Aggressive hydraTion in patients with ST-Elevation Myocardial infarction undergoing Primary percutaneous coronary intervention to prevenT contrast-induced nephropathy (ATTEMPT): Study design and protocol for the randomized, controlled trial, the ATTEMPT, RESCIND 1 (First study for REduction of contraSt-induCed nephropathy followINg carDiac catheterization) trial

Febuxostat combined with hydration for the prevention of contrast-induced nephropathy in hyperuricemia patients undergoing percutaneous coronary intervention: A CONSORT-compliant randomized controlled trial

BACKGROUND

To assess the efficacy of febuxostat combined with hydration on contrast-induced nephropathy (CIN) in coronary heart disease patients with hyperuricemia undergoing percutaneous coronary intervention (PCI).

METHODS

Patients with hyperuricemia who underwent PCI were randomly assigned to 2 groups. The control group was given hydration only, and the febuxostat group received febuxostat 40 mg daily before administration of contrast agent and hydration. The primary endpoint of the study was the incidence of CIN, defined as an increase in baseline serum creatinine concentration by 25% at 2 days after contrast media administration, and variations in the serum levels of creatinine, neutrophil gelatinase-associated lipocalin, uric acid, and estimated glomerular filtration rate were compared.

RESULTS

A total of 202 patients with hyperuricemia were randomly assigned to either the febuxostat group (n = 100) or the control group (n = 102). The baseline characteristics of the 2 groups were similar. The incidence of CIN was 6.0% (6/100) in the febuxostat group and 14.71% (15/102) in the control group.The levels of neutrophil gelatinase-associated lipocalin at 6-hour and serum creatinine and uric acid at 48-hour in the febuxostat combined hydration group were lower than those in the control group after surgery, and the level of estimated glomerular filtration rate was higher than that in the control group (all P < .05). Multivariate logistic regression analysis revealed that febuxostat was an independent predictor of CIN.

CONCLUSION

Our study demonstrated that prophylactic treatment with febuxostat combined with hydration can reduce the incidence of CIN in patients with coronary heart disease and hyperuricemia after PCI.

Hydration for prevention of kidney injury after primary coronary intervention for acute myocardial infarction: a randomised clinical trial

OBJECTIVE

To evaluate the efficacy of aggressive hydration compared with general hydration for contrast-induced acute kidney injury (CI-AKI) prevention among patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (pPCI).

METHODS

The Aggressive hydraTion in patients with STEMI undergoing pPCI to prevenT Contrast-Induced Acute Kidney Injury study is an open-label, randomised controlled study at 15 teaching hospitals in China. A total of 560 adult patients were randomly assigned (1:1) to receive aggressive hydration or general hydration treatment. Aggressive hydration group received preprocedural loading dose of 125/250 mL normal saline within 30 min, followed by postprocedural hydration performed for 4 hours under left ventricular end-diastolic pressure guidance and additional hydration until 24 hours after pPCI. General hydration group received ≤500 mL 0.9% saline at 1 mL/kg/hour for 6 hours after randomisation. The primary end point is CI-AKI, defined as a >25% or 0.5 mg/dL increased in serum creatinine from baseline during the first 48-72 hours after primary angioplasty. The safety end point is acute heart failure.

RESULTS

From July 2014 to May 2018, 469 patients were enrolled in the final analysis. CI-AKI occurred less frequently in aggressive hydration group than in general hydration group (21.8% vs 31.1%; risk ratio (RR) 0.70, 95% CI 0.52 to 0.96). Acute heart failure did not significantly differ between the aggressive hydration group and the general hydration group (8.1% vs 6.4%, RR 1.13, 95% CI 0.66 to 2.44). Several subgroup analysis showed the better effect of aggressive hydration in CI-AKI prevention in male, renal insufficient and non-anterior myocardial infarction participants.

CONCLUSIONS

Comparing with general hydration, the peri-operative aggressive hydration seems to be safe and effective in preventing CI-AKI among patients with STEMI undergoing pPCI.

Could sST2 Predict Contrast-Induced Nephropathy in ST-Segment Elevation Myocardial Infarction?

Background and Aim

One of the most worrying complications of primary percutaneous coronary interventions is contrast-induced nephropathy (CIN) that is associated with increased mortality and morbidity in myocardial infarction. In this study, we questioned whether soluble suppression of tumorigenesis-2 (sST2), which has thought to play a role in inflammatory processes, cardiac remodeling, and fibrosis could give an idea about the development of CIN in ST-elevation myocardial infarction (STEMI) patients.

Patients and Methods

This study is a cross-sectional observational study and includes 357 consecutive STEMI patients. Demographic features, medical history, laboratory parameters, and procedural characteristics were compared according to CIN's development. The multivariate logistic regression analysis was selected to detect independent risk factors of CIN.

Results

In the study, 81 patients (22.7%) who developed CIN were identified. The concentration of sST2 in CIN (+) group was higher than that of CIN (-) group (40.6±21.0 ng/mL vs 31.5±13.0 ng/L, p<0.001). Independent predictors of CIN development were diabetes mellitus (OR, 2.059; 95% CI, 1.093-3.879; p=0.025), eGFR (OR, 0.983; 95% CI, 0.972-0.995; p=0.006), lower systolic blood pressure (OR, 0.976; 95% CI, 0.960-0.993; p=0.006), total procedure time (OR, 1.030; 95% CI, 1.011-1.049; p=0.002), and sST2 (OR, 1.101; 95% CI; 1.046-1.160; p<0.001). Besides, the risk of developing CIN in the high sST2 group is 3.06 times higher than the low group sST2 group regardless of other risk factors.

Conclusion

sST2 levels on admission in STEMI patients are useful in predicting CIN development.

The relationship between hyperuricemia and contrast-induced acute kidney injury undergoing primary percutaneous coronary intervention: secondary analysis protocol for the ATTEMPT RESCIND-1 study

Background

Contrast-induced acute kidney injury (CI-AKI) contributes toward unfavorable clinical outcomes after primary percutaneous coronary intervention (pPCI). We will assess whether hyperuricemia is an independent predictor of CI-AKI and outcomes in patients undergoing pPCI.

Methods/design

Our study is a secondary analysis for the database from ATTEMPT study, enrolling 560 ST-segment elevation myocardial infarction (STEMI) patients undergoing pPCI. Patients will be divided into 2 groups according to the admission serum uric acid (SUA) level. Hyperuricemia will be defined as a SUA level > 7 mg/dL (417 mmol/L) in males and > 6 mg/dL (357 mmol/L) in females. The primary endpoint was CI-AKI, defined as > 25% or 0.5 mg/dL increase in serum creatinine from baseline during the first 48–72 h post-procedurally. Multivariate analyses for CI-AKI and long-term mortality will be performed using the logistic regression and Cox regression analyses, respectively.

Discussion

This study will determine the predictive value of hyperuricemia for the development of CI-AKI and outcomes in patients with STEMI undergoing pPCI. We predict that hyperuricemia will be associated with a risk of CI-AKI in patients with pPCI. Furthermore, after adjusting for other variables, long-term mortality after pPCI may be higher in those with hyperuricemia than in those with normouricemia. Results of this study may provide scientific evidence for the effect of hyperuricemia on CI-AKI and long-term outcomes, thereby offering the potential possibility of lowering SUA on the development of CI-AKI and outcomes.

Trial registration

ClinicalTrials.gov NCT02067195, Registered on 20 February 2014.

Statistical analysis plan for aggressive hydraTion in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention to prevenT contrast-induced nephropathy (ATTEMPT) study

Background

The ATTEMPT study is a multicenter, randomized controlled trial which is investigator-based and open label in nature. For the study, 560 patients with ST-segment elevation myocardial infarction (STEMI) underwent primary percutaneous coronary intervention (pPCI) have been randomized (1:1) for treatment with periprocedural aggressive hydration (treatment group) or general hydration (control group). To improve the quality of the study’s analysis and to minimize analysis bias based on the study’s findings.

