Impact of chronic kidney disease on clinical outcomes in patients with non-ST elevation myocardial infarction receiving percutaneous coronary intervention - A five-year observational study

Prognosis of patients with renal failure one year following non-ST-segment elevation myocardial infarction treated with percutaneous coronary intervention

OBJECTIVE

Kidney failure is highly prevalent in patients with non-ST-elevation myocardial infarction (NSTEMI). The aim of the study was to evaluate the prognostic significance of baseline renal function regarding in-hospital and 1-year mortality among patients with NSTEMI and treated with percutaneous coronary intervention (PCI).

METHODS

Data were obtained from the Polish Registry of Acute Coronary Syndromes (PL-ACS) and included 47,052 NSTEMI patients treated with PCI between 2017 and 2021. The cumulative incidence of all-cause mortality during the 1-year follow-up was presented using the Kaplan-Meier curves. The multivariable Cox regression model was created to adjust the relationship between eGFR (as a spline term) and all-cause mortality for potential confounders.

RESULTS

After considering the exclusion criteria, 20,834 cases were evaluated, with a median eGFR of 72.7 (IQR 56.6-87.5) mL/min/1.73 m2. The median age was 69 (62-76) years. The study comprised 4,505 patients with normal (90-120), 10,189 with mild (60-89), 5,539 with moderate (30-59), and 601 with severe eGFR impairment (15-29). Lower eGFR was associated with worse baseline clinical profile and longer in-hospital delay to coronary angiography. There was a stepwise increase in the crude all-cause death rates across the groups at 1 year. The Cox regression model with a spline term revealed that the relationship between eGFR and the risk of death at 1 year was non-linear (reverse J-shaped), and the risk was the lowest in patients with eGFR∼90 mL/min/1.73 m2.

CONCLUSIONS

There is a J-curve relationship between the eGFR value and 1-year all-cause mortality in patients with NSTEMI and treated with PCI.

Estimated glomerular filtration rate derived from different formulas and prognosis in acute coronary syndrome: Findings from the improving care for cardiovascular disease in China-acute coronary syndrome project

BACKGROUND

The optimal formula for the estimation of glomerular filtration rate (GFR) in patients with acute coronary syndrome (ACS) in terms of predicting in-hospital mortality and adverse events remains unclear.

METHODS

A nationwide registry study, Improving CCC (Care for Cardiovascular Disease in China) ACS project, was launched in 2014 as a collaborative study of the American Heart Association and Chinese Society of Cardiology. The Cockcroft-Gault, modification of diet in renal disease (MDRD) formula for Chinese (C-MDRD), Mayo, and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formulas were used to calculate estimated GFR in 61,545 ACS patients (38,734 with ST-segment elevation myocardial infarction [STEMI] and 22,811 with non-ST-segment-elevation ACS [NSTE-ACS]).

RESULTS

Prevalence of moderate to severe renal dysfunction was inconsistent among four formulas, ranging from 11.6% to 22.4% in NSTE-ACS and from 8.3% to 16.8% in STEMI, respectively. The in-hospital mortality rate in patients with ACS was inversely associated with estimated GFR. In STEMI, the Mayo-derived eGFR exhibited the highest predictive power for in-hospital death compared with the Cockcroft-Gault-derived eGFR (area under the curve [AUC]: 0.782 vs. 0.768, p=0.004), C-MDRD-derived eGFR (AUC: 0.782 vs. 0.740, p<0.001) and CKD-EPI-derived eGFR (AUC: 0.782 vs. 0.767, p<0.001). In NSTE-ACS, the Mayo-derived eGFR exhibited a similar predictive value with the Cockcroft-Gault (AUC: 0.781 vs. 0.787, p>0.05) and CKD-EPI-derived eGFR (AUC: 0.781 vs. 0.784, p>0.05).

CONCLUSIONS

The Mayo formula was superior to Cockcroft-Gault, C-MDRD, and CKD-EPI formulas for predicting in-hospital mortality in ACS patients, especially for STEMI. The Mayo-derived eGFR may serve as a risk-stratification tool for in-hospital adverse events in ACS patients.

CLINICAL TRIAL REGISTRATION

URL: http://www.

CLINICALTRIALS

gov. Unique identifier: NCT02306616.

Patients with end-stage renal disease requiring hemodialysis benefit from percutaneous coronary intervention after non-ST-segment elevation myocardial infarction

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.

Predictors of in-hospital mortality in diabetic patients with non-ST-elevation myocardial infarction

Background

There have been little data about the additive effects of coronary risk factors on mortality in diabetic patients presenting with non-ST-segment elevation myocardial infarction (NSTEMI). This study aimed to evaluate the predictors of mortality in diabetic patients presenting with NSTEMI. All patients admitted to Tehran Heart Center (THC) with a confirmed diagnosis of NSTEMI and a history of diabetes mellitus (DM) type 2 between September 2003 and April 2017 were included. Clinical characteristics and paraclinical data such as lipid profiles, creatinine, hemoglobin, and hemoglobin A1C (HbA1C) were evaluated in these patients to predict in-hospital mortality. The approach for model calibration was a logistic regression with the backward elimination method.

Results

Of a total of 9158 patients with non-ST-segment elevation myocardial infarction, 3133 had diabetes mellitus type 2 and met our criteria to enter the final analysis. In the multivariable analysis, age, chronic obstructive pulmonary disease, and a severely reduced left ventricular ejection fraction (LVEF) significantly increased the rate of in-hospital mortality, whereas mildly and moderately reduced left ventricular ejection fraction did not increase the rate of mortality.

Conclusions

Age, chronic obstructive pulmonary disease (COPD), and severely reduced LVEF (< 30%) independently increased in-hospital mortality in our diabetic patients with a confirmed diagnosis of NSTEMI. Severely reduced LVEF had the strongest relationship with in-hospital mortality, whereas the mean HbA1C level and the type of DM management exerted no significant effect on in-hospital mortality.

Value of the high-sensitivity troponin T assay for diagnosis of acute myocardial infarction in patients with and without renal insufficiency

BACKGROUND

Cardiac troponins are important markers for diagnosis of acute myocardial infarction (AMI) in general population; however, chronically-elevated troponins levels are often seen in patients with renal insufficiency, which reduce their diagnostic accuracy. The aim of our study was to access the diagnostic values of initial high-sensitive cardiac troponin T (hs-cTnT) and relative change of hs-cTnT for AMI in patients with and without renal insufficiency.

METHODS

Cardiac care unit patients with elevated hs-cTnT levels in 2017-2018 were enrolled. Receiver operating characteristic (ROC) curves were used to evaluate initial hs-cTnT levels and relative changes after 3 h of enrollment for diagnosis of AMI in patients with estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m² (low), and eGFR ≥ 60 mL/min/1.73 m² (normal).

RESULTS

Of 359 patients, 240 patients had low eGFR, and 119 patients had normal eGFR. The area under the ROC curve (AUC) for the initial hs-cTnT levels was 0.58 (95% CI, 0.5-0.65, p = 0.053) among patients with low eGFR and 0.54 (95% CI, 0.4-0.67, p = 0.612) among patients with normal eGFR. AUCs for relative changes of hs-cTnT were 0.82 (95% CI, 0.76-0.88, p < 0.001) in patients with low eGFR and 0.82 (95% CI, 0.71-0.91, p < 0.001) in patients with normal eGFR. Optimal cutoff values for the relative changes in hs-cTnT were 16% and 12% in patients with low eGFR and normal eGFR, respectively.

CONCLUSIONS

Relative changes in hs-cTnT levels had better diagnostic accuracy than initial hs-cTnT levels.

Impact of electrocardiographic morphology on clinical outcomes in patients with non-ST elevation myocardial infarction receiving coronary angiography and intervention: a retrospective study

Background

The impact of electrocardiography (ECG) morphology on clinical outcomes in patients with non-ST segment elevation myocardial infarction (NSTEMI) receiving percutaneous coronary intervention (PCI) is unknown. This study investigated whether different ST morphologies had different clinical outcomes in patients with NSTEMI receiving PCI.

Methods

This retrospective study analyzed record-linked data of 362 patients who had received PCI for NSTEMI between January 2008 and December 2010. ECG revealed ST depression in 67 patients, inverted T wave in 91 patients, and no significant ST-T changes in 204 patients. The primary endpoint was long-term all-cause mortality. The secondary endpoint was long-term cardiac death and non-fatal major adverse cardiac events.

Results

Compared to those patients whose ECG showed an inverted T wave and non-specific ST-T changes, patients whose ECG showed ST depression had more diabetes mellitus, advanced chronic kidney disease (CKD) and left main artery disease, as well as more in-hospital mortality, cardiac death and pulmonary edema during hospitalization. Patients with ST depression had a significantly higher rate of long-term total mortality and cardiac death. Finally, multiple stepwise Cox regression analysis showed that an advanced Killip score, age, advanced CKD, prior percutaneous transluminal coronary angioplasty and ST depression were independent predictors of the primary endpoint.

Conclusions

Among NSTEMI patients undergoing coronary angiography, those with ST depression had more in-hospital mortality and cardiac death. Long-term follow-up of patients with ST depression consistently reveals poor outcomes.

