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Varian FL, Parker WAE, Fotheringham J, Storey RF. Treatment inequity in antiplatelet therapy for ischaemic heart disease in patients with advanced chronic kidney disease: releasing the evidence vacuum. Platelets 2023; 34:2154330. [DOI: 10.1080/09537104.2022.2154330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Frances L. Varian
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK and
| | - William A. E. Parker
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK and
| | - James Fotheringham
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Robert F. Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK and
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Kim JA, Kim SE, El Hachem K, Virk HUH, Alam M, Virani SS, Sharma S, House A, Krittanawong C. Medical Management of Coronary Artery Disease in Patients with Chronic Kidney Disease. Am J Med 2023; 136:1147-1159. [PMID: 37380060 DOI: 10.1016/j.amjmed.2023.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 06/15/2023] [Indexed: 06/30/2023]
Abstract
Chronic kidney disease patients are at increased risk of cardiovascular disease, which is the leading cause of mortality among this population. In addition, chronic kidney disease is a major risk factor for the development of coronary artery disease and is widely regarded as a coronary artery disease risk equivalent. Medical therapy is the cornerstone of coronary artery disease management in the general population. However, there are few trials to guide medical therapy of coronary artery disease in chronic kidney disease, with most data extrapolated from clinical trials of mainly non-chronic kidney disease patients, which were not adequately powered to evaluate this subgroup. There is some evidence to suggest that the efficacy of certain therapies such as aspirin and statins is attenuated with declining estimated glomerular filtration rate, with questionable benefit among end-stage renal disease (ESRD) patients. Furthermore, chronic kidney disease and ESRD patients are at higher risk of potential side effects with therapy, which may limit their use. In this review, we summarize the available evidence supporting the safety and efficacy of medical therapy of coronary artery disease in chronic kidney disease and ESRD patients. We also discuss the data on new emerging therapies, including PCSK9i, SGLT2i, GLP1 receptor agonists, and nonsteroidal mineralocorticoid receptor antagonists, which show promise at reducing risk of cardiovascular events in the chronic kidney disease population and may offer additional treatment options. Overall, dedicated studies directly evaluating chronic kidney disease patients, particularly those with advanced chronic kidney disease and ESRD, are greatly needed to establish the optimal medical therapy for coronary artery disease and improve outcomes in this vulnerable population.
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Affiliation(s)
- Jitae A Kim
- Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Seulgi E Kim
- Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Karim El Hachem
- Division of Nephrology, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, NY
| | - Hafeez Ul Hassan Virk
- Harrington Heart & Vascular Institute, Case Western Reserve University, University Hospitals Cleveland Medical Center, Ohio
| | - Mahboob Alam
- Texas Heart Institute and Baylor College of Medicine, Houston
| | - Salim S Virani
- Section of Cardiology, Baylor College of Medicine, Houston, Texas; Office of the Vice Provost (Research), The Aga Khan University, Karachi, Pakistan
| | - Samin Sharma
- Cardiac Catheterization Laboratory of the Cardiovascular Institute, Mount Sinai Hospital, New York, NY
| | - Andrew House
- Division of Nephrology, Department of Medicine, Western University and London Health Sciences Centre, Ont, Canada
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Weisbord SD, Mor MK, Hochheiser H, Kim N, Ho PM, Bhatt DL, Fine MJ, Palevsky PM. Utilization and Outcomes of Clinically Indicated Invasive Cardiac Care in Veterans with Acute Coronary Syndrome and Chronic Kidney Disease. J Am Soc Nephrol 2023; 34:694-705. [PMID: 36735537 PMCID: PMC10103279 DOI: 10.1681/asn.0000000000000067] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 12/08/2022] [Indexed: 02/04/2023] Open
Abstract
SIGNIFICANCE STATEMENT Of studies reporting an association of CKD with lower use of invasive cardiac care to treat acute coronary syndrome (ACS), just one accounted for the appropriateness of such care. However, its findings in patients hospitalized nearly 30 years ago may not apply to current practice. In a more recent cohort of 64,695 veterans hospitalized with ACS, CKD was associated with a 32% lower likelihood of receiving invasive care determined to be clinically indicated. Among patients with CKD, not receiving such care was associated with a 1.39-fold higher risk of 6-month mortality. Efforts to elucidate the reasons for this disparity in invasive care in patients with ACS and CKD and implement tailored interventions to enhance its use in this population may offer the potential to improve clinical outcomes. BACKGROUND Previous studies have shown that patients with CKD are less likely than those without CKD to receive invasive care to treat acute coronary syndrome (ACS). However, few studies have accounted for whether such care was clinically indicated or assessed whether nonuse of such care was associated with adverse health outcomes. METHODS We conducted a retrospective cohort study of US veterans who were hospitalized at Veterans Affairs Medical Centers from January 2013 through December 2017 and received a discharge diagnosis of ACS. We used multivariable logistic regression to investigate the association of CKD with use of invasive care (coronary angiography, with or without revascularization; coronary artery bypass graft surgery; or both) deemed clinically indicated based on Global Registry of Acute Coronary Events 2.0 risk scores that denoted a 6-month predicted all-cause mortality ≥5%. Using propensity scoring and inverse probability weighting, we examined the association of nonuse of clinically indicated invasive care with 6-month all-cause mortality. RESULTS Among 34,430 patients with a clinical indication for invasive care, the 18,780 patients with CKD were less likely than the 15,650 without CKD to receive such care (adjusted odds ratio, 0.68; 95% confidence interval, 0.65 to 0.72). Among patients with CKD, nonuse of invasive care was associated with higher risk of 6-month all-cause mortality (absolute risk, 21.5% versus 15.5%; absolute risk difference 6.0%; adjusted risk ratio, 1.39; 95% confidence interval, 1.29 to 1.49). Findings were consistent across multiple sensitivity analyses. CONCLUSIONS In contemporary practice, veterans with CKD who experience ACS are less likely than those without CKD to receive clinically indicated invasive cardiac care. Nonuse of such care is associated with increased mortality.
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Affiliation(s)
- Steven D. Weisbord
- From the Renal Section, VA Pittsburgh Healthcare System, Pittsburgh Pennsylvania
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Maria K. Mor
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - Harry Hochheiser
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Nadejda Kim
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - P. Michael Ho
- Cardiology Section, VA Eastern Colorado Health Care System, Aurora, Colorado
| | - Deepak L. Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai Health System, New York, NY
| | - Michael J. Fine
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Paul M. Palevsky
- From the Renal Section, VA Pittsburgh Healthcare System, Pittsburgh Pennsylvania
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Abu Ghosh Z, Amir O, Carasso S, Planer D, Alcalai R, Golomb M, Dagan G, Kalmanovich E, Blatt A, Elbaz-Greener G. Outcomes of Acute Coronary Syndrome Patients Who Presented with Cardiogenic Shock versus Patients Who Developed Cardiogenic Shock during Hospitalization. J Clin Med 2023; 12:2603. [PMID: 37048686 PMCID: PMC10095064 DOI: 10.3390/jcm12072603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 03/23/2023] [Accepted: 03/28/2023] [Indexed: 04/03/2023] Open
Abstract
Background: Cardiogenic shock (CS) continues to be a severe and fatal complication of acute coronary syndrome (ACS). CS patients have a high mortality rate despite significant progress in primary reperfusion, the management of heart failure and the expansion of mechanical circulatory support strategies. The present study addressed the clinical characteristics, management, and outcomes of ACS patients complicated with CS. Methods: We performed an observational study, using the 2000-2013 Acute Coronary Syndrome Israeli Surveys (ACSIS) database and identified hospitalizations of ACS patients complicated with CS. Patients' demographics and clinical characteristics, complications and outcomes were evaluated. We assessed the outcomes of ACS patients with CS at arrival (on the day of admission) compared with ACS patients who arrived without CS and developed CS during hospitalization. Results: The cohort included 13,434 patients with ACS diagnoses during the study period. Of these, 4.2% were complicated with CS; 224 patients were admitted with both ACS and CS; while 341 ACS patients developed CS only during the hospitalization period. The latter patients had significantly higher rates of MACEs compared with the group of ACS patients who presented with CS at arrival (73% vs. 51%; p < 0.0001). Similarly, the rates of in-hospital mortality (55% vs. 36%; p < 0.0001), 30-day mortality (64% vs. 50%; p = 0.0013) and 1-year mortality (73% vs. 59%; p = 0.0016) were higher in ACS patients who developed CS during hospitalization vs. ACS patients with CS at admission. There was a significant decrease in 1-year mortality trends during the 13 years of this study presented in ACS patients from both groups. Conclusions: Patients who developed CS during hospitalization had higher mortality and MACE rates compared with those who presented with CS at arrival. Further studies should focus on this subgroup of high-risk patients.
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Affiliation(s)
- Zahi Abu Ghosh
- Department of Cardiology, Hadassah Medical Center, The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9190501, Israel
| | - Offer Amir
- Department of Cardiology, Hadassah Medical Center, The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9190501, Israel
- The Azrieli Faculty of Medicine in the Galilee, Bar-Ilan University, Safed 5290002, Israel
| | - Shemy Carasso
- The Azrieli Faculty of Medicine in the Galilee, Bar-Ilan University, Safed 5290002, Israel
- The Jesselson Integrated Heart Center, Shaare Zedek Medical Center, Jerusalem 9103102, Israel
| | - David Planer
- Department of Cardiology, Hadassah Medical Center, The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9190501, Israel
| | - Ronny Alcalai
- Department of Cardiology, Hadassah Medical Center, The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9190501, Israel
| | - Mordechai Golomb
- Department of Cardiology, Hadassah Medical Center, The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9190501, Israel
| | - Gil Dagan
- Department of Cardiology, Hadassah Medical Center, The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9190501, Israel
| | - Eran Kalmanovich
- Department of Cardiology, Shamir Medical Center, Sackler School of Medicine, Tel-Aviv University, Tel Aviv-Yafo 6997801, Israel
| | - Alex Blatt
- Kaplan Heart Center, Hebrew University, Jerusalem 9190501, Israel
| | - Gabby Elbaz-Greener
- Department of Cardiology, Hadassah Medical Center, The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9190501, Israel
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Sacco A, Montalto C, Bravi F, Ruzzenenti G, Garatti L, Oreglia JA, Bartorelli AL, Crimi G, LA Vecchia C, Savonitto S, Leonardi S, Oliva FG, Morici N. Non-ST-elevation acute coronary syndrome in chronic kidney disease: prognostic implication of an early invasive strategy. Minerva Cardiol Angiol 2023; 71:44-50. [PMID: 35212503 DOI: 10.23736/s2724-5683.21.05839-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The optimal timing of PCI for NSTE-ACS with CKD is unclear. The aim of our study was to assess whether early percutaneous coronary intervention (PCI) (within 24 hours from admission) is associated with improved in-hospital (mortality or acute kidney injury) and long-term events (composite of mortality, myocardial infarction, stroke and bleeding events) in patients with non-ST-elevation acute coronary syndromes (NSTE-ACS) with chronic kidney disease (CKD). METHODS We retrospectively studied NSTE-ACS patients who underwent PCI in large tertiary centers. CKD was defined as estimated glomerular filtration rate (eGFR)<60 mL/min/1.73 m2. A propensity score for the likelihood of an early invasive strategy was calculated. Relative risks (RR) and adjusted hazard ratios (HR) were estimated for in-hospital and follow-up events. RESULTS We included 821 patients, mean age was 69±12 years; 492 (60%) received an early PCI, and 273 (33%) had an eGFR <60. Median follow-up was 391 days. At univariate analysis, early treatment was associated with significantly lower in-hospital and follow-up events. However, after adjustment for major prognostic factors, there was no significant association with both in-hospital (RR=1.06; 95% CI 0.83-1.36) and follow-up events (RR=1.07; 95% CI 0.83-1.37). When the association was assessed in strata of CKD, lack of statistically significant association was confirmed, even if a trend emerged in patients with preserved renal function both on primary outcome (RR=0.47, 95% 0.18-1.22) and time to secondary outcome (HR=0.62, 95% CI 0.36-1.08). CONCLUSIONS In conclusion in a cohort of NSTE-ACS patients, an early invasive strategy does not independently affect prognosis.
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Affiliation(s)
- Alice Sacco
- Intensive Cardiac Care Unit, De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy -
| | - Claudio Montalto
- University of Pavia and Coronary Care Unit, IRCCS San Matteo Polyclinic Foundation, Pavia, Italy
| | - Francesca Bravi
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Giacomo Ruzzenenti
- Intensive Cardiac Care Unit, De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Laura Garatti
- Intensive Cardiac Care Unit, De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Jacopo A Oreglia
- Interventional Cardiology Division, De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Antonio L Bartorelli
- Centro Cardiologico Monzino IRCCS, Luigi Sacco Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Gabriele Crimi
- Division of Cardiology, San Martino Hospital, Genoa, Italy
| | | | | | - Sergio Leonardi
- University of Pavia and Coronary Care Unit, IRCCS San Matteo Polyclinic Foundation, Pavia, Italy
| | - Fabrizio G Oliva
- Intensive Cardiac Care Unit, De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Nuccia Morici
- Intensive Cardiac Care Unit, De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
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6
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Acute myocardial infarction in young adults with chronic kidney disease. Coron Artery Dis 2022; 33:553-558. [PMID: 35942623 DOI: 10.1097/mca.0000000000001179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The goal of this study was to evaluate the prevalence of chronic kidney disease (CKD) in young patients with acute myocardial infarction (AMI) and to report their characteristics and clinical outcomes. BACKGROUND Underlying renal dysfunction is a risk factor for poor cardiovascular outcomes in older patients. The implication of CKD in young patients with AMI is not well studied. METHODS This is a retrospective population-based cohort study of patients aged 18-50 who presented with AMI between 2006 and 2016. Medical records were reviewed to confirm diagnosis and to identify treatment and long-term outcomes. Cox regression models were used to evaluate the association of CKD with mortality. RESULTS Among 1753 young patients with type 1 AMI (median age 45 years, 85.3% male), CKD was present in 112 (6.8%) patients. A higher proportion of CKD patients had concomitant hypertension, hyperlipidemia, diabetes, and obesity. Use of statin and P2Y12 inhibitors post-AMI was lower in CKD patients. Over a median follow-up of 7.2 years, CKD was associated with higher all-cause mortality [hazard ratio (HR), 9.3; 95% CI, 6.3-13.8]. This association persisted after adjusting for demographics, comorbidities, and treatment (adjusted HR, 3.6; 95% CI, 2.2-6.0). CONCLUSION Presence of CKD was associated with 3.6-fold higher mortality over a median follow-up of 7.2 years. A lower proportion of CKD patients were treated with statin therapy and P2Y12 inhibitors. These findings highlight the need for intensive risk factor modification and optimal use of guideline-directed medical therapies in this high-risk population.
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7
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Recent Advances in Understanding of Cardiovascular Diseases in Patients with Chronic Kidney Disease. J Clin Med 2022; 11:jcm11164653. [PMID: 36012887 PMCID: PMC9409994 DOI: 10.3390/jcm11164653] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 08/08/2022] [Indexed: 11/21/2022] Open
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Abstract
AKI is a potential complication of intravascular iodinated contrast exposure. Contrast-associated AKI, which typically manifests as small and transient decrements in kidney function that develop within several days of contrast administration, is associated with serious adverse outcomes, including progressive kidney dysfunction and death. However, a causal link between the small increases in serum creatinine that characteristically occur with contrast-associated AKI and serious adverse outcomes remains unproven. This is important given mounting evidence that clinically indicated, potentially lifesaving radiographic procedures are underutilized in patients with CKD. This has been hypothesized to be related to provider concern about precipitating contrast-associated AKI. Intravascular gadolinium-based contrast, an alternative to iodinated contrast that is administered with magnetic resonance imaging, has also been linked with potential serious adverse events, notably the development of nephrogenic systemic fibrosis in patients with severe impairment in kidney function. Patients hospitalized in the intensive care unit frequently have clinical indications for diagnostic and therapeutic procedures that involve the intravascular administration of contrast media. Accordingly, critical care providers and others treating critically ill patients should possess a sound understanding of the risk factors for and incidence of such outcomes, the ability to perform evidence-based risk-benefit assessments regarding intravascular contrast administration, and knowledge of empirical data on the prevention of these iatrogenic complications.
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Affiliation(s)
- Winn Cashion
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Steven D Weisbord
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania .,Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Renal Section, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
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Fu Y, Sun H, Zuo K, Guo Z, Xu L, Chen M, Wang L. Patients with end-stage renal disease requiring hemodialysis benefit from percutaneous coronary intervention after non-ST-segment elevation myocardial infarction. Intern Emerg Med 2022; 17:1087-1095. [PMID: 35018545 DOI: 10.1007/s11739-021-02921-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 12/16/2021] [Indexed: 11/05/2022]
Abstract
Percutaneous coronary intervention (PCI) treatment significantly improves outcomes after acute myocardial infarction (AMI). It remains unclear whether the benefits of PCI exist in patients with end-stage renal disease (ESRD) and non-ST-segment elevation myocardial infarction (NSTEMI). The present study was designed to investigate the effects of PCI on the short- and long-term prognosis of patients with ESRD and NSTEMI. We conducted a retrospective study from 1 January 2015 to 1 January 2020, which includes 148 consecutive patients with ESRD and NSTEMI. All patients were estimated glomerular filtration rate (eGFR) < 15 mL/min/1.73 m2 and had received regular hemodialysis treatment before hospitalization. Logistic regression analyses were used to identify the risk factors for in-hospital mortality. Cox proportional hazard model was used to identify independent predictors of 1-year major adverse cardiac events (MACE). In this study, 62 patients received PCI treatment. Univariable logistic regression analysis showed that PCI treatment was associated with the trend of reduction in the risk of in-hospital mortality (11.3% vs 43%, P = 0.022), but was not independently related to lower in-hospital mortality risk after multivariable logistic regression analysis (P = 0.131). After a 1-year follow-up, Kaplan-Meier survival analysis demonstrated that MACE rate was significantly lower in patients with ESRD and NSTEMI who had received PCI treatment during hospitalization (P < 0.001). After multivariate Cox proportional hazard analysis, no PCI treatment was independently associated with 1-year MACE (hazard ratios 3.217, 95% CI 2.03-8.489, P = 0.003). PCI treatment during hospitalization is associated with reduced 1-year MACE in patients with ESRD and NSTEMI, which suggests that more aggressive therapies may be beneficial for this special higher risk population.
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Affiliation(s)
- Yuan Fu
- Heart Center and Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Hao Sun
- Heart Center and Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Kun Zuo
- Heart Center and Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Zongsheng Guo
- Heart Center and Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Li Xu
- Heart Center and Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Mulei Chen
- Heart Center and Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Lefeng Wang
- Heart Center and Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China.
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10
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Rymer JA, Li S, Pun PH, Thomas L, Wang TY. Racial Disparities in Invasive Management for Patients With Acute Myocardial Infarction With Chronic Kidney Disease. Circ Cardiovasc Interv 2021; 15:e011171. [PMID: 34915722 DOI: 10.1161/circinterventions.121.011171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Due to increased risks of contrast nephropathy, chronic kidney disease (CKD) can deter consideration of invasive management for patients with myocardial infarction (MI). Black patients have a higher prevalence of CKD. Whether racial disparities exist in the use of invasive MI management for patients with CKD presenting with MI is unknown. METHODS We examined 717 012 White and 99 882 Black patients with MI treated from 2008 to 2017 at 914 hospitals in the National Cardiovascular Data Registry Chest Pain-MI Registry. CKD status was defined as estimated glomerular filtration rate (eGFR) ≥90 mL/(min·1.73 m2; no CKD), eGFR <90 but ≥60 (mild), eGFR <60 but ≥30 (moderate), and eGFR <30 or dialysis (severe). We used multivariable logistic regression models to examine the interaction of race and CKD severity in invasive MI management. RESULTS Among those with MI, Black patients were more likely than White patients to have CKD (eGFR <90; 61.4% versus 58.5%; P<0.001). Among those with MI and CKD, Black patients were more likely than White patients to have severe CKD (21.2% versus 12.4%; P<0.001). Patients with CKD were more likely than those without CKD to have diabetes or heart failure; Black patients with CKD were more likely to have these comorbidities when compared with White patients with CKD (all P<0.0001). Black race and CKD were associated with a lower likelihood of invasive management (adjusted odds ratio, 0.78 [95% CI, 0.75-0.81]; adjusted odds ratio, 0.72 [95% CI, 0.70-0.74]; P<0.001 for both). At eGFR levels ≥10, Black patients were significantly less likely than White patients to undergo invasive management. CONCLUSIONS Black patients with MI and mild or moderate CKD were less likely to undergo invasive management compared with White patients with similar CKD severity. National efforts are needed to address racial disparities that may remain in the invasive management of MI.
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Affiliation(s)
- Jennifer A Rymer
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Shuang Li
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Patrick H Pun
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Laine Thomas
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Tracy Y Wang
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
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Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM, Bischoff JM, Bittl JA, Cohen MG, DiMaio JM, Don CW, Fremes SE, Gaudino MF, Goldberger ZD, Grant MC, Jaswal JB, Kurlansky PA, Mehran R, Metkus TS, Nnacheta LC, Rao SV, Sellke FW, Sharma G, Yong CM, Zwischenberger BA. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2021; 145:e18-e114. [PMID: 34882435 DOI: 10.1161/cir.0000000000001038] [Citation(s) in RCA: 139] [Impact Index Per Article: 46.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
AIM The guideline for coronary artery revascularization replaces the 2011 coronary artery bypass graft surgery and the 2011 and 2015 percutaneous coronary intervention guidelines, providing a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization as well as the supporting documentation to encourage their use. METHODS A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered. Structure: Coronary artery disease remains a leading cause of morbidity and mortality globally. Coronary revascularization is an important therapeutic option when managing patients with coronary artery disease. The 2021 coronary artery revascularization guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with coronary artery disease who are being considered for coronary revascularization, with the intent to improve quality of care and align with patients' interests.
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12
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Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM, Bischoff JM, Bittl JA, Cohen MG, DiMaio JM, Don CW, Fremes SE, Gaudino MF, Goldberger ZD, Grant MC, Jaswal JB, Kurlansky PA, Mehran R, Metkus TS, Nnacheta LC, Rao SV, Sellke FW, Sharma G, Yong CM, Zwischenberger BA. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2021; 79:e21-e129. [PMID: 34895950 DOI: 10.1016/j.jacc.2021.09.006] [Citation(s) in RCA: 493] [Impact Index Per Article: 164.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIM The guideline for coronary artery revascularization replaces the 2011 coronary artery bypass graft surgery and the 2011 and 2015 percutaneous coronary intervention guidelines, providing a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization as well as the supporting documentation to encourage their use. METHODS A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered. STRUCTURE Coronary artery disease remains a leading cause of morbidity and mortality globally. Coronary revascularization is an important therapeutic option when managing patients with coronary artery disease. The 2021 coronary artery revascularization guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with coronary artery disease who are being considered for coronary revascularization, with the intent to improve quality of care and align with patients' interests.
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13
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Yan P, Zhang NY, Luo XQ, Wang M, Deng YH, Wu T, Wu X, Liu Q, Wang HS, Wang L, Kang YX, Duan SB. Is intravenous iodinated contrast medium administration really harmful in hospitalized acute kidney injury patients: a propensity score-matched study. Eur Radiol 2021; 32:1163-1172. [PMID: 34342692 DOI: 10.1007/s00330-021-08192-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 06/09/2021] [Accepted: 06/29/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVES To evaluate the effects of intravenous iodinated contrast medium (ICM) administration on the deterioration of renal function (DRF), new renal replacement therapy (RRT) induction and mortality of hospitalized acute kidney injury (AKI) patients. METHODS Adult hospitalized patients undergoing a contrast-enhanced or unenhanced CT scan within 7 days after AKI diagnosis from January 2015 to December 2019 were identified in this retrospective study. Propensity score matching was performed. Outcomes in 7 and 30 days after CT scan were compared between the contrast and non-contrast groups. Additional analyses were also performed in patients stratified by SCr levels at AKI diagnosis, times and time of CT scan, and in patients without chronic kidney disease or RRT requirement prior to CT scan. RESULTS In total, 1172 pairs were generated after 1:1 propensity score matching from 1336 cases exposed to ICM and 2724 unexposed. No significant differences were found in the outcomes between the two groups: DRF, 7.8% vs 9.0% (odds ratio (OR) 0.83, 95% confidence interval (CI) 0.62-1.11) in 7 days, 5.1% vs 5.4% (OR 0.93, 95%CI 0.64-1.34) in 30 days; new RRT induction, 2.3% vs 3.3% (OR 0.72,95%CI 0.43-1.18) in 7 days, 4.2% vs 4.5% (OR 0.95,95%CI 0.64-1.41) in 30 days; and mortality, 3.9% vs 4.8% (OR 0.83,95%CI 0.56-1.22) in 7 days, 9.0% vs 10.2% (OR 0.88,95%CI 0.68-1.15) in 30 days. Subset analyses showed similar results. CONCLUSION Intravenous ICM administration during AKI duration did not increase the risks of DRF, new RRT induction, and mortality in 7 and 30 days after CT scan. KEY POINTS • Intravenous ICM administration in hospitalized AKI patients does not increase the risks of deterioration of renal function, RRT induction, and mortality in 7 and 30 days after CT scan. • The effects of intravenous ICM on adverse outcomes are minimal even in AKI patients with high level of SCr values or multiple CT scans.
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Affiliation(s)
- Ping Yan
- Department of Nephrology, The Second Xiangya Hospital of Central South University, Hunan Key Laboratory of Kidney Disease and Blood Purification, 139 Renmin Road, Changsha, 410011, Hunan, China
| | - Ning-Ya Zhang
- Information Center, The Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, China
| | - Xiao-Qin Luo
- Department of Nephrology, The Second Xiangya Hospital of Central South University, Hunan Key Laboratory of Kidney Disease and Blood Purification, 139 Renmin Road, Changsha, 410011, Hunan, China
| | - Mei Wang
- Department of Nephrology, The Second Xiangya Hospital of Central South University, Hunan Key Laboratory of Kidney Disease and Blood Purification, 139 Renmin Road, Changsha, 410011, Hunan, China
| | - Ying-Hao Deng
- Department of Nephrology, The Second Xiangya Hospital of Central South University, Hunan Key Laboratory of Kidney Disease and Blood Purification, 139 Renmin Road, Changsha, 410011, Hunan, China
| | - Ting Wu
- Department of Nephrology, The Second Xiangya Hospital of Central South University, Hunan Key Laboratory of Kidney Disease and Blood Purification, 139 Renmin Road, Changsha, 410011, Hunan, China
| | - Xi Wu
- Department of Nephrology, The Second Xiangya Hospital of Central South University, Hunan Key Laboratory of Kidney Disease and Blood Purification, 139 Renmin Road, Changsha, 410011, Hunan, China
| | - Qian Liu
- Department of Nephrology, The Second Xiangya Hospital of Central South University, Hunan Key Laboratory of Kidney Disease and Blood Purification, 139 Renmin Road, Changsha, 410011, Hunan, China
| | - Hong-Shen Wang
- Department of Nephrology, The Second Xiangya Hospital of Central South University, Hunan Key Laboratory of Kidney Disease and Blood Purification, 139 Renmin Road, Changsha, 410011, Hunan, China
| | - Lin Wang
- Department of Nephrology, The Second Xiangya Hospital of Central South University, Hunan Key Laboratory of Kidney Disease and Blood Purification, 139 Renmin Road, Changsha, 410011, Hunan, China
| | - Yi-Xin Kang
- Department of Nephrology, The Second Xiangya Hospital of Central South University, Hunan Key Laboratory of Kidney Disease and Blood Purification, 139 Renmin Road, Changsha, 410011, Hunan, China
| | - Shao-Bin Duan
- Department of Nephrology, The Second Xiangya Hospital of Central South University, Hunan Key Laboratory of Kidney Disease and Blood Purification, 139 Renmin Road, Changsha, 410011, Hunan, China.
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Treatment rationale for coronary heart disease in advanced CKD. Herz 2021; 46:221-227. [PMID: 33566140 DOI: 10.1007/s00059-021-05025-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2021] [Indexed: 10/22/2022]
Abstract
Chronic kidney disease (CKD) is accompanied by coronary artery disease (CAD) in most patients. In this article we describe differences in the pathogenesis, diagnosis, and treatment of CAD compared with patients without kidney impairment. The histological phenotype as well as the clinical presentation of acute and chronic coronary syndromes differ from those of patients with normal kidney function. The risk of cardiovascular events including death is strikingly increased with higher stages of CKD. Traditional but even more nontraditional cardiovascular risk factors are contributing to this increase. Screening and diagnostic procedures show limited sensitivity and specificity. Lifestyle modification is important for reducing the progression of both CKD and CAD. A special emphasis should be placed on physical exercising. Equally important is a strict antihypertensive therapy due to the very high incidences of hypertension in CKD patients. Blockade of the renin-angiotensin-system is imperative providing that adverse effects can be managed. Target blood pressure should be at 130 mm Hg systolic. Antiglycemic treatment should be implemented with metformin and SGLT2-inhibitors as first-line therapy, and glomerular filtration rate thresholds must be respected for both drugs. The risk of hypoglycemia is increased with worsening kidney function. Statins are indicated for up to stage 5 CKD. When a revascularization procedure is indicated (percutaneous intervention or bypass grafting), higher rates or peri-interventional morbidity and mortality must be anticipated. Taken together, the available literature on patients with CKD and CAD is clearly restricted compared with that on CAD patients with preserved kidney function. Mechanisms of arteriosclerosis and atheromatosis in CKD deserve more attention in the future. One major innovation in the field is SGLT2-inhibitor treatment with its concordant advantages for kidney and cardiac protection.
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Contemporary National Outcomes of Acute Myocardial Infarction-Cardiogenic Shock in Patients with Prior Chronic Kidney Disease and End-Stage Renal Disease. J Clin Med 2020; 9:jcm9113702. [PMID: 33218121 PMCID: PMC7698908 DOI: 10.3390/jcm9113702] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 11/11/2020] [Accepted: 11/17/2020] [Indexed: 02/06/2023] Open
Abstract
Background: There are limited data on acute myocardial infarction with cardiogenic shock (AMI-CS) stratified by chronic kidney disease (CKD) stages. Objective: To assess clinical outcomes in AMI-CS stratified by CKD stages. Methods: A retrospective cohort of AMI-CS during 2005–2016 from the National Inpatient Sample was categorized as no CKD, CKD stage-III (CKD-III), CKD stage-IV (CKD-IV) and end-stage renal disease (ESRD). CKD-I/II were excluded. Outcomes included in-hospital mortality, use of coronary angiography, percutaneous coronary intervention (PCI) and mechanical circulatory support (MCS). We also evaluated acute kidney injury (AKI) and acute hemodialysis in non-ESRD admissions. Results: Of 372,412 AMI-CS admissions, CKD-III, CKD-IV and ESRD comprised 20,380 (5.5%), 7367 (2.0%) and 18,109 (4.9%), respectively. Admissions with CKD were, on average, older, of the White race, bearing Medicare insurance, of a lower socioeconomic stratum, with higher comorbidities, and higher rates of acute organ failure. Compared to the cohort without CKD, CKD-III, CKD-IV and ESRD had lower use of coronary angiography (72.7%, 67.1%, 56.9%, 61.1%), PCI (53.7%, 43.8%, 38.4%, 37.6%) and MCS (47.9%, 38.3%, 33.3%, 34.2%), respectively (all p < 0.001). AKI and acute hemodialysis use increased with increase in CKD stage (no CKD–38.5%, 2.6%; CKD-III–79.1%, 6.5%; CKD-IV–84.3%, 12.3%; p < 0.001). ESRD (adjusted odds ratio [OR] 1.25 [95% confidence interval {CI} 1.21–1.31]; p < 0.001), but not CKD-III (OR 0.72 [95% CI 0.69–0.75); p < 0.001) or CKD-IV (OR 0.82 [95 CI 0.77–0.87] was predictive of in-hospital mortality. Conclusions: CKD/ESRD is associated with lower use of evidence-based therapies. ESRD was an independent predictor of higher in-hospital mortality in AMI-CS.
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Liu C, Mor MK, Palevsky PM, Kaufman JS, Thiessen Philbrook H, Weisbord SD, Parikh CR. Postangiography Increases in Serum Creatinine and Biomarkers of Injury and Repair. Clin J Am Soc Nephrol 2020; 15:1240-1250. [PMID: 32839195 PMCID: PMC7480551 DOI: 10.2215/cjn.15931219] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Accepted: 07/02/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND OBJECTIVES It is unknown whether iodinated contrast causes kidney parenchymal damage. Biomarkers that are more specific to nephron injury than serum creatinine may provide insight into whether contrast-associated AKI reflects tubular damage. We assessed the association between biomarker changes after contrast angiography with contrast-associated AKI and 90-day major adverse kidney events and death. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We conducted a longitudinal analysis of participants from the biomarker substudy of the Prevention of Serious Adverse Events following Angiography trial. We measured injury (kidney injury molecule-1, neutrophil gelatinase-associated lipocalin, IL-18) and repair (monocyte chemoattractant protein-1, uromodulin, YKL-40) proteins from plasma and urine samples at baseline and 2-4 hours postangiography. We assessed the associations between absolute changes and relative ratios of biomarkers with contrast-associated AKI and 90-day major adverse kidney events and death. RESULTS Participants (n=922) were predominately men (97%) with diabetes (82%). Mean age was 70±8 years, and eGFR was 48±13 ml/min per 1.73 m2; 73 (8%) and 60 (7%) participants experienced contrast-associated AKI and 90-day major adverse kidney events and death, respectively. No postangiography urine biomarkers were associated with contrast-associated AKI. Postangiography plasma kidney injury molecule-1 and IL-18 were significantly higher in participants with contrast-associated AKI compared with those who did not develop contrast-associated AKI: 428 (248, 745) versus 306 (179, 567) mg/dl; P=0.04 and 325 (247, 422) versus 280 (212, 366) mg/dl; P=0.009, respectively. The majority of patients did not experience an increase in urine or plasma biomarkers. Absolute changes in plasma IL-18 were comparable in participants with contrast-associated AKI (-30 [-71, -9] mg/dl) and those without contrast-associated AKI (-27 [-53, -10] mg/dl; P=0.62). Relative ratios of plasma IL-18 were also comparable in participants with contrast-associated AKI (0.91; 0.86, 0.97) and those without contrast-associated AKI (0.91; 0.85, 0.96; P=0.54). CONCLUSIONS The lack of significant differences in the absolute changes and relative ratios of injury and repair biomarkers by contrast-associated AKI status suggests that the majority of mild contrast-associated AKI cases may be driven by hemodynamic changes at the kidney.
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Affiliation(s)
- Caroline Liu
- Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Maria K Mor
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania .,Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - Paul M Palevsky
- Renal Section, Medical Service, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - James S Kaufman
- Division of Nephrology, Veterans Affairs New York Harbor Healthcare System and New York University School of Medicine, New York, New York
| | | | - Steven D Weisbord
- Renal Section, Medical Service, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Renal Section, Medical Service and Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Chirag R Parikh
- Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Ultra-low-contrast angiography in patients with advanced chronic kidney disease and previous coronary artery bypass surgery. Coron Artery Dis 2020; 30:346-351. [PMID: 31094895 DOI: 10.1097/mca.0000000000000741] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE We sought to describe a technique for ultra-low-contrast angiography (ULCA) in patients with advanced chronic kidney disease (CKD) and previous coronary artery bypass surgery (CABG). BACKGROUND Patients with advanced CKD and previous CABG are at high risk of developing contrast-induced nephropathy (CIN) because of the additional contrast often required to identify bypass grafts. Apart from hydration, reduced contrast administration is the only established method to minimize the risk of CIN. PATIENTS AND METHODS Ten patients underwent ULCA, whereby an intracoronary injection of saline and coronary guidewires were used instead of test injections of contrast for engagement of bypass grafts with catheters. Estimated glomerular filtration rate (eGFR) before and 30 days following angiography were recorded as was the need for renal replacement therapy 1 year after the procedure. RESULTS All patients completed a diagnostic angiogram without complications. The median volume of contrast delivered was 13.5 ml (interquartile range: 10.5-17.8). The median eGFR was 18.3 ml/min/1.73 m (interquartile range: 16.5-28.2). There was no statistically significant difference in eGFR before the procedure and 30 days after the procedure (P=0.79). No patient required dialysis 30 days after the procedure. Two patients required initiation of dialysis at 1 year after the procedure. CONCLUSION In patients with advanced CKD and previous CABG, ULCA may be performed with high procedural success and without complications, minimizing the risk of CIN in these high-risk patients.
