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Scott J, Bidulka P, Taylor DM, Udayaraj U, Caskey FJ, Birnie K, Deanfield J, de Belder M, Denaxas S, Weston C, Adlam D, Nitsch D. Management and outcomes of myocardial infarction in people with impaired kidney function in England. BMC Nephrol 2023; 24:325. [PMID: 37919679 PMCID: PMC10623815 DOI: 10.1186/s12882-023-03377-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 10/23/2023] [Indexed: 11/04/2023] Open
Abstract
BACKGROUND Acute myocardial infarction (AMI) causes significant mortality and morbidity in people with impaired kidney function. Previous observational research has demonstrated reduced use of invasive management strategies and inferior outcomes in this population. Studies from the USA have suggested that disparities in care have reduced over time. It is unclear whether these findings extend to Europe and the UK. METHODS Linked data from four national healthcare datasets were used to investigate management and outcomes of AMI by estimated glomerular filtration rate (eGFR) category in England. Multivariable logistic and Cox regression models compared management strategies and outcomes by eGFR category among people with kidney impairment hospitalised for AMI between 2015-2017. RESULTS In a cohort of 5 835 people, we found reduced odds of invasive management in people with eGFR < 60mls/min/1.73m2 compared with people with eGFR ≥ 60 when hospitalised for non-ST segment elevation MI (NSTEMI). The association between eGFR and odds of invasive management for ST-elevation MI (STEMI) varied depending on the availability of percutaneous coronary intervention. A graded association between mortality and eGFR category was demonstrated both in-hospital and after discharge for all people. CONCLUSIONS In England, patients with reduced eGFR are less likely to receive invasive management compared to those with preserved eGFR. Disparities in care may however be decreasing over time, with the least difference seen in patients with STEMI managed via the primary percutaneous coronary intervention pathway. Reduced eGFR continues to be associated with worse outcomes after AMI.
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Affiliation(s)
- Jemima Scott
- Population Health Sciences, University of Bristol, Bristol, England.
- Richard Bright Renal Service, North Bristol NHS Trust, Southmead Hospital, Bristol, England.
| | - Patrick Bidulka
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, Keppel Street, London, England
| | - Dominic M Taylor
- Population Health Sciences, University of Bristol, Bristol, England
- Richard Bright Renal Service, North Bristol NHS Trust, Southmead Hospital, Bristol, England
| | - Udaya Udayaraj
- Oxford Kidney Unit, Churchill Hospital, Oxford, England
- Nuffield Department of Medicine, University of Oxford, Oxford, England
| | - Fergus J Caskey
- Population Health Sciences, University of Bristol, Bristol, England
- Richard Bright Renal Service, North Bristol NHS Trust, Southmead Hospital, Bristol, England
| | - Kate Birnie
- Population Health Sciences, University of Bristol, Bristol, England
| | - John Deanfield
- National Institute for Cardiovascular Outcomes Research (NICOR), NHS Arden & Greater East Midlands Commissioning Support Unit, Leicester, England
- Institute of Cardiovascular Sciences, University College London, London, UK
| | - Mark de Belder
- National Institute for Cardiovascular Outcomes Research (NICOR), NHS Arden & Greater East Midlands Commissioning Support Unit, Leicester, England
| | - Spiros Denaxas
- British Heart Foundation, Data Science Centre, London, UK
- University College London Hospitals Biomedical Research Centre, London, UK
| | - Clive Weston
- Glangwili General Hospital, Dolgwili Road, Carmarthen, Wales, UK
| | - David Adlam
- Department of Cardiovascular Sciences, University of Leicester, and NIHR Leicester Biomedical Research Centre, Leicester, UK
| | - Dorothea Nitsch
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, Keppel Street, London, England
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Fujii T, Ikari Y. Additional effect of hemodialysis on mortality estimated from renal function in ischemic heart disease. Future Cardiol 2022; 18:857-865. [PMID: 36169210 DOI: 10.2217/fca-2022-0036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Aim: The present study examined whether hemodialysis in patients with ischemic heart disease increases mortality more than the estimated mortality from renal function. Patients & methods: A total of 1621 patients with angina pectoris (n = 815), ST-elevation myocardial infarction (n = 421) or non-ST-elevation acute coronary syndrome (n = 385) were examined. An estimated mortality curve according to the estimated glomerular filtration rate was drawn using the marginal effect from the logit model. The probability of mortality in patients with hemodialysis was plotted on these curves. Results: The probability of mortality in patients undergoing hemodialysis crossed the estimated mortality curves at the estimated glomerular filtration rate of 5.7 ml/min/1.73 m2 in angina pectoris, 31.3 ml/min/1.73 m2 in STEMI and 45.9 ml/min/1.73 m2 in non-ST-elevation acute coronary syndrome. Conclusion: Hemodialysis does not have an additional adverse impact on the estimated mortality.
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Kırıs T, Avcı E, Çelik A. Combined value of left ventricular ejection fraction and the Model for End-Stage Liver Disease (MELD) score for predicting mortality in patients with acute coronary syndrome who were undergoing percutaneous coronary intervention. BMC Cardiovasc Disord 2018; 18:44. [PMID: 29499644 PMCID: PMC5833061 DOI: 10.1186/s12872-018-0782-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 02/23/2018] [Indexed: 12/16/2022] Open
Abstract
Background The purpose of the study was to investigate whether the addition of left ventricular ejection fraction (LVEF) to the MELD score enhances the prediction of mortality in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI). Methods This retrospective study analyzed 846 consecutive patients with ACS undergoing PCI who were not receiving previous anticoagulant therapy. The patients were grouped as survivors or non-survivors. The MELD score and LVEF were calculated in all patients. The primary end point was all-cause death during the median follow-up of 28 months. Results During the follow-up, there were 183 deaths (21.6%). MELD score was significantly higher in non-survivors than survivors (10.1 ± 4.4 vs 7.8 ± 2.4, p < 0.001). LVEF was lower in non-survivors compared with survivors (41.3 ± 11.8% vs. 47.5 ± 10.0%, p < 0.001). In multivariate analysis, both MELD score and LVEF were independent predictors of total mortality. (HR: 1.116, 95%CI: 1.069–1.164, p < 0.001; HR: 0.972, 95%CI: 0.958–0.986, p < 0.001, respectively). The addition of LVEF to MELD score was associated with significant improvement in predicting mortality compared with the MELD score alone (AUC:0.733 vs 0.690, p < 0.05). Also, the combining LVEF with MELD score improved the reclassification (NRI:24.6%, p < 0.001) and integrated discrimination (IDI:0.045, p < 0.001) of patients compared with MELD score alone. Conclusions Our study demonstrated that the combining LVEF with MELD score may be useful to predict long-term survival in patients with ACS who were undergoing PCI. Electronic supplementary material The online version of this article (10.1186/s12872-018-0782-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Tuncay Kırıs
- Department of Cardiology, Izmir Katip Celebi University, Ataturk Training and Research Hospital, 35360, Izmir, Turkey
| | - Eyüp Avcı
- Department of Cardiology, Balikesir University Faculty of Medicine, 10345, Balikesir, Turkey.
| | - Aykan Çelik
- Department of Cardiology, Izmir Katip Celebi University, Ataturk Training and Research Hospital, 35360, Izmir, Turkey
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Foraker RE, Guha A, Chang H, O'Brien EC, Bower JK, Crouser ED, Rosamond WD, Raman SV. Survival After MI in a Community Cohort Study: Contribution of Comorbidities in NSTEMI. Glob Heart 2018; 13:13-18. [PMID: 29409724 PMCID: PMC5963709 DOI: 10.1016/j.gheart.2018.01.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 12/24/2017] [Accepted: 01/05/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Non-ST-segment elevation myocardial infarction (NSTEMI) comprises the majority of MI worldwide, yet mortality remains high. Management of NSTEMI is relatively delayed and heterogeneous compared with the "time is muscle" approach to ST-segment elevation MI, though it is unknown to what extent comorbid conditions drive NSTEMI mortality. OBJECTIVES We sought to quantify mortality due to MI versus comorbid conditions in patients with NSTEMI. METHODS Participants of the ARIC (Atherosclerosis Risk in Communities) study cohort ages 45 to 64 years, who developed incident NSTEMI were identified and incidence-density matched to participants who did not experience an MI by age group, sex, race, and study community. We estimated hazard ratios for all-cause mortality, comparing those who developed NSTEMI to those who did not experience an MI. RESULTS ARIC participants with incident NSTEMI were more likely at baseline to be smokers, have diabetes and renal dysfunction, and take blood pressure or cholesterol-lowering medications than were participants who did not have an MI. Over one-half of participants experiencing NSTEMI died over a median follow-up of 8.4 years; incident NSTEMI was associated with 30% higher risk of mortality after adjusting for comorbid conditions (hazard ratio: 1.30; 95% confidence interval: 1.11 to 1.53). CONCLUSIONS NSTEMI confers a significantly higher mortality hazard beyond what can be attributed to comorbid conditions. More consistent and effective strategies are needed to reduce mortality in NSTEMI amid comorbid conditions.