Methods

The design of the statistical analysis plan (SAP) was created by chief investigators and statisticians and received permission from the aggressive hydraTion in patients with ST-Elevation Myocardial infarction undergoing Primary percutaneous coronary intervention to prevenT contrast-induced nephropathy (ATTEMPT) management committee. Treatment allocation and research data were reviewed by the Data Safety and Monitoring Committee and researchers were kept blind. We produced data shells based on a pre-existing published protocol and produced detailed descriptions of statistical analyses. This study includes primary, secondary and safety endpoints. Relevant statistical comparisons were planned and discussed in a transparent manner. They are publicly available, verifiable and were determined prior to the data collection process being completed.

Results

We developed a SAP for the ATTEMPT study and an outline and list of mock tables were also created. We produced descriptions of analyses of baseline characteristics, patient care approaches, efficacy measures, and outcomes. This study defined five previously specified subgroups and compared the statistics of groups within these subgroups.

Conclusions

This SAP has been developed for the ATTEMPT study and has high-quality standards of internal validity to minimize analysis bias.

Trial registration

ClinicalTrials.gov number, NCT02067195.

Role of Hydration in Contrast-Induced Nephropathy in Patients Who Underwent Primary Percutaneous Coronary Intervention

Patients with ST-segment elevation myocardial infarction (STEMI) who are treated by primary percutaneous coronary intervention (PPCI) have an increased risk of developing contrast-induced nephropathy (CIN) when compared with patients undergoing elective percutaneous coronary intervention (PCI). However, CIN prevention measures are less frequently applied in PPCI than in elective PCI. At present, no preventive strategy has been recommended by the current guidelines for patients with STEMI undergoing PPCI.Published research was scanned by formal searches of electronic databases (PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials) from 1966 to July 2018. Internet-based sources of information on the results of clinical trials in cardiology were also searched.A total of three randomized trials involving 924 patients were included in the present meta-analysis, of whom 462 received hydration with isotonic saline (hydration group) and 462 received no hydration (control group). Periprocedural hydration with isotonic saline was associated with a significant decrease in the rate of CIN (16.9% in the hydration group versus 26.4% in the control group; summary risk ratio: 0.64, 95% confidence interval: 0.50-0.82, P = 0.0005). There was no difference in the rate of postprocedural hemodialysis or death between the groups.Intravenous saline hydration during PPCI reduced the risk of CIN without significantly altering the rate of requirement for renal replacement therapy or mortality.

Routine iso-osmolar contrast media use and acute kidney injury following percutaneous coronary intervention for ST elevation myocardial infarction

BACKGROUND

Temporal changes in contrast-induced acute kidney injury (CI-AKI) incidence following primary percutaneous coronary intervention (PPCI) are poorly defined. Additionally, the benefits of iso-osmolar contrast media (IOCM) compared to low osmolar CM (LOCM) are uncertain.

METHODS

Using data from a regional PPCI service, temporal changes in baseline risk and annual incidence of CI-AKI were studied. A CM protocol change occurred in 2013 allowing a comparison of the incidence of CI-AKI between LOCM (2012-13) and IOCM (2013-15).

RESULTS

Between 2012 and 2015, 208 of 1310 patients experienced CI-AKI (15.9%). The Mehran AKI risk score did not change during the study period although there was an increase in the incidence of CI-AKI in later study years (P<0.001 for trend) when IOCM was used. Factors independently associated with CI-AKI were IOCM use (OR=1.96, [95% CI: 1.39-2.75]), age per year (OR=1.02, 95% CI: 1.01-1.04), baseline creatinine per µmol/L (OR=1.006, 95% CI: 1.003-1.01) and contrast volume per milliliter (OR=1.002, 95% CI: 1.001-1.004). The baseline characteristics of patients treated using IOCM (N.=783) vs. LOCM (N.=527) were similar (Mehran Score 6.6 vs. 6.9, P=0.173) but CI-AKI occurred more frequently with IOCM compared to LOCM (19.2% vs. 11.2%, P<0.001). Use of IOCM was independently associated with CI-AKI (OR=1.98, 95% CI: 1.339-2.774, P<0.001) with consistency across all sub-groups of age, gender, baseline creatinine, contrast volume, shock and diabetes. The adjusted in-hospital mortality was increased with IOCM compared to LOCM (OR=3.03, 95% CI: 1.313-6.994, P=0.009).

