or even multiplicative with regard to cardiovascular benefit.

Long-term statin use before primary percutaneous coronary intervention improves treatment outcomes of acute myocardial infarction

Numerous studies have reported that high-dose statin loading therapy prior to primary percutaneous coronary intervention (PPCI) improves the clinical outcomes of patients following acute myocardial infarction (AMI). However, little is known about the effects of long-term statin use prior to PPCI on such outcomes. Therefore, the aim of the present analysis was to clarify the effects of long-term statin use before PPCI on the treatment outcomes of patients following AMI. The records of 213 patients who had AMI and met the inclusion criteria were retrospectively reviewed. Patients were divided into two groups: A control group (n=178) who had received no statin pretreatment before AMI onset, and a statin group (n=35) who had received statin treatment for ≥1 month before AMI onset. All patients received a standard treatment regimen for the secondary prevention of coronary artery disease after PPCI. Baseline clinical variables, details of the PPCI procedure and clinical outcomes within 3 months after treatment were reviewed. Patients in the statin group were significantly older than those in the control group (P=0.003). Compared with the control group, there was a greater proportion of patients with hyperlipidemia and previous angina pectoris in the statin group. There were no differences in the use of other drugs (aspirin, β-blockers and angiotensin-converting enzyme inhibitors) prior to PPCI between the two groups. The corrected TIMI frame count (cTFC) was significantly lower in the statin group than in the control group (24.1±12.8 vs. 29.4±14.3, respectively; P=0.043). Multivariable linear regression analysis showed that long-term statin use before AMI was a significant predictor of cTFC after PPCI (P=0.012). Furthermore, the incidence of major adverse cardiac events within 3 months after PPCI was higher in the control group than in the statin group (16.8 vs. 2.9%, respectively; P=0.032). Logistic regression analysis showed that previous statin use was associated with the incidence of major adverse cardiac events within 3 months after treatment (P=0.012). The results of the present study demonstrate that long-term statin use prior to PPCI improved treatment outcomes after AMI in actual clinical practice.

ST elevation myocardial infarction: recent advances and updates

ST elevation myocardial infarction (STEMI) remains a leading cause of morbidity, mortality and disability worldwide. Statistically, a trend towards improvements in morbidity and mortality has been consistent over the years, which is attributed primarily to the modification of risk factors, healthier lifestyles, treatment advances and better management of door-to-balloon times via STEMI systems. However, a major challenge in the coming years will be the baby boomers (born between the years 1946 and 1964) coming into old age. The first baby boomers turned 65 in year 2011. As the baby boomers age in the coming years, the incidence of coronary heart disease is likely to increase, and so there will be a greater need to have major advances in the management of coronary heart disease in order to deal with this additional incidence. The scope of this article is to review recent advances in the management of STEMI and to provide an updated overview.

Microalbuminuria in non-diabetic STEMI: an independent predictor for acute kidney injury

AIMS

To assess the impact of microalbuminuria on the development of acute kidney injury and to investigate its prognostic role at long term follow-up in 526 consecutive patients with ST elevation myocardial infarction without previously known diabetes.

METHODS

Microalbuminuria was measured using immunonephelemetry in the urine collected in the night.

RESULTS

Patients with microalbuminuria were older (p = 0.013). They showed higher values of peak glycemia (p = 0.017), peak Tn I (p < 0.001), NT-pro BNP (p = 0.020), ESR (p = 0.003), CRP (p = 0.020), and leukocyte count (p < 0.001). Lower eGFR was observed in patients with microalbuminuria both on admission and during ICCU stay (p = 0.048 and p = 0.003, respectively). A positive correlation was observed between CRP and microalbuminuria (Spearman's rho 0.114, p = 0.024). The composite end point was observed in 73 patients (18 patients died and 59 patients developed acute kidney injury). At multivariable regression analysis, microalbuminuria was an independent predictor of acute kidney injury. At follow-up [42.6 (25th-75th percentile, 17.5-56.8) months], Kaplan-Meier curve analysis showed that patients with microalbuminuria had a lower survival rate in respect to patients without microalbuminuria. Cox regression analysis documented that microalbuminuria was an independent predictor of long term mortality (HR: 1.089; 97% CI 1.036-1.145; p < 0.001).

CONCLUSIONS

In a large series of STEMI patients without previously known diabetes submitted to PCI, microalbuminuria, as a marker of endothelial permeability following higher systemic inflammatory activation and larger infarct lesions, is an independent predictor for the development acute kidney injury. Furthermore, microalbuminuria identifies a subset of patients at higher risk for long term mortality.