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Affiliation(s)
- Randi E Foraker
- Division of Cardiovascular Medicine, Ohio State University, Columbus, OH, USA; Division of Epidemiology, College of Public Health, Ohio State University, Columbus, OH, USA; Davis Heart and Lung Research Institute, Ohio State University, Columbus, OH, USA
| | - Avirup Guha
- Division of Cardiovascular Medicine, Ohio State University, Columbus, OH, USA
| | - Henry Chang
- Davis Heart and Lung Research Institute, Ohio State University, Columbus, OH, USA
| | | | - Julie K Bower
- Division of Epidemiology, College of Public Health, Ohio State University, Columbus, OH, USA
| | - Elliott D Crouser
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Ohio State University, Columbus, OH, USA
| | - Wayne D Rosamond
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Subha V Raman
- Division of Cardiovascular Medicine, Ohio State University, Columbus, OH, USA; Davis Heart and Lung Research Institute, Ohio State University, Columbus, OH, USA.
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Rozenbaum Z, Benchetrit S, Minha S, Neuman Y, Shlezinger M, Goldenberg I, Mosseri M, Pereg D. The Effect of Admission Renal Function on the Treatment and Outcome of Patients with Acute Coronary Syndrome. Cardiorenal Med 2017; 7:169-178. [PMID: 28736557 DOI: 10.1159/000455239] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Accepted: 12/11/2016] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Chronic kidney disease is a frequent comorbidity among patients with acute coronary syndrome (ACS). We aimed to evaluate treatment characteristics in ACS patients according to their renal function and to assess the effect of differences in therapy on clinical outcomes. METHODS Included were patients with ACS enrolled in the biennial Acute Coronary Syndrome Israeli Surveys (ACSIS) during 2000-2013. Excluded were patients with cardiogenic shock at presentation. The estimated glomerular filtration rate (eGFR) was calculated using the simplified Modification of Diet in Renal Disease (MDRD) formula. The distribution of the eGFRs was divided into 4 categories (<45, 45-59.9, 60-74.9, and ≥75 mL/min/1.73 m2). The primary endpoint was all-cause mortality at 1 year. RESULTS A total of 13,194 patients with ACS were included. Patients with a reduced eGFR were less likely to be admitted to a coronary care unit and had lower rates of coronary angiograms and subsequent percutaneous coronary interventions. Furthermore, as the eGFR was lower, the patients were less frequently treated with aspirin, clopidogrel, β-blockers, and ACE inhibitors/angiotensin receptor blockers. We demonstrated an inverse association between renal function and 1-year mortality, with the highest mortality rates observed in the group with the lowest eGFR (HR = 3.8, 95% CI 2.9-4.9, p < 0.0001). Differences in mortality remained significant following a multivariate analysis for all the baseline characteristics as well as for invasive and medical treatment (HR = 2.7, 95% CI 1.9-3.7, p < 0.0001). CONCLUSIONS ACS patients with chronic kidney disease represent a high-risk group with an increased mortality risk. Despite this high risk, these patients are less frequently selected for an invasive treatment strategy and are less commonly treated with guideline-based medications. However, reduced renal function was associated with higher mortality regardless of the variations in therapy.