The dose-response association between estimated glomerular filtration rate and prognosis of patients with ST-segment elevation myocardial infarction from rural areas of China's Liaoning province

We aimed to investigate the dose-response associations between chronic kidney disease (CKD), and short and long-term cardiovascular outcomes, to characterize these associations by drawing dose-response curves based on a Chinese rural ST-segment elevation myocardial infarction (STEMI) population.In all, 1067 patients with STEMI were consecutively enrolled from 12 secondary hospitals of China's Liaoning province (from June 2009 to June 2010 and January 2015 to December 2015). The follow-up was regularly performed by telephone. Patients were grouped by estimated glomerular filter rate (eGFR): normal, eGFR ≥90 mL/min/1.73 m; mild CKD, 60 to 90 mL/min/1.73 m; CKD, <60 mL/min/1.73 m. Adjusted logistic or Cox regression models were employed to compare short and long-term cardiovascular outcomes across different eGFR groups. Dose-response curves were plotted using restricted cubic spline functions.About 18.46% of the STEMI patients had CKD. Patients with CKD were more likely to suffer from other comorbidities, but less likely to receive evidence-based therapies. CKD was independently associated with in-hospital mortality and major adverse cardiac events (MACE) as compared with patients with normal renal function (for in-hospital mortality, adjusted odds ratio [OR] 2.39, 95% confidence interval [CI] 1.18-4.85, P = .02; for in-hospital MACE, adjusted OR 2.01, 95% CI 1.09-3.70, P < .01). Likewise, CKD was significantly associated with long-term mortality as well (CKD vs normal, adjusted hazard ratio 2.55, 95% CI 1.17-5.57, P = .02). The dose-response associations between eGFR, and short and long-term cardiovascular outcomes were found to be linear (all with P values for nonlinear associations >.05).CKD is an independent predictor of worse in-hospital and long-term clinical outcomes. The assessment of eGFR is essential to enable risk stratification, tailored therapy, and early and aggressive management.

Prognostic Value of Chronic Kidney Disease Measures in Patients With Cardiac Disease

Chronic kidney disease (CKD) is considered a global public health issue. The latest international clinical guideline emphasizes characterization of CKD with both glomerular filtration rate (GFR) and albuminuria. CKD is closely related to cardiac disease and increases the risk of adverse outcomes among patients with cardiovascular disease (CVD). Indeed, numerous studies have investigated the association of CKD measures with prognosis among patients with CVD, but most of them have focused on kidney function, with limited data on albuminuria. Consequently, although there are several risk prediction tools for patients with CVD incorporating kidney function, to our knowledge, none of them include albuminuria. Moreover, the selection of the kidney function measure (e.g., serum creatinine, creatinine-based estimated GFR, or blood urea nitrogen) in these tools is heterogeneous. In this review, we will summarize these aspects, as well as the burden of CKD in patients with CVD, in the current literature. We will also discuss potential mechanisms linking CKD to secondary events and consider future research directions. Given their clinical and public health importance, for CVD we will focus on 2 representative cardiac diseases: myocardial infarction and heart failure.

Prognostic comparison between creatinine-based glomerular filtration rate formulas for the prediction of 10-year outcome in patients with non-ST elevation acute coronary syndrome treated by percutaneous coronary intervention

Background:

Estimated glomerular filtration rate (eGFR) is a predictor of outcome among patients with non-ST-elevation acute coronary syndrome (NSTE-ACS), but which estimation formula provides the best long-term risk stratification in this setting is still unclear. We compared the prognostic performance of four creatinine-based formulas for the prediction of 10-year outcome in a NSTE-ACS population treated by percutaneous coronary intervention.

Methods:

In 222 NSTE-ACS patients submitted to percutaneous coronary intervention, eGFR was calculated using four formulas: Cockcroft–Gault, re-expressed modification of diet in renal disease (MDRD), chronic kidney disease epidemiology collaboration (CKD-Epi), and Mayo-quadratic. Predefined endpoints were all-cause death and a composite of cardiovascular death, non-fatal reinfarction, clinically driven repeat revascularisation, and heart failure hospitalisation.

Results:

The different eGFR values showed poor agreement, with prevalences of renal dysfunction ranging from 14% to 35%. Over a median follow-up of 10.2 years, eGFR calculated by the CKD-Epi and Mayo-quadratic formulas independently predicted outcome, with an increase in the risk of death and events by up to 17% and 11%, respectively, for each decrement of 10 ml/min/1.73 m2. The Cockcroft–Gault and MDRD equations showed a borderline association with mortality and did not predict events. When compared in terms of goodness of fit, discrimination and calibration, the Mayo-quadratic outperformed the other formulas for the prediction of death and the CKD-Epi showed the best performance for the prediction of events (net reclassification improvement values 0.33–0.35).

Conclusions:

eGFR is an independent predictor of long-term outcome in patients with NSTE-ACS treated by percutaneous coronary intervention. The Mayo-quadratic and CKD-Epi equations might be superior to classic eGFR formulas for risk stratification in these patients.