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Weisbord SD, Palevsky PM, Kaufman JS, Wu H, Androsenko M, Ferguson RE, Parikh CR, Bhatt DL, Gallagher M. Contrast-Associated Acute Kidney Injury and Serious Adverse Outcomes Following Angiography. J Am Coll Cardiol 2020; 75:1311-1320. [DOI: 10.1016/j.jacc.2020.01.023] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 12/17/2019] [Accepted: 01/07/2020] [Indexed: 02/07/2023]
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19
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Zero-Contrast Multivessel Revascularization for Acute Coronary Syndrome in a Patient With Chronic Kidney Disease. JACC Case Rep 2019; 1:774-780. [PMID: 34316930 PMCID: PMC8288793 DOI: 10.1016/j.jaccas.2019.11.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 10/31/2019] [Accepted: 11/01/2019] [Indexed: 11/22/2022]
Abstract
Patients with chronic kidney disease are at elevated risk for adverse events after traditional coronary angiography and percutaneous intervention with contrast media. The case presented in this report highlights the potential benefits of zero-contrast multivessel percutaneous coronary intervention in a patient presenting with a non–ST-segment elevation acute coronary syndrome. (Level of Difficulty: Beginner.)
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Key Words
- CAD, coronary artery disease
- CKD, chronic kidney disease
- CSA, cross-sectional area
- ISR, in-stent restenosis
- IVUS, intravascular ultrasound
- LAD, left anterior descending
- LCX, left circumflex
- MLD, minimal lumen diameter
- NSTEACS, non–ST-segment elevation acute coronary syndrome
- OM, obtuse marginal
- PCI, percutaneous coronary intervention
- RCA, right coronary artery
- coronary angiography
- iFR, instantaneous wave-free ratio
- intravascular ultrasound
- percutaneous coronary intervention
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20
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Affiliation(s)
- Roxana Mehran
- From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (R.M., G.D.D.); and the Veterans Affairs Pittsburgh Healthcare System and University of Pittsburgh School of Medicine, Pittsburgh (S.D.W.)
| | - George D Dangas
- From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (R.M., G.D.D.); and the Veterans Affairs Pittsburgh Healthcare System and University of Pittsburgh School of Medicine, Pittsburgh (S.D.W.)
| | - Steven D Weisbord
- From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (R.M., G.D.D.); and the Veterans Affairs Pittsburgh Healthcare System and University of Pittsburgh School of Medicine, Pittsburgh (S.D.W.)
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Perioperative acute myocardial infarction rate in chronic renal disease patients undergoing orthopedic surgery: Is there any difference between dialyzed and nondialyzed patients? PLoS One 2019; 14:e0210554. [PMID: 30653544 PMCID: PMC6336305 DOI: 10.1371/journal.pone.0210554] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 12/27/2018] [Indexed: 11/30/2022] Open
Abstract
Background The incidence of acute myocardial infarction (AMI) in healthy patients undergoing noncardiac surgery is <1%. When patients with chronic kidney disease (CKD) undergo orthopedic surgery, AMI incidence can be expected to be relatively high. However, data on a population-wide scale is lacking. Objective To investigate AMI incidence in patients with CKD (with and without dialysis) undergoing orthopedic surgery. Design A population-based study covering the period from January 1, 1997, to December 31, 2011. Setting Data from the Taiwan National Health Insurance Research Database. Participants Participants were 219,195 patients with CKD who underwent surgery between January 1, 1997, and December 31, 2011. Results AMI occurred in 2,708 participants (1.24%). The AMI incidence rate in the dialyzed group was 1.52%, which was higher than that in the nondialyzed group after propensity score matching. Dialysis (odds ratio [OR]: 1.79; 95% confidence interval [CI]: 1.62–1.98), male (OR: 1.42; 95% CI: 1.28–1.57), diabetes mellitus (OR: 1.61; 95% CI: 1.44–1.80), hyperlipidemia (OR: 1.88; 95% CI: 1.68–2.11), old myocardial infarction (OR: 18.87; 95% CI: 16.26–1.21.90), and cerebral vascular disease (CVA) (OR: 1.29; 95% CI: 1.30–1.47) were all associated with AMI in the patients with CKD. Conclusions The AMI risk was higher in the patients with CKD undergoing orthopedic surgery than in the general population, and the dialyzed group had a higher risk of AMI than did the nondialyzed group.
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Correa S, Bonaca MP, Scirica BM, Murphy SA, Goodrich EL, Morrow DA, O’Donoghue ML. Efficacy and safety of more potent antiplatelet therapy with vorapaxar in patients with impaired renal function. J Thromb Thrombolysis 2018; 47:353-360. [DOI: 10.1007/s11239-018-1779-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Topaz G, Gharra W, Eisen A, Hershko AY, Shilo L, Beeri G, Kitay-Cohen Y, Pereg D. Impaired renal function is associated with adverse outcomes in patients with chest pain discharged from internal medicine wards. Eur J Intern Med 2018; 53:57-61. [PMID: 29422376 DOI: 10.1016/j.ejim.2018.01.034] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 01/06/2018] [Accepted: 01/31/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND Assessment of chest pain is one of the most common reasons for hospital admissions in internal medicine wards. However, little is known regarding predictors for poor prognosis in patients discharged from internal medicine wards after acute coronary syndrome (ACS) rule-out. OBJECTIVE To assess the association of kidney function with mortality and hospital admissions due to ACS in patients with chest pain who were discharged from internal medicine wards following ACS rule-out. METHODS Included were patients admitted to an internal medicine ward who were subsequently discharged following an ACSrule-out during 2010-2016. The primary endpoint was the composite of all-cause mortality and hospital admission due to ACS at 30-days following hospital discharge. RESULTS Included in the study were12,337 patients who were divided into 3 groups according to renal function. Considering patients with an eGFR ≥ 60 ml/min/1.73m2 as the reference group yielded adjusted hazard ratios for the composite of 30-day all-cause mortality and hospital admission for ACS that increased with reduced eGFR (HR = 2, 95%CI = 1.3-3.3, HR = 4.8, 95%CI = 3-7.6, for patients with eGFR of 45 to 59.9 or <45 ml/min/1.73m2, respectively, p < 0.001). Similarly, reduced renal function was associated with increased 1-year all-cause mortality (HR = 1.6, 95%CI = 1.2-2.2, HR = 4.5, 95%CI = 3.4-5.9, for patients with eGFR of 45-59.9 or <45 ml/min/1.73m2, respectively, p < 0.001). CONCLUSION We found an independent graded association between lower eGFR and the risk of death and ACS among patients with chest pain who were discharged from internal medicine wards following an ACS rule-out. The eGFR may be combined in the risk stratification of patients with chest pain.
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Affiliation(s)
- Guy Topaz
- Department of Internal Medicine C, Meir Medical Center, Kfar Saba, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Wesal Gharra
- Department of Internal Medicine C, Meir Medical Center, Kfar Saba, Israel
| | - Alon Eisen
- Department of Cardiology, Rabin Medical Center, Petah Tikva, Israel
| | - Alon Y Hershko
- Department of Internal Medicine C, Meir Medical Center, Kfar Saba, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Lotan Shilo
- Department of Internal Medicine C, Meir Medical Center, Kfar Saba, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Gil Beeri
- Department of Cardiology, Meir Medical Center, Kfar Saba, Israel
| | - Yona Kitay-Cohen
- Department of Internal Medicine C, Meir Medical Center, Kfar Saba, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - David Pereg
- Department of Cardiology, Meir Medical Center, Kfar Saba, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
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Weir MA, Herzog CA. Beta blockers in patients with end-stage renal disease-Evidence-based recommendations. Semin Dial 2018; 31:219-225. [PMID: 29482260 DOI: 10.1111/sdi.12691] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
For patients who require hemodialysis, beta blockers offer a simultaneous opportunity and challenge in the treatment of cardiovascular disease. Beta blockers are well supported by data from nondialysis populations and directly mitigate the sympathetic overactivity that links chronic kidney disease with cardiovascular sequelae. However, the evidence supporting their use in patients receiving hemodialysis is sparse and the heterogeneity of the beta blocker class makes it difficult to prescribe these medications with confidence. Despite these limitations, both trial and observational data exist that can help guide the use of these medications. In this review, we outline the reasons to consider beta blockers for patients receiving hemodialysis, discuss the barriers to their use, and provide specific evidence-based recommendations for beta blocker use in patients with heart failure, hypertension, ischemic heart disease and arrhythmia.
