Different Types of Renal Dysfunction in Patients with Acute Myocardial Infarction Treated with Percutaneous Coronary Intervention

Impact of Renal Insufficiency on Prognosis of Patients with Acute Coronary Syndrome

Purpose

Chronic kidney disease (CKD) is common in patients admitted with acute coronary syndrome (ACS), and it is associated with poor outcomes. However, data are limited. Hence, we examined the long-term prognostic significance of estimated glomerular filtration rate (eGFR) among Chinese patients hospitalized with ACS.

Patients and Methods

This is a multicenter, observational study that included 1860 ACS patients enrolled between March 2014 and June 2019 from 11 hospitals in Chengdu. CKD-EPI equation was used to calculate the baseline eGFR. Patients were divided into three groups: eGFR ≥ 90 mL/min (normal renal function), eGFR 60 to <90 mL/min (mild impaired renal function), and eGFR < 60 mL/min (moderate or severe renal dysfunction). The endpoint was all-cause death during follow-up.

Results

At baseline, 714 patients had normal renal function, while 746 patients had mild impaired renal function, and 400 patients had moderate or severe renal dysfunction. In the follow-up of 15 months (10 months, 22 months), 261 (14.0%) patients died;, 139 (34.8%) in the moderate or severe renal dysfunction group, 94 (12.6%) in the mild impaired renal function group, and 28 (3.9%) in the normal renal function group (log-rank p-value from Kaplan–Meier analysis <0.001). In multivariable Cox Proportional hazard analysis, age, systolic blood pressure (SBP), heart rate, eGFR, ST-elevation myocardial infarction (STEMI), and percutaneous coronary intervention (PCI) were independent predictors of all-cause death.

Conclusion

In this study, among Chinese patients with ACS, renal insufficiency was associated with unfavorable long-term prognosis. Age, SBP, heart rate, eGFR, STEMI, and PCI could identify those at risk.

Contrast-induced nephropathy after cardiac resynchronization therapy implant impairs the recovery of ejection fraction in responders

Aims

Data regarding contrast‐induced nephropathy (CIN) after cardiac resynchronization therapy (CRT) implant are limited. We aimed to investigate the incidence and determinants of CIN and its impact on CRT response and outcomes.

Methods and results

Patients who underwent CRT implant were retrospectively analysed, and CIN was defined as an increase of serum creatinine ≥0.3 mg/dL or ≥1.5 times the baseline value. Response to CRT was defined as a reduction of left ventricle end‐systolic volume (LVESV) of 15% or the increase of five percentage points in ejection fraction (EF) as assessed by echocardiography at 6 months. Follow‐up visits were scheduled at 3, 6, and 12 months.

Contrast‐induced nephropathy occurred in 13/107 patients (12%). Among baseline clinical, echocardiographic, and laboratory characteristics, only a high baseline serum creatinine was associated with the occurrence of CