Taxa de filtração glomerular: que fórmula deverá ser usada em doentes com enfarte agudo do miocárdio?

Cardiometabolic Risk Factors Related to Atrial Fibrillation and Metabolic Syndrome in the Pakistani Population

Background and Objectives: This study aimed to examine the relationship between cardiometabolic risk factors and atrial fibrillation (AF) and the simultaneous presence of AF and metabolic syndrome (MetS) in the Pakistani population. Materials and Methods: A total of 690 subjects were enrolled (n = 230 patients with AF, n = 230 patients with AF and MetS, and n = 230 controls). The associations between cardiometabolic parameters and AF with and without MetS were analyzed by univariable and multivariable binary regression analyses. Results: Body mass index (BMI), fasting blood glucose (FBG), and triglycerides (TG) were independently positively correlated, but the glomerular filtration rate (GFR) and sodium were independently negatively correlated with AF. An increase in BMI, FBG, and TG levels by one unit measure increased the probability by 55.1%, 20.6%, and 1.3%, respectively, for the AF occurrence. A decrease in GFR and sodium levels increased the probability by 4.3% and 33.6%, respectively, for the AF occurrence. On the other hand, uric acid was independently negatively correlated, whereas sodium was independently positively correlated, with MetS and AF. A decrease in uric acid levels and an increase in sodium levels by 1 unit measure increased the probability for MetS and AF by 23.2% and 7.5%, respectively. Conclusions: Cost-effective and routinely measured parameters, i.e., BMI, FBG TG, GFR, and sodium levels, can be reliable indicators of AF, whereas serum uric acid and sodium levels are independently associated with AF and MetS in the Pakistani population. Timely recognition and the control of modifiable cardiometabolic risk factors are of great significance in the prevention of AF development.

Exploring the Diversity of Visceral, Subcutaneous and Perivascular Adipose Tissue in a Vascular Surgery Population

The prevalence of obesity has doubled, with a concomitant increase in cardiovascular disease. This study aimed to compare the characteristics of visceral, subcutaneous and peri-aortic adipose tissue determined with computed tomography (CT) scans and to correlate them with cardiovascular risk factors, anthropometric measures and medication. An observational and prospective study was conducted, and 177 subjects were included. Peri-aortic adipose tissue had the highest density, while the subcutaneous adipose tissue had the lowest. The density of subcutaneous adipose tissue differs from the density of visceral (p = 0.00) and peri-aortic adipose tissue (p = 0.00). Smokers/ex-smokers had a lower area (p = 0.00) and density (p = 0.02) of subcutaneous adipose tissue. Multiple linear regression analysis showed that sex was a predictor of subcutaneous adipose tissue area (β = -0.27, t = -3.12, p = 0.00) but smoking habits were not. After controlling for sex, we found that the association between smokers/ex-smokers and area of subcutaneous adipose tissue was lost, but the association with density persisted. Patients with hypertension had a higher visceral adipose tissue area, and this relationship was maintained even after adjusting for gender. Peri-aortic adipose tissue is similar to visceral and distinct from subcutaneous adipose tissue. Cardiovascular risk factors have different influences in distinct adipose compartments.

Chronic kidney disease in acute coronary syndromes: real world data of long-term outcomes

Aim: Patients with chronic kidney disease (CKD) are at increased cardiovascular risk. Methods: Patients with acute coronary syndrome were retrospectively allocated to three groups (stage 3A, stage 3B or stage 4) based on the Kidney Disease Improving Global Outcomes classification formulas: the CKD Epidemiology Collaboration (CKD-EPI; N = 401) and the modification of diet in renal disease (n = 355). The primary end point was all-cause mortality (median follow-up time, 32 months [15-70]). Results: Study results showed decreased median survival was associated with poor renal function for both the CKD-EPI (78 vs 61 vs 40 months, p = 0.014) and modification of diet in renal disease groups (68 vs 57 vs 32 months, p = 0.006). After adjustment, age (OR: 1.07; 95% CI: 1.01-1.14) and pulmonary artery systolic pressure (OR: 1.08; 95% CI: 1.03-1.14), but not estimated glomerular filtration rate, were associated with decreased survival. Conclusion: Study results suggest that poor outcomes after an acute coronary syndrome were associated with comorbidities rather than estimated glomerular filtration rate level.

Impact of Chronic Renal Failure on Ischemic and Bleeding Events at 1 Year in Patients With Acute Coronary Syndrome (from the Multicenter START ANTIPLATELET Registry)