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Affiliation(s)
- Matthew A Weir
- Division of Nephrology, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.,Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Charles A Herzog
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis, MN, USA.,Division of Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, MN, USA
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Smilowitz NR, Gupta N, Guo Y, Mauricio R, Bangalore S. Management and outcomes of acute myocardial infarction in patients with chronic kidney disease. Int J Cardiol 2017; 227:1-7. [DOI: 10.1016/j.ijcard.2016.11.026] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2016] [Accepted: 11/04/2016] [Indexed: 10/20/2022]
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An Elevated Glycemic Gap is Associated with Adverse Outcomes in Diabetic Patients with Acute Myocardial Infarction. Sci Rep 2016; 6:27770. [PMID: 27291987 PMCID: PMC4904212 DOI: 10.1038/srep27770] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 05/24/2016] [Indexed: 02/07/2023] Open
Abstract
Acute hyperglycemia is a frequent finding in patients presenting to the emergency department (ED) with acute myocardial infarction (AMI). The prognostic role of hyperglycemia in diabetic patients with AMI remains controversial. We retrospectively reviewed patients' medical records to obtain demographic data, clinical presentation, major adverse cardiac events (MACEs), several clinical scores and laboratory data, including the plasma glucose level at initial presentation and HbA1c levels. The glycemic gap, which represents changes in serum glucose levels during the index event, was calculated from the glucose level upon ED admission minus the HbA1c-derived average glucose (ADAG). We enrolled 331 patients after the review of medical records. An elevated glycemic gap between admission serum glucose levels and ADAG were associated with an increased risk of mortality in patients. The glycemic gap showed superior discriminative power regarding the development of MACEs when compared with the admission glucose level. The calculation of the glycemic gap may increase the discriminative powers of established clinical scoring systems in diabetic patients presenting to the ED with AMI. In conclusion, the glycemic gap could be used as an adjunct parameter to assess the severity and prognosis of diabetic patients presenting with AMI. However, the usefulness of the glycemic gap should be further explored in prospective longitudinal studies.
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Vavalle JP, van Diepen S, Clare RM, Hochman JS, Weaver WD, Mehta RH, Pieper KS, Patel MR, Patel UD, Armstrong PW, Granger CB, Lopes RD. Renal failure in patients with ST-segment elevation acute myocardial infarction treated with primary percutaneous coronary intervention: Predictors, clinical and angiographic features, and outcomes. Am Heart J 2016; 173:57-66. [PMID: 26920597 DOI: 10.1016/j.ahj.2015.12.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 12/05/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Among patients presenting with ST-segment elevation myocardial infarction (STEMI) for primary percutaneous coronary intervention (PCI), the associations between clinical outcomes and both baseline renal function and the development of acute kidney injury (AKI) have not been reported in a trial population with unselected baseline renal function. METHODS Patients enrolled in the APEX-AMI trial who underwent primary PCI for the treatment of STEMI were categorized according to (a) baseline renal function and (b) the development of AKI. Patient characteristics, clinical outcomes, and treatment patterns were analyzed according to baseline renal function and the development of AKI. A prediction model for AKI after primary PCI for STEMI was also developed. RESULTS A total of 5,244 patients were included in this analysis and stratified according to baseline estimated glomerular filtration rate (eGFR) (milliliters per minute per 1.73 m(2)) of >90, 60 to 90, 30 to 59, or <30 or as dialysis dependent. Patients with lower eGFR were older, more often female, and less often treated with evidence-based medicines and had worse angiographic outcomes and higher mortality. The rates of AKI for patients with a baseline eGFR of >90, 60 to 90, 30 to 59, and <30 were 2.5%, 4.1%, 8.1%, and 1.6%, respectively (P < .0001). The strongest predictors of AKI were age and presenting in Killip class III or IV. CONCLUSIONS Among patients undergoing primary PCI for STEMI, impaired renal function at presentation and development of post-PCI AKI were highly associated with worse clinical and angiographic outcomes, including death. The risk of developing AKI was low and only modestly associated with baseline renal function.
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Washam JB, Herzog CA, Beitelshees AL, Cohen MG, Henry TD, Kapur NK, Mega JL, Menon V, Page RL, Newby LK. Pharmacotherapy in Chronic Kidney Disease Patients Presenting With Acute Coronary Syndrome. Circulation 2015; 131:1123-49. [DOI: 10.1161/cir.0000000000000183] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Turan B, Erkol A, Gül M, Fındıkçıoğlu U, Erden İ. Effect of Contrast-Induced Nephropathy on the Long-Term Outcome of Patients with Non-ST Segment Elevation Myocardial Infarction. Cardiorenal Med 2015; 5:116-24. [PMID: 25999960 DOI: 10.1159/000371900] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2014] [Accepted: 12/28/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Contrast-induced nephropathy (CIN) has been traditionally associated with increased mortality and adverse cardiovascular events. We sought to determine whether CIN has a negative impact on the long-term outcome of patients with non-ST segment elevation myocardial infarction (NSTEMI). METHODS A total of 312 consecutive patients (mean age 59 years, 76% male) who presented with NSTEMI and had undergone an early invasive procedure were retrospectively included. CIN was defined as either a 25% or 0.5-mg/dl increase in baseline serum creatinine (Cr) 72 h after the procedure. The primary endpoint of the study was mortality in the long-term follow-up (38 months, interquartile range 30-40). The secondary endpoint consisted of mortality and myocardial infarction (MI). RESULTS CIN developed in 30 (9.6%) patients. Independent predictors of CIN were the contrast volume-to-Cr clearance ratio, left ventricular ejection fraction and hemoglobin concentration. The primary (20 vs. 8.5%, p = 0.042) and secondary endpoints (33.3 vs. 17%, p = 0.029) were observed more frequently in patients with CIN during long-term follow-up. The unadjusted odds ratio (OR) of CIN was 2.55 [95% confidence intervals (CI) 1.04-6.24, p = 0.040] for mortality and 2.15 (CI 1.09-4.25, p = 0.028) for mortality/MI. However, after adjustment for confounding factors, CIN was not an independent predictor of either mortality (OR 1.62, CI 0.21-12.57, p = 0.646) or mortality/MI (OR 1.12, CI 0.31-4.0, p = 0.860). CONCLUSION The effect of CIN on the long-term outcome of patients with NSTEMI was substantially influenced by confounding factors. CIN was a marker, rather than a mediator, of increased cardiovascular risk, and the baseline renal function was more conclusive as a long-term prognosticator.
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Affiliation(s)
- Burak Turan
- Cardiology Department, Kocaeli Derince Training and Research Hospital, Kocaeli, Istanbul, Turkey
| | - Ayhan Erkol
- Cardiology Department, Kocaeli Derince Training and Research Hospital, Kocaeli, Istanbul, Turkey
| | - Mehmet Gül
- Cardiology Department, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Uğur Fındıkçıoğlu
- Cardiology Department, Dr. Lütfi Kırdar Kartal Training and Research Hospital, Istanbul, Turkey
| | - İsmail Erden
- Cardiology Department, Kocaeli Derince Training and Research Hospital, Kocaeli, Istanbul, Turkey
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Weisbord SD. AKI and medical care after coronary angiography: renalism revisited. Clin J Am Soc Nephrol 2014; 9:1823-5. [PMID: 25318756 DOI: 10.2215/cjn.09430914] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Steven D Weisbord
- Renal Section, Medicine Service Line, Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; and Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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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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Baber U, Auguste U. Patients with chronic kidney disease/diabetes mellitus: the high-risk profile in acute coronary syndrome. Curr Cardiol Rep 2014; 15:386. [PMID: 23843182 DOI: 10.1007/s11886-013-0386-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Chronic kidney disease (CKD) and diabetes mellitus (DM) are highly prevalent, morbid diseases that are very common among patients presenting with acute coronary syndromes (ACS). Despite significant reductions in cardiovascular morbidity and mortality over the last half century, residual vascular risk remains disproportionately high in these populations. In large part, this is attributable to pre-existing vascular morbidity and substantial enrichment of traditional risk factors among those with either CKD or DM. Other factors, such as less aggressive therapeutic intervention and a unique atherothrombotic phenotype, are also contributory. The introduction of novel antiplatelet and antithrombotic agents over the last several years provides fresh opportunities to improve the adverse prognosis among patients with CKD or DM and concomitant ACS.
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Affiliation(s)
- Usman Baber
- The Zena and Michael A. Wiener Cardiovascular Institute, The Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA.
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Takaya Y, Kumasaka R, Arakawa T, Ohara T, Nakanishi M, Noguchi T, Yanase M, Takaki H, Kawano Y, Goto Y. Impact of Cardiac Rehabilitation on Renal Function in Patients With and Without Chronic Kidney Disease After Acute Myocardial Infarction. Circ J 2014; 78:377-84. [DOI: 10.1253/circj.cj-13-0779] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Yoichi Takaya
- Departments of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Reon Kumasaka
- Departments of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Tetsuo Arakawa
- Departments of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Takahiro Ohara
- Departments of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Michio Nakanishi
- Departments of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Teruo Noguchi
- Departments of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Masanobu Yanase
- Departments of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Hiroshi Takaki
- Departments of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Yuhei Kawano
- Hypertension and Nephrology, National Cerebral and Cardiovascular Center
| | - Yoichi Goto
- Departments of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
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Balancing the risk of mortality and major bleeding in the treatment of NSTEMI patients - a report from the National Cardiovascular Data Registry. Am Heart J 2013; 166:1043-1049.e1. [PMID: 24268219 DOI: 10.1016/j.ahj.2013.09.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Accepted: 09/04/2013] [Indexed: 11/22/2022]
Abstract
OBJECTIVES We sought to describe real-world patterns of care in NSTEMI patients across different risk profiles for bleeding and mortality. BACKGROUND The NCDR ACTION Registry-GWTG in-hospital mortality and major bleeding risk scores were developed to assess patient risk and optimize treatment decisions. However, little is known about the alignment of contemporary clinical management patterns with these risk estimates. METHODS We studied 61,366 NSTEMI patients in the NCDR ACTION-Registry-GWTG from January 2007 to March 2009, stratifying them into four groups based on estimated risk of mortality and major bleeding. RESULTS There were 24,709 (40.3%) patients in each of the concordant risk groups (low:low; high:high) and 5974 (9.7%) in each of the discordant risk groups (low:high; high:low). Subjects at high estimated risk for both mortality and major bleeding were least likely to receive guideline-based adjunctive pharmacotherapy or to undergo angiography within 48 hours but most likely to receive an excess dose of an antithrombotic agent. Patients at low estimated risk for mortality and bleeding received the most intensive adjunctive therapy and were most likely to undergo invasive angiography. CONCLUSION There are significant differences in contemporary patterns of care across varying risk profiles of mortality and major bleeding. Despite practice patterns which seem to emphasize avoiding harm with reduced use of antithrombotic therapy, patients at high risk for major bleeding continue to receive excess doses of antithrombotic therapy. Additional performance improvement efforts are needed to optimize outcomes in NSTEMI patients with high risk for both bleeding and mortality.
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Patients with severe chronic kidney disease benefit from early revascularization after acute coronary syndrome. Int J Cardiol 2013; 168:3741-6. [DOI: 10.1016/j.ijcard.2013.06.013] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2012] [Revised: 02/01/2013] [Accepted: 06/15/2013] [Indexed: 11/20/2022]
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Narala KR, Hassan S, LaLonde TA, McCullough PA. Management of coronary atherosclerosis and acute coronary syndromes in patients with chronic kidney disease. Curr Probl Cardiol 2013; 38:165-206. [PMID: 23590761 DOI: 10.1016/j.cpcardiol.2012.12.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Atherosclerosis of the coronary arteries is common, extensive, and more unstable among patients with chronic renal impairment or chronic kidney disease (CKD). The initial presentation of coronary disease is often acute coronary syndrome (ACS) that tends to be more complicated and has a higher risk of death in this population. Medical treatment of ACS includes antianginal agents, antiplatelet therapy, anticoagulants, and pharmacotherapies that modify the natural history of ventricular remodeling after injury. Revascularization, primarily with percutaneous coronary intervention and stenting, is critical for optimal outcomes in those at moderate and high risk for reinfarction, the development of heart failure, and death in predialysis patients with CKD. The benefit of revascularization in ACS may not extend to those with end-stage renal disease because of competing sources of all-cause mortality. In stable patients with CKD and multivessel coronary artery disease, observational studies have found that bypass surgery is associated with a reduced mortality as compared with percutaneous coronary intervention when patients are followed for several years. This article will review the guidelines-recommended therapeutic armamentarium for the treatment of stable coronary atherosclerosis and ACS and give specific guidance on benefits, hazards, dose adjustments, and caveats concerning patients with baseline CKD.
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Chou MT, Wang JJ, Sun YM, Sheu MJ, Chu CC, Weng SF, Chio CC, Kan WC, Chien CC. Epidemiology and mortality among dialysis patients with acute coronary syndrome: Taiwan National Cohort Study. Int J Cardiol 2013; 167:2719-23. [DOI: 10.1016/j.ijcard.2012.06.108] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2012] [Accepted: 06/24/2012] [Indexed: 10/28/2022]
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Blicher TM, Hommel K, Olesen JB, Torp-Pedersen C, Madsen M, Kamper AL. Less use of standard guideline-based treatment of myocardial infarction in patients with chronic kidney disease: a Danish nation-wide cohort study. Eur Heart J 2013; 34:2916-23. [DOI: 10.1093/eurheartj/eht220] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS, Zoghbi WA, Arend TE, Oetgen WJ, May C, Bradfield L, Keller S, Ramadhan E, Tomaselli GF, Brown N, Robertson RM, Whitman GR, Bezanson JL, Hundley J. 2012 ACCF/AHA Focused Update Incorporated Into the ACCF/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction. Circulation 2013; 127:e663-828. [DOI: 10.1161/cir.0b013e31828478ac] [Citation(s) in RCA: 181] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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40
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Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS, Jneid H, Ettinger SM, Ganiats TG, Philippides GJ, Jacobs AK, Halperin JL, Albert NM, Creager MA, DeMets D, Guyton RA, Kushner FG, Ohman EM, Stevenson W, Yancy CW. 2012 ACCF/AHA focused update incorporated into the ACCF/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013; 61:e179-347. [PMID: 23639841 DOI: 10.1016/j.jacc.2013.01.014] [Citation(s) in RCA: 373] [Impact Index Per Article: 33.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Dohi T, Kasai T, Miyauchi K, Takasu K, Kajimoto K, Kubota N, Amano A, Daida H. Prognostic impact of chronic kidney disease on 10-year clinical outcomes among patients with acute coronary syndrome. J Cardiol 2012; 60:438-42. [DOI: 10.1016/j.jjcc.2012.08.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2012] [Revised: 07/21/2012] [Accepted: 08/13/2012] [Indexed: 02/01/2023]
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Marenzi G, Cabiati A, Assanelli E. Chronic kidney disease in acute coronary syndromes. World J Nephrol 2012; 1:134-45. [PMID: 24175251 PMCID: PMC3782212 DOI: 10.5527/wjn.v1.i5.134] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2011] [Revised: 08/20/2012] [Accepted: 09/25/2012] [Indexed: 02/06/2023] Open
Abstract
Chronic kidney disease (CKD) is associated with a high burden of coronary artery disease. In patients with acute coronary syndromes (ACS), CKD is highly prevalent and associated with poor short- and long-term outcomes. Management of patients with CKD presenting with ACS is more complex than in the general population because of the lack of well-designed randomized trials assessing therapeutic strategies in such patients. The almost uniform exclusion of patients with CKD from randomized studies evaluating new targeted therapies for ACS, coupled with concerns about further deterioration of renal function and therapy-related toxic effects, may explain the less frequent use of proven medical therapies in this subgroup of high-risk patients. However, these patients potentially have much to gain from conventional revascularization strategies used in the general population. The objective of this review is to summarize the current evidence regarding the epidemiology and the clinical and prognostic relevance of CKD in ACS patients, in particular with respect to unresolved issues and uncertainties regarding recommended medical therapies and coronary revascularization strategies.
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Affiliation(s)
- Giancarlo Marenzi
- Giancarlo Marenzi, Angelo Cabiati, Emilio Assanelli, Centro Cardiologico Monzino, IRCCS Department of Cardiovascular Sciences, University of Milan, 20138 Milan, Italy
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Hanna EB, Chen AY, Roe MT, Saucedo JF. Characteristics and in-hospital outcomes of patients presenting with non-ST-segment elevation myocardial infarction found to have significant coronary artery disease on coronary angiography and managed medically: stratification according to renal function. Am Heart J 2012; 164:52-7.e1. [PMID: 22795282 DOI: 10.1016/j.ahj.2012.04.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2011] [Accepted: 04/22/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND The characteristics, therapies, and outcomes of patients presenting with non-ST-segment elevation myocardial infarction, found to have significant coronary artery disease on coronary angiography, and managed without revascularization ("nonrevascularized patients") have not been evaluated previously in a large-scale registry. METHODS We examined data on 13,872 non-ST-segment elevation myocardial infarction nonrevascularized patients who were captured by the Acute Coronary Treatment and Intervention Outcomes Network registry. Patients were divided according to baseline renal function in 4 groups: no chronic kidney disease (CKD) and CKD stages 3, 4, and 5. RESULTS The in-hospital mortality of nonrevascularized patients was 3.7%, whereas their in-hospital major bleeding rate was 10.8%. Overall, 44.2% (n = 6,132) of nonrevascularized patients had CKD. Compared with patients with normal renal function, nonrevascularized patients with CKD had significantly more history of myocardial infarction, heart failure, more 3-vessel coronary artery disease, and received fewer antithrombotic therapies. In addition, they had significantly higher rates of in-hospital mortality and major bleeding; CKD stage 4 was associated with the highest risk of adverse events. The multivariable-adjusted odds ratios of in-hospital mortality for CKD stages 3, 4, and 5 relative to no CKD were 1.5, 2.5, and 2.2, respectively (global P < .0001), and the analogous adjusted odds ratios of major bleeding were 1.5, 2.5, and 1.8 (global P < .0001). CONCLUSION Nonrevascularized patients have a high in-hospital mortality. Nonrevascularized patients with CKD have more comorbidities than patients without CKD and less frequently receive guideline-recommended therapies. Chronic kidney disease is strongly associated with in-hospital mortality and bleeding.