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Affiliation(s)
- Zach Rozenbaum
- Department of Internal Medicine D, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Sydney Benchetrit
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Nephrology and Hypertension, Meir Medical Center, Kfar Saba, Israel
| | - Saar Minha
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Cardiology Department, Assaf HaRofeh Medical Center, Tzrifin, Israel
| | - Yoram Neuman
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Cardiology, Meir Medical Center, Kfar Saba, Israel
| | - Meital Shlezinger
- Department of Cardiology, Sheba Medical Center, Tel HaShomer, Israel
| | - Ilan Goldenberg
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Cardiology, Sheba Medical Center, Tel HaShomer, Israel
| | - Morris Mosseri
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Cardiology, Meir Medical Center, Kfar Saba, Israel
| | - David Pereg
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Cardiology, Meir Medical Center, Kfar Saba, Israel
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Impact of chronic kidney disease on clinical outcomes in patients with non-ST elevation myocardial infarction receiving percutaneous coronary intervention - A five-year observational study. Int J Cardiol 2016; 220:166-72. [PMID: 27379919 DOI: 10.1016/j.ijcard.2016.06.184] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 06/24/2016] [Indexed: 11/22/2022]
Abstract
BACKGROUND Patients with chronic kidney disease (CKD) experience poor outcomes after acute myocardial infarction. This study investigated how CKD affects clinical outcomes in patients with non-ST segment elevation myocardial infarction (NSTEMI) receiving PCI. METHODS This retrospective study analyzed record-linked data for 314 patients who had received PCI for NSTEMI between January 2008 and September 2010. The 141 patients with advanced CKD were compared with 173 patients who had mild or no CKD. The primary endpoint was long-term mortality. The secondary endpoint was long-term major adverse cardiac events. RESULTS Compared to the control group, the advanced CKD group had older patients, more females, and more patients with diabetes mellitus and hypertension. The advanced CKD group also had a lower left ventricular ejection fraction and more patients with advanced HF and pulmonary edema. The advanced CKD group and the control group did not significantly differ in total in-hospital mortality, cardiac death or temporary hemodialysis post-PCI. The advanced CKD group had a significantly higher rate of long-term events. Finally, multiple stepwise Cox regression analysis showed that old age, advanced CKD and advanced HF were independent predictors of primary endpoint. The best predictors of secondary endpoint were post-PCI Thrombolysis in Myocardial Infarction-3 flow, multiple vessel disease, advanced HF and advanced CKD. CONCLUSIONS In NSTEMI patients undergoing PCI, in-hospital mortality does not significantly differ between patients with and without advanced CKD. However, long-term follow up of CKD patients consistently reveals poor outcomes.
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7
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Rozenbaum Z, Leader A, Neuman Y, Shlezinger M, Goldenberg I, Mosseri M, Pereg D. Prevalence and Significance of Unrecognized Renal Dysfunction in Patients with Acute Coronary Syndrome. Am J Med 2016; 129:187-94. [PMID: 26344629 DOI: 10.1016/j.amjmed.2015.08.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Revised: 08/22/2015] [Accepted: 08/24/2015] [Indexed: 12/26/2022]
Abstract
BACKGROUND Unrecognized renal insufficiency, defined as estimated glomerular filtration rate <60 mL/min/1.73 m(2) in the presence of normal serum creatinine, is common among patients with acute coronary syndrome. We aimed to determine the prevalence and clinical significance of unrecognized renal insufficiency in a large unselected population of patients with acute coronary syndrome. METHODS The study population consisted of patients with acute coronary syndrome included in the Acute Coronary Syndrome Israeli biennial Surveys during 2000-2013. The estimated glomerular filtration rate was calculated using the simplified Modification of Diet in Renal Disease formula. Patients were stratified into 3 groups: 1) normal renal function (estimated glomerular filtration rates ≥60 mL/min/1/73 m(2)); 2) unrecognized renal insufficiency (estimated glomerular filtration rates <60 mL/min/1/73 m(2) with serum creatinine ≤1.2 mg/dL); and 3) recognized renal insufficiency (estimated glomerular filtration rates <60 mL/min/1/73 m(2) with serum creatinine ≥1.2 mg/dL). The primary endpoint was all-cause mortality at 1 year. RESULTS Included in the study were 12,830 acute coronary syndrome patients. Unrecognized renal insufficiency was present in 2536 (19.8%). Patients with unrecognized renal insufficiency were older and more frequently females. All-cause mortality rates at 1 year were highest among patients with recognized renal insufficiency, followed by patients with unrecognized renal insufficiency, with the lowest mortality rates observed in patients with normal renal function (19.4%, 9.9%, and 3.3%, respectively, P <.0001). Despite their increased risk, patients with renal insufficiency were less frequently referred for coronary angiography and were less commonly treated with guideline-based cardiovascular medications. CONCLUSIONS Acute coronary syndrome patients with unrecognized renal insufficiency should be considered as a high-risk population. The question of whether this group would benefit from a more aggressive therapeutic approach should still be evaluated.
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Affiliation(s)
- Zach Rozenbaum
- Department of Internal Medicine D, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Avi Leader
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel; Department of Internal Medicine A, Meir Medical Center, Kfar Saba, Israel
| | - Yoram Neuman
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel; Department of Cardiology, Meir Medical Center, Kfar Saba, Israel
| | - Meital Shlezinger
- Department of Cardiology, Sheba Medical Center, Tel HaShomer, Israel
| | - Ilan Goldenberg
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel; Department of Cardiology, Sheba Medical Center, Tel HaShomer, Israel
| | - Morris Mosseri
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel; Department of Cardiology, Meir Medical Center, Kfar Saba, Israel
| | - David Pereg
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel; Department of Cardiology, Meir Medical Center, Kfar Saba, Israel.
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Saad M, Karam B, Faddoul G, Douaihy YE, Yacoub H, Baydoun H, Boumitri C, Barakat I, Saifan C, El-Charabaty E, Sayegh SE. Is kidney function affecting the management of myocardial infarction? A retrospective cohort study in patients with normal kidney function, chronic kidney disease stage III-V, and ESRD. Int J Nephrol Renovasc Dis 2016; 9:5-10. [PMID: 26858529 PMCID: PMC4730996 DOI: 10.2147/ijnrd.s91567] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Patients with chronic kidney disease (CKD) are three times more likely to have myocardial infarction (MI) and suffer from increased morbidity and higher mortality. Traditional and unique risk factors are prevalent and constitute challenges for the standard of care. However, CKD patients have been largely excluded from clinical trials and little evidence is available to guide evidence-based treatment of coronary artery disease in patients with CKD. Our objective was to assess whether a difference exists in the management of MI (ST-segment elevation myocardial infarction and non-ST-segment elevation myocardial infarction) among patients with normal kidney function, CKD stage III–V, and end-stage renal disease (ESRD) patients. We conducted a retrospective cohort study on patients admitted to Staten Island University Hospital for the diagnosis of MI between January 2005 and December 2012. Patients were assigned to one of three groups according to their kidney function: Data collected on the medical management and the use of statins, platelet inhibitors, beta-blockers, and angiotensin converting enzyme inhibitors/angiotensin receptor blockers were compared among the three cohorts, as well as medical interventions including: catheterization and coronary artery bypass graft (CABG) when indicated. Chi-square test was used to compare the proportions between nominal variables. Binary logistic analysis was used in order to determine associations between treatment modalities and comorbidities, and to account for possible confounding factors. Three hundred and thirty-four patients (mean age 67.2±13.9 years) were included. In terms of management, medical treatment was not different among the three groups. However, cardiac catheterization was performed less in ESRD when compared with no CKD and CKD stage III–V (45.6% vs 74% and 93.9%) (P<0.001). CABG was performed in comparable proportions in the three groups and CABG was not associated with the degree of CKD (P=0.078) in binary logistics regression. Cardiac catheterization on the other hand carried the strongest association among all studied variables (P<0.001). This association was maintained after adjusting for other comorbidities. The length of stay for the three cohorts (non-CKD, CKD stage III–V, and ESRD on hemodialysis) was 16, 17, and 15 days, respectively and was not statistically different. Many observations have reported discrimination of care for patients with CKD considered suboptimal candidates for aggressive management of their cardiac disease. In our study, medical therapy was achieved at high percentage and was comparable among groups of different kidney function. However, kidney disease seems to affect the management of patients with acute MI; percutaneous coronary angiography is not uniformly performed in patients with CKD and ESRD when compared with patients with normal kidney function.