Chronic renal failure (CRF) impairs prognosis in patients with acute coronary syndromes (ACS); the differential impact of CRF on ischemic and bleeding events in the setting of ACS is unclear. We explored the predictive role of CRF, identified by different equations for the glomerular filtration rate estimation, on the occurrence of the composite end point, including both ischemic cardiovascular and major bleeding (major adverse cardiovascular and bleeding events [MACBE]) at 1 year, and its components. We accessed each patients data from 718 participants in the prospective, multicenter, and START ANTIPLATELET registry, performed on patients with ACS. The ability to predict the risk of MACBE was modest and similar for Cockcroft-Gault, MDRD, and CKD-EPI equations (area under the curves: 0.55, 95% confidence interval [CI] 0.47 to 0.63; 0.53, 95% CI 0.45 to 0.61; 0.54, 95% CI 0.46 to 0.62; respectively, overall p = 0.63). The incidence of MACBE in patients with CRF was 12.6 versus 7.4 per 100 patients/year in those with preserved renal function (adjusted odds ratio [OR] 1.80, 1.02 to 3.20, p = 0.045); the absolute excess in events rate due to CRF was higher for ischemic events (3.5%) than for major bleeding (2.6%). The increased occurrence of MACBE was even greater in patients with CRF and concomitant anemia (OR 2.16) and in patients with severe CRF (OR 2.78). In conclusion, our study indicates that, in patients with ACS, CRF impairs the clinical outcome at 1 year, especially when severe and when is concomitant with anemia. CRF is associated with greater absolute increase of ischemic events than major bleeding.

Disparities in the Estimation of Glomerular Filtration Rate According to Cockcroft-Gault, Modification of Diet in Renal Disease-4, and Chronic Kidney Disease Epidemiology Collaboration Equations and Relation With Outcomes in Patients With Acute Coronary Syndrome

BACKGROUND

A simple method to assess renal function is the estimated glomerular filtration rate, and it shows prognostic implications. However, it remains unknown which equation should be used in patients with acute coronary syndrome. We compared the ability and correlation of the Cockcroft-Gault, Modification of Diet in Renal Disease-4 (MDRD-4), and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations and their predictive performance for major adverse cardiovascular events, all-cause mortality, and major bleeding in a cohort of patients with acute coronary syndrome.

METHODS AND RESULTS

Multicenter prospective registry involving 1699 consecutive patients with acute coronary syndrome from 3 tertiary institutions. At entry, renal function was assessed using the Cockcroft-Gault, MDRD-4, and CKD-EPI-creatinine equations. During 12 months of follow-up, we recorded all major adverse cardiovascular events (composite of cardiovascular death, nonfatal myocardial infarction, and nonfatal ischemic stroke), bleeding events (Bleeding Academic Research Consortium classification), and all-cause mortality. Receiver operating characteristic curve comparisons demonstrated that Cockcroft-Gault equation had higher predictive ability compared with MDRD-4 equation for major adverse cardiovascular events (0.651 versus 0.616; P=0.023), major bleeding (0.600 versus 0.551; P=0.005), and all-cause mortality (0.754 versus 0.717; P=0.033), as well as higher predictive ability compared with CKD-EPI equation for major bleeding (0.600 versus 0.564; P=0.018). Integrated discrimination improvement and net reclassification improvement analyses showed superior discrimination and reclassification of Cockcroft-Gault equation. Decision curve analyses graphically demonstrated higher net benefit and clinical usefulness of the Cockcroft-Gault equation in comparison with MDRD-4 and CKD-EPI equations.

CONCLUSIONS

In patients with acute coronary syndrome, the Cockcroft-Gault equation presented superior predictive ability for major adverse cardiovascular events, major bleeding, and all-cause mortality compared with MDRD-4 equation, and superior predictive ability for major bleeding compared with CKD-EPI equation. The Cockcroft-Gault equation also showed higher net benefit and clinical usefulness.

Estimating glomerular filtration rate in acute coronary syndromes: Different equations, different mortality risk prediction

AIMS

Renal dysfunction is a powerful predictor of adverse outcomes in patients hospitalized for acute coronary syndrome. Three new glomerular filtration rate (GFR) estimating equations recently emerged, based on serum creatinine (CKD-EPIcreat), serum cystatin C (CKD-EPIcyst) or a combination of both (CKD-EPIcreat/cyst), and they are currently recommended to confirm the presence of renal dysfunction. Our aim was to analyse the predictive value of these new estimated GFR (eGFR) equations regarding mid-term mortality in patients with acute coronary syndrome, and compare them with the traditional Modification of Diet in Renal Disease (MDRD-4) formula.

METHODS AND RESULTS

801 patients admitted for acute coronary syndrome (age 67.3±13.3 years, 68.5% male) and followed for 23.6±9.8 months were included. For each equation, patient risk stratification was performed based on eGFR values: high-risk group (eGFR<60ml/min per 1.73m(2)) and low-risk group (eGFR⩾60ml/min per 1.73m(2)). The predictive performances of these equations were compared using area under each receiver operating characteristic curves (AUCs). Overall risk stratification improvement was assessed by the net reclassification improvement index. The incidence of the primary endpoint was 18.1%. The CKD-EPIcyst equation had the highest overall discriminate performance regarding mid-term mortality (AUC 0.782±0.20) and outperformed all other equations (ρ<0.001 in all comparisons). When compared with the MDRD-4 formula, the CKD-EPIcyst equation accurately reclassified a significant percentage of patients into more appropriate risk categories (net reclassification improvement index of 11.9% (p=0.003)). The CKD-EPIcyst equation added prognostic power to the Global Registry of Acute Coronary Events (GRACE) score in the prediction of mid-term mortality.

CONCLUSION

The CKD-EPIcyst equation provides a novel and improved method for assessing the mid-term mortality risk in patients admitted for acute coronary syndrome, outperforming the most widely used formula (MDRD-4), and improving the predictive value of the GRACE score. These results reinforce the added value of cystatin C as a risk marker in these patients.