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Abeygunasekara SC, Horner CWM. High prevalence of undiagnosed kidney disease in those presenting with troponin positive acute coronary syndrome. Ren Fail 2012; 34:845-8. [PMID: 22680915 DOI: 10.3109/0886022x.2012.690716] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIM The aim of this study is to assess the prevalence and knowledge of chronic kidney disease (CKD) in those presenting to a District General Hospital (DGH) in the United Kingdom with troponin positive acute coronary syndrome (ACS) as compared to a sample of the general population. METHODS A retrospective observational study. Data were collected from ProForma completed during the 18-month period from 1 November 2007 to 30 April 2009. The stage of CKD and the proportion of undocumented CKD at presentation were calculated and the mean stage was compared with the general practice population (of similar demographics) sampled by de Lusignan et al. (Identifying patients with chronic kidney disease from general practice computer records. Fam Pract. 2005;22:234-241.) using the t-test statistics. RESULTS A total of 936 patients (600 men and 336 women) presented with troponin positive ACS; their mean stage of CKD = 2.874 ± 0.024. This was significantly different from the mean stage of CKD = 1.999 ± 0.004 found within the general population (p < 0.001). About 58.6% of patients with CKD stages 4 or 5 had no knowledge or documentation of their renal impairment. CONCLUSIONS Among those presenting to hospital with troponin positive ACS were many patients with undocumented severe renal impairment, emphasizing the need for general practitioners to screen for renal disease and refer to specialist nephrology services where appropriate. Joint renal and cardiac clinics may offer better care for this group of patients' long-term care.
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Okusa MD, Molitoris BA, Palevsky PM, Chinchilli VM, Liu KD, Cheung AK, Weisbord SD, Faubel S, Kellum JA, Wald R, Chertow GM, Levin A, Waikar SS, Murray PT, Parikh CR, Shaw AD, Go AS, Chawla LS, Kaufman JS, Devarajan P, Toto RM, Hsu CY, Greene TH, Mehta RL, Stokes JB, Thompson AM, Thompson BT, Westenfelder CS, Tumlin JA, Warnock DG, Shah SV, Xie Y, Duggan EG, Kimmel PL, Star RA. Design of clinical trials in acute kidney injury: a report from an NIDDK workshop--prevention trials. Clin J Am Soc Nephrol 2012; 7:851-5. [PMID: 22442188 DOI: 10.2215/cjn.12811211] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AKI is an important clinical problem that has become increasingly more common. Mortality rates associated with AKI remain high despite advances in supportive care. Patients surviving AKI have increased long-term mortality and appear to be at increased risk of developing CKD and progressing to ESRD. No proven effective pharmacologic therapies are currently available for the prevention or treatment of AKI. Advances in addressing this unmet need will require the development of novel therapeutic agents based on precise understanding of key pathophysiological events and the implementation of well designed clinical trials. To address this need, the National Institute of Diabetes and Digestive and Kidney Diseases sponsored the "Clinical Trials in Acute Kidney Injury: Current Opportunities and Barriers" workshop in December 2010. The event brought together representatives from academia, industry, the National Institutes of Health, and the US Food and Drug Administration. We report the discussions of workgroups that developed outlines of clinical trials for the prevention of AKI in two patient populations: patients undergoing elective surgery who are at risk for or who develop AKI, and patients who are at risk for contrast-induced AKI. In both of these populations, primary prevention or secondary therapy can be delivered at an optimal time relative to kidney injury. The workgroups detailed primary and secondary endpoints for studies in these groups, and explored the use of adaptive clinical trial designs for trials of novel preventive strategies to improve outcomes of patients with AKI.
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Affiliation(s)
- Mark D Okusa
- Division of Nephrology, University of Virginia Health System, Charlottesville, VA 22908-0133, USA
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Shroff GR, Frederick PD, Herzog CA. Renal failure and acute myocardial infarction: clinical characteristics in patients with advanced chronic kidney disease, on dialysis, and without chronic kidney disease. A collaborative project of the United States Renal Data System/National Institutes of Health and the National Registry of Myocardial Infarction. Am Heart J 2012; 163:399-406. [PMID: 22424010 DOI: 10.1016/j.ahj.2011.12.002] [Citation(s) in RCA: 94] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2011] [Accepted: 12/12/2011] [Indexed: 11/30/2022]
Abstract
BACKGROUND Patients with chronic kidney disease (CKD) experience poor outcomes after acute myocardial infarction (AMI). We sought to compare clinical characteristics of advanced CKD, dialysis, and non-CKD patients hospitalized with AMI. METHODS This observational study used record-linked data from the US Renal Data System and Third National Registry of Myocardial Infarction to identify 2,390 dialysis patients with AMI hospitalizations between April 1998 and June 2000. Advanced CKD patients (n = 29,319) were identified by baseline creatinine level ≥2.5 mg/dL. Clinical characteristics of CKD, dialysis, and non-CKD patients (n = 274,777) were compared using the χ(2) test. RESULTS Clinically significant differences among patients with advanced CKD (dialysis and non-CKD, respectively) on admission were chest pain, 40.4% (41.1% and 61.6%); diagnosis other than acute coronary syndrome, 44% (47.7% and 25.8%); and ST elevation, 15.9% (17.6% and 32.5%). In-hospital adverse outcomes were mortality, 23% (21.7% and 12.6%); unexpected cardiac arrest, 8.9% (12.3% and 6%); congestive heart failure, 41% (25.8% and 21.1%); and major bleeding, 4.9% (4.4% and 3%); P < .001 for all comparisons. In a logistic regression model, the adjusted odds ratio for in-hospital mortality for CKD (vs non-CKD) patients was 1.44 (95% CI 1.39-1.49). CONCLUSIONS The clinical characteristics of non-dialysis-dependent, advanced CKD patients with AMI are similar to characteristics of dialysis patients and likely contribute to poor outcomes. Intensive efforts for timely, accurate recognition of AMI in advanced CKD patients are warranted.
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Affiliation(s)
- Gautam R Shroff
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis, MN, USA
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Hanna EB, Chen AY, Roe MT, Wiviott SD, Fox CS, Saucedo JF. Characteristics and in-hospital outcomes of patients with non-ST-segment elevation myocardial infarction and chronic kidney disease undergoing percutaneous coronary intervention. JACC Cardiovasc Interv 2012; 4:1002-8. [PMID: 21939940 DOI: 10.1016/j.jcin.2011.05.022] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2010] [Revised: 04/21/2011] [Accepted: 05/24/2011] [Indexed: 01/26/2023]
Abstract
OBJECTIVES This study sought to evaluate the characteristics, therapies, and outcomes of patients with chronic kidney disease (CKD) presenting with non-ST-segment elevation myocardial infarction (NSTEMI) and managed with percutaneous coronary intervention (PCI). This specific population has not been evaluated previously. BACKGROUND Among patients with acute coronary syndrome, the presence of renal dysfunction is associated with an increased risk of death and major bleeding. METHODS We examined data on 40,074 NSTEMI patients managed with PCI who were captured by the ACTION (Acute Coronary Treatment and Intervention Outcomes Network) registry. Patients were divided according to baseline renal function in 4 groups: no CKD and CKD stages 3, 4, and 5. RESULTS Overall, 31.1% (n = 12,045) of patients with NSTEMI undergoing PCI had CKD. Compared with patients with normal renal function, CKD patients managed with PCI had significantly more history of myocardial infarction, heart failure, and more 3-vessel coronary artery disease. They received fewer antithrombotic therapies but were treated more frequently with bivalirudin. In addition, they had significantly higher rates of in-hospital mortality and major bleeding. CKD stage 4 was associated with the highest risk of adverse events relative to no CKD. The multivariable adjusted odds ratios of in-hospital mortality for CKD stages 3, 4, and 5 relative to no CKD were 2.0, 2.8, and 2.6, respectively (global p value <0.0001), and the analogous adjusted odds ratios of major bleeding were 1.5, 2.8, and 1.8, respectively (global p value <0.0001). CONCLUSIONS CKD patients presenting with NSTEMI and managed with PCI have more comorbidities and receive guideline-recommended therapies less frequently than do patients without CKD. CKD is strongly associated with in-hospital mortality and bleeding in NSTEMI patients undergoing PCI.
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Affiliation(s)
- Elias B Hanna
- Department of Medicine, Cardiovascular Section, Louisiana State University, New Orleans, Louisiana 70112, USA.
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Saltzman AJ, Stone GW, Claessen BE, Narula A, Leon-Reyes S, Weisz G, Brodie B, Witzenbichler B, Guagliumi G, Kornowski R, Dudek D, Metzger DC, Lansky AJ, Nikolsky E, Dangas GD, Mehran R. Long-Term Impact of Chronic Kidney Disease in Patients With ST-Segment Elevation Myocardial Infarction Treated With Primary Percutaneous Coronary Intervention. JACC Cardiovasc Interv 2011; 4:1011-9. [DOI: 10.1016/j.jcin.2011.06.012] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2011] [Revised: 06/08/2011] [Accepted: 06/23/2011] [Indexed: 12/13/2022]
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Marroquin OC, Weisbord S. Cardiovascular evaluation before renal transplantation: to cath or not to cath? Clin J Am Soc Nephrol 2011; 6:1807-9. [PMID: 21784833 DOI: 10.2215/cjn.06420611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Wright RS, Anderson JL, Adams CD, Bridges CR, Casey DE, Ettinger SM, Fesmire FM, Ganiats TG, Jneid H, Lincoff AM, Peterson ED, Philippides GJ, Theroux P, Wenger NK, Zidar JP, Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Zidar JP. 2011 ACCF/AHA focused update incorporated into the ACC/AHA 2007 Guidelines for the Management of Patients with Unstable Angina/Non-ST-Elevation Myocardial Infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines developed in collaboration with the American Academy of Family Physicians, Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons. J Am Coll Cardiol 2011; 57:e215-367. [PMID: 21545940 DOI: 10.1016/j.jacc.2011.02.011] [Citation(s) in RCA: 276] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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