CONCLUSIONS

IOCM use was observed to be associated with an increased occurrence of CI-AKI, and an increase in in-hospital mortality after primary PCI.

Left ventricular end-diastolic pressure-guided hydration for the prevention of contrast-induced acute kidney injury in patients with stable ischemic heart disease: the LAKESIDE trial

OBJECTIVES

Contrast-induced acute kidney injury (CI-AKI) is a serious complication in patients undergoing diagnostic cardiac angiography or percutaneous coronary intervention. We aimed to evaluate the preventive effects of left ventricular end-diastolic pressure (LVEDP)-guided hydration for the prevention of CI-AKI in patients with chronic kidney disease undergoing cardiac catheterization.

METHODS

This prospective randomized single-blind clinical trial enrolled 114 eligible patients with an estimated glomerular filtration rate (eGFR) of 15 < eGFR ≤ 60 mL/min/1.73 m² [according to the level-modified Modification of Diet in Renal Disease formula (MDRD)] and stable ischemic heart disease undergoing coronary procedures. The patients were randomly allocated 1:1 into the LVEDP-guided hydration group (n = 57) or the standard hydration group (n = 57). CI-AKI was defined as a greater than 25% or greater than 0.5 mg/dL (44.2 mmol/L) increase in the serum creatinine concentration compared with the baseline value. Hydration with 0.9% sodium chloride at a rate of 1 mL/kg/h (0.5 mL/kg/h if left ventricular ejection fraction < 40%) within 12 h was given to all the patients in both groups before the procedure. In the LVEDP-guided group, the hydration infusion rate was adjusted according to the LVEDP level during and after the procedure.

RESULTS

The incidence of CI-AKI was 7.01% (4/57) in the LVEDP-guided group vs 3.84% (2/52) in the standard hydration group (summary odds ratio 0.53, 95% CI 0.093-3.022; P = 0.463). Major adverse cardiac events, hemodialysis, or related deaths occurred in neither of the groups during hospitalization or the 30-day follow-up.

CONCLUSIONS

In the present study, LVEDP-guided fluid administration, by comparison with standard hydration, failed to offer protection against the risk of CI-AKI in patients with renal insufficiency undergoing coronary angiography with or without percutaneous coronary intervention.

Efficacy of post-procedural oral hydration volume on risk of contrast-induced acute kidney injury following primary percutaneous coronary intervention: study protocol for a randomized controlled trial

BACKGROUND

Contrast-induced acute kidney injury (CI-AKI) contributes toward unfavorable clinical outcomes. Oral hydration with water is inexpensive and it may be effective in the prevention of CI-AKI, but its efficacy among patients undergoing primary percutaneous coronary intervention (PCI) remains unknown.

METHODS/DESIGN

Our study is a secondary analysis on the database from the ATTEMPT study. We enrolled ST-elevation myocardial infarction (STEMI) patients undergoing primary PCI. Eligible patients received peri-procedural aggressive (left ventricular end-diastolic pressure-guided) or routine (≤ 500 mL) intravenous hydration with an isotonic solution (0.9% NaCl) with randomization. The primary endpoint was CI-AKI, defined as a > 25% or 0.5 mg/dL increase in serum creatinine from baseline during the first 48-72 h post-procedurally. All patients drank unrestricted amounts of fluids freely, the volume of which was recorded until 24 h following primary PCI. Oral hydration volume/weight (OHV/W) ratios were calculated. The association between post-procedural oral hydration (quartiles) and CI-AKI was assessed using multivariable analysis controlling for confounders, including intravenous hydration strategies.