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Affiliation(s)
- Marc Saad
- Department of Internal Medicine, Staten Island University Hospital, Staten Island, NY, USA
| | - Boutros Karam
- Department of Internal Medicine, Staten Island University Hospital, Staten Island, NY, USA
| | - Geovani Faddoul
- Department of Nephrology, Icahn School of Medicine, New York, NY, USA
| | - Youssef El Douaihy
- Department of Internal Medicine, Staten Island University Hospital, Staten Island, NY, USA
| | - Harout Yacoub
- Department of Internal Medicine, Staten Island University Hospital, Staten Island, NY, USA
| | - Hassan Baydoun
- Department of Cardiology, Tulane University Medical Center, New Orleans, LA, USA
| | - Christine Boumitri
- Department of Internal Medicine, Staten Island University Hospital, Staten Island, NY, USA
| | - Iskandar Barakat
- Department of Internal Medicine, Staten Island University Hospital, Staten Island, NY, USA
| | - Chadi Saifan
- Department of Nephrology, Staten Island University Hospital, Staten Island, NY, USA
| | - Elie El-Charabaty
- Department of Nephrology, Staten Island University Hospital, Staten Island, NY, USA
| | - Suzanne El Sayegh
- Department of Nephrology, Staten Island University Hospital, Staten Island, NY, USA
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Roberts JK, McCullough PA. The management of acute coronary syndromes in patients with chronic kidney disease. Adv Chronic Kidney Dis 2014; 21:472-9. [PMID: 25443572 DOI: 10.1053/j.ackd.2014.08.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Revised: 08/13/2014] [Accepted: 08/25/2014] [Indexed: 11/11/2022]
Abstract
Coronary heart disease is highly prevalent in patients with CKD, and survival after acute coronary syndrome (ACS) is worse compared with the general population. Many trials that define guidelines for cardiovascular disease excluded patients with kidney disease, leaving a gap between the evidence base and clinical reality. The underlying pathophysiology of vascular disease appears to be different in the setting of CKD. Patients with CKD are more likely to present with myocardial infarction and less likely to be diagnosed with ACS on admission compared with the general population. Patients with CKD appear to benefit with angiography and revascularization compared with medical management alone. However, the increased risk of in-hospital bleeding and risk of contrast-induced acute kidney injury are 2 factors that can limit overall benefit for some. Thus, judicious application of available therapies for the management of ACS is warranted to extend survival and reduce hospitalizations in this high-risk population. In this review, we highlight the clinical challenges and potential solutions for managing ACS in patients with CKD.
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10
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Udeanu M, Guizzardi G, Di Pasquale G, Marchetti A, Romani F, Dalmastri V, Capelli I, Stalteri L, Cianciolo G, Rucci P, La Manna G. Relationship between coronary artery disease and C-reactive protein levels in NSTEMI patients with renal dysfunction: a retrospective study. BMC Nephrol 2014; 15:152. [PMID: 25230678 PMCID: PMC4175282 DOI: 10.1186/1471-2369-15-152] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Accepted: 09/10/2014] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND While chronic renal damage is a condition with low-grade inflammation, the potential role of inflammation in kidney disease as a marker of cardiovascular damage is of current interest. This study analyzed the relationship between renal dysfunction, chronic inflammation, and extension of coronary atherosclerosis in patients with non-ST-segment elevation myocardial infarction (NSTEMI). METHODS This retrospective study was carried out on consecutive patients presenting with NSTEMI to Maggiore Hospital's emergency department between January 1, 2010 and December 31, 2011. Patients' electronic charts were reviewed to gather information on patients' history, clinical and biochemical variables, with a special focus on inflammatory markers, coronary vessel damage, and drug treatments. RESULTS Of the 320 individuals in the study population, 138 (43.1%) had an admission GFR <60 mL/min/1.73 m2. Kidney dysfunction was significantly associated with age (OR = 1.09, 95% CI 1.06 to 1.12), history of heart failure (OR = 2.13, 95% CI 1.08 to 4.17), and hypertension (OR = 2.31, 95% 1.12 to 4.74). C-reactive protein (CRP) and uric acid levels were significantly increased in patients with severe renal dysfunction (SRD) by bivariate and multivariate analyses, adjusted for gender, age and comorbidities at admission. The extent of coronary artery disease (CAD) was significantly higher in the SRD group (p < 0.001). Individuals with SRD were less likely to receive immediate evidence-based therapies (62.9% vs. 76.7% and 82.0% in those with intermediate and no/mild renal dysfunction, p < 0.001). Hospital stay was significantly longer in individuals with a greater extent of CAD, diabetes, and a history of heart failure, and was borderline significantly associated with renal dysfunction (p = 0.08). Older age, CAD severity, and renal function were associated with worsening GFR during hospitalization, whereas immediate evidence-based treatment was unrelated to a GFR change. CONCLUSIONS Among individuals hospitalized for NSTEMI, those with SRD had a more extensive CAD and a higher prevalence of pre-existing cardiovascular disease. CRP was positively correlated with renal dysfunction and the number of involved coronary vessels, confirming its potential as a biomarker. Uric acid was associated with renal dysfunction but not with the number of diseased coronary vessels.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Gaetano La Manna
- Department of Experimental, Diagnostic and Specialty Medicine, Nephrology Dialysis and Transplantation Unit, S, Orsola Hospital, University of Bologna, Bologna, Italy.
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11
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Kalra PR, García-Moll X, Zamorano J, Kalra PA, Fox KM, Ford I, Ferrari R, Tardif JC, Tendera M, Greenlaw N, Steg PG. Impact of chronic kidney disease on use of evidence-based therapy in stable coronary artery disease: a prospective analysis of 22,272 patients. PLoS One 2014; 9:e102335. [PMID: 25051258 PMCID: PMC4106833 DOI: 10.1371/journal.pone.0102335] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Accepted: 06/17/2014] [Indexed: 11/23/2022] Open
Abstract
Purpose To assess the frequency of chronic kidney disease (CKD), define the associated demographics, and evaluate its association with use of evidence-based drug therapy in a contemporary global study of patients with stable coronary artery disease. Methods 22,272 patients from the ProspeCtive observational LongitudinAl RegIstry oF patients with stable coronary arterY disease (CLARIFY) were included. Baseline estimated glomerular filtration rate (eGFR) was calculated (CKD-Epidemiology Collaboration formula) and patients categorised according to CKD stage: >89, 60–89, 45–59 and <45 mL/min/1.73 m2. Results Mean (SD) age was 63.9±10.4 years, 77.3% were male, 61.8% had a history of myocardial infarction, 71.9% hypertension, 30.4% diabetes and 75.4% dyslipidaemia. Chronic kidney disease (eGFR<60 mL/min/1.73 m2) was seen in 22.1% of the cohort (6.9% with eGFR<45 mL/min/1.73 m2); lower eGFR was associated with increasing age, female sex, cardiovascular risk factors, overt vascular disease, other comorbidities and higher systolic but lower diastolic blood pressure. High use of secondary prevention was seen across all CKD stages (overall 93.4% lipid-lowering drugs, 95.3% antiplatelets, 75.9% beta-blockers). The proportion of patients taking statins was lower in patients with CKD. Antiplatelet use was significantly lower in patients with CKD whereas oral anticoagulant use was higher. Angiotensin-converting enzyme inhibitor use was lower (52.0% overall) and inversely related to declining eGFR, whereas angiotensin-receptor blockers were more frequently prescribed in patients with reduced eGFR. Conclusions Chronic kidney disease is common in patients with stable coronary artery disease and is associated with comorbidities. Whilst use of individual evidence-based medications for secondary prevention was high across all CKD categories, there remains an opportunity to improve the proportion who take all three classes of preventive therapies. Angiotensin-converting enzyme inhibitors were used less frequently in lower eGRF categories. Surprisingly the reverse was seen for angiotensin-receptor blockers. Further evaluation is required to fully understand these associations. The CLARIFY (ProspeCtive observational LongitudinAl RegIstry oF patients with stable coronary arterY disease) Registry is registered in the ISRCTN registry of clinical trials with the number ISRCTN43070564. http://www.controlled-trials.com/ISRCTN43070564.
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Affiliation(s)
- Paul R Kalra
- Portsmouth Hospitals NHS Trust, Portsmouth, United Kingdom; NHLI Imperial College, ICMS, London, United Kingdom
| | - Xavier García-Moll
- Unitat Hospitalització, Servei de Cardiologia, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | | | - Philip A Kalra
- Salford Royal NHS Foundation Trust, Salford, United Kingdom
| | - Kim M Fox
- NHLI Imperial College, ICMS, London, United Kingdom; Royal Brompton Hospital, London, United Kingdom
| | - Ian Ford
- University of Glasgow, Glasgow, United Kingdom
| | - Roberto Ferrari
- Department of Cardiology, Azienda Ospedaliero-Universitaria di Ferrara, Ospedale di Cona, Cona, Italy
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12
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Cai Q, Mukku VK, Ahmad M. Coronary artery disease in patients with chronic kidney disease: a clinical update. Curr Cardiol Rev 2014; 9:331-9. [PMID: 24527682 PMCID: PMC3941098 DOI: 10.2174/1573403x10666140214122234] [Citation(s) in RCA: 132] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2013] [Revised: 11/27/2013] [Accepted: 12/04/2013] [Indexed: 01/07/2023] Open
Abstract
Chronic kidney disease (CKD) is an independent risk factor for coronary artery disease (CAD). Coronary artery
disease is the leading cause of morbidity and mortality in patients with CKD. The outcomes of CAD are poorer in patients
with CKD. In addition to traditional risk factors, several uremia-related risk factors such as inflammation, oxidative stress,
endothelial dysfunction, coronary artery calcification, hyperhomocysteinemia, and immunosuppressants have been associated
with accelerated atherosclerosis. A number of uremia-related biomarkers are identified as predictors of cardiac outcomes
in CKD patients. The symptoms of CAD may not be typical in patients with CKD. Both dobutamine stress echocardiography
and radionuclide myocardial perfusion imaging have moderate sensitivity and specificity in detecting obstructive
CAD in CKD patients. Invasive coronary angiography carries a risk of contrast nephropathy in patients with advanced
CKD. It should be reserved for those patients with a high risk for CAD and those who would benefit from revascularization.
Guideline-recommended therapies are, in general, underutilized in renal patients. Medical therapy should be
considered the initial strategy for clinically stable CAD. The effects of statins in patients with advanced CKD have been
neutral despite a lipid-lowering effect. Compared to non-CKD population, percutaneous coronary intervention (PCI) is associated
with higher procedure complications, restenosis, and future cardiac events even in the drug-eluting stent era in
patients with CKD. Compared with PCI, coronary artery bypass grafting (CABG) reduces repeat revascularizations but is
associated with significant perioperative morbidity and mortality. Screening for CAD is an important part of preoperative
evaluation for kidney transplant candidates.
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Affiliation(s)
| | | | - Masood Ahmad
- Department of Cardiology, McFarland Clinic, 1215 Duff Avenue, Ames, IA 50010.
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13
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Shroff GR, Herzog CA. Acute myocardial infarction in patients with chronic kidney disease: how are the most vulnerable patients doing? Kidney Int 2014; 84:230-3. [PMID: 23903416 DOI: 10.1038/ki.2013.151] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Patients with advanced chronic kidney disease sustain extremely high mortality rates following acute myocardial infarction. Nauta et al. evaluated temporal trends in 12,087 patients with acute myocardial infarction from a single institution over 24 years and report a reduction in 30-day mortality in the most recent decade for all patients, including patients with chronic kidney disease. This trend is optimistic, but understanding contributory factors would be critical in future studies to further improve survival.
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Affiliation(s)
- Gautam R Shroff
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis, Minnesota 55415, USA.
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