DISCUSSION

Our study determined the effects of post-procedural oral hydration on CI-AKI following primary PCI, which is a potential strategy for CI-AKI prevention among patients with STEMI at very high risk.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02067195 . Registered on 21 February 2014.

Effects of intravenous hydration on risk of contrast induced nephropathy and in-hospital mortality in STEMI patients undergoing primary percutaneous coronary intervention: a systematic review and meta-analysis of randomized controlled trials

Background

The role of intravenous hydration at the time of primary percutaneous intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) remains unclear. Guidelines are vague, supported by low level evidence, and hydration is used less often than other clinical settings.To perform a systematic review and meta-analysis of all randomized controlled trials assessing intravenous hydration compared with non-hydration for prevention of contrast induced nephropathy (CIN) and In-hospital mortality in patients with STEMI undergoing primary PCI.

Methods

Medline, EMBASE and the Cochrane Register were searched to September 2018. Included studies reported the incidence of CIN, In-hospital mortality, requirement for dialysis and heart failure. Relative risks with 95% confidence intervals (CIs) for individual trials were pooled using a random effects model.

Results

Three moderate quality trials were identified including 1074 patients. Overall, compared with no hydration, intravenous hydration significantly reduced the incidence of CIN by 42% (RR 0.58; 95% CI: 0.45 to 0.74, p < 0.001). The estimated effects upon all-cause mortality (RR 0.56; 95% CI: 0.30 to 1.02, p = 0.057) and the requirement for dialysis (RR 0.52, 95% CI 0.14–1.88, p = 0.462) were not statistically significant. The outcome of heart failure was not consistently reported.

Conclusions

Intravenous hydration likely reduces the incidence of CIN in patients with STEMI undergoing primary PCI. However, for key clinical outcomes such as mortality, heart failure and dialysis the effect estimates were imprecise. Further high quality studies are needed to clarify the appropriate volume of fluid and effects on outcomes.

Electronic supplementary material

The online version of this article (10.1186/s12872-019-1054-y) contains supplementary material, which is available to authorized users.

The Effect of Spironolactone on the Incidence of Contrast-Induced Nephropathy in Patients Undergoing Cardiac Catheterization: Study Design and Rationale

Introduction

Patients undergoing coronary catheterization are at high risk of developing contrast-induced nephropathy (CIN) acute kidney injury (AKI). Several approaches have been supposed to limit such an effect but with mixed results or non-practical methods. Spironolactone is supposed to be effective as a nephroprotective agent in animal studies. This study will try to measure the effect of spironolactone on the incidence of CIN-AKI in patients undergoing coronary catheterization (angiography angioplasty).

Methods

This study is a single-center, investigator-driven, double-blinded randomized controlled study in Iraq-Basra. More than 400 patients admitted for coronary angio unit in our center will be allocated in a 1:1 ratio to receive either spironolactone 200 mg single dose or placebo in addition to their usual premedication.

Planned Outcomes

Primary end point will be CIN defined as more than 25% or 0.3 mg/dl elevation in serum creatinine (S.Cr.) from baseline during the first 2–3 days after the procedure. We hope to identify or answer an important question regarding CIN in such high-risk patients.

Trial Registration

ClinicalTrials.gov Identifier, NCT03329443.

The expression of microRNA-23a regulates acute myocardial infarction in patients and in vitro through targeting PTEN

Cardiovascular disease is responsible for one of the highest rates of fatality worldwide. The present study investigated the presence and influence of microRNA (miRNA)-23a in the regulation of acute myocardial infarction (AMI). A total of 6 patients with AMI and 6 normal volunteers without myocardial disease were included, and blood samples were taken to analyze the expression of miRNA‑23a by reverse transcription‑quantitative polymerase chain reaction. miRNA‑23a expression in patients with AMI was downregulated compared with the normal group. In H9C2 cells treated with H2O2, upregulation of miRNA‑23a expression increased the superoxide dismutase, glutathione and catalase activity levels, and suppressed the malonaldehyde activity level, as determined by ELISA. Western blot analysis and a caspase‑3 substrate assay demonstrated that upregulation of miRNA‑23a expression suppressed the Bcl‑2‑associated X (Bax)/Bcl‑2 protein expression ratio, caspase‑3 activity level and tumor suppressor p53 (p53) protein expression in H2O2‑induced H9C2 cells. Furthermore, downregulation of phosphatase and tensin homolog (PTEN), by the PTEN inhibitor bpV(HOpic), increased miRNA‑23a expression and suppressed the Bax/Bcl‑2 protein expression ratio, caspase‑3 activity level and p53 protein expression in H2O2‑induced H9C2 cells. Therefore, the results of the present study indicate that the expression of miRNA‑23a may regulate AMI through targeting PTEN in patients and in vitro, and PTEN/miRNA‑23a may therefore be potential targets for the clinical treatment of AMI.

Association of post-procedural early (within 24h) increases in serum creatinine with all-cause mortality after coronary angiography

BACKGROUND

The majority of patients undergoing coronary angiography (CAG) or percutaneous coronary intervention (PCI) are discharged early, with only early (within 24h) serum creatinine (SCr) data available without evidence of clinical prognosis. We aimed to systemically evaluate the association between post-procedural early increase in SCr and all-cause mortality following CAG.

METHODS

We performed a retrospective sub-study analysis within a prospective observational study including 3091 consecutive patients with baseline and post-procedural early (within 24h) SCr data. The degree (mild, moderate, or large) of absolute and relative increases in SCr from baseline. The mean follow-up time was 2.49years.

RESULT

Moderate or large early increases in SCr were relatively rare (large increase: >1.0mg/dl [0.5%], >100% [0.4%]), whereas mild absolute and relative increases in SCr were more common (mild increase: 0.25 to 0.50mg/dl [4.5%], 25% to 50% [5.9%]). During the follow-up period, there were 136 post-procedural deaths (5.6%). After adjustment for confounders, mild absolute and relative increases in SCr were associated with increased mortality (hazard ratio [HR]: 1.9 and 1.8, respectively, both P<0.05). Moderate or large increases in SCr were associated with higher mortality, even higher than with pre-existing renal dysfunction (HR: 5.36 and 4.12 for moderate increase [0.5 to 1.0mg/dl] and estimated glomerular filtration rate<60ml/min).

CONCLUSION

Post-procedural mild, moderate, or large early increase in SCr, is associated with significantly increased long-term mortality. Although moderate or large increase in SCr following CAG was relatively rare, the prognosis is more serious, and is worse than that of pre-existing renal dysfunction.

CLINICAL TRIAL REGISTRATION

Predictive Value of Contrast Volume to Creatinine Clearance Ratio (PRECOMIN, ClinicalTrials.govNCT01400295).

Post-Hoc Study: Intravenous Hydration Treatment in Chinese Patients with High Risk of Contrast-Induced Nephropathy Following Percutaneous Coronary Intervention

Contrast-induced nephropathy (CIN) develops after the injection of iodinated contrast media. This is a post hoc analysis of the data obtained from the TRUST study, which was a prospective, multicentre, observational study conducted to evaluate the safety and tolerability of the contrast medium iopromide in patients undergoing cardiac catheterization from August 2010 to September 2011 in China, conducted to explore the current status, trends and risk predictors of hydration treatment. The status of hydration to prevent CIN in each patient was recorded. Of the total 17,139 patients from the TRUST study (mean age, 60.33 ± 10.38 years), the overall hydration usage was 46.1% in patients undergoing percutaneous coronary intervention (PCI) and 77.4%, 51.7%, and 48.5% in patients with pre-existing renal disease, diabetes mellitus, and hypertension, respectively. The proportion of hydration use increased from 36.5% to 55.5% from August 2010 to September 2011, which was independently associated with risk predictors like older age, pre-existing renal disease, hypertension, diabetes mellitus, prior myocardial infarction, ST segment elevation MI, high contrast dose, multi-vessel disease and reduced LVEF (<45%). Overall, the usage of intravenous hydration treatment for patients with a high risk of CIN following PCI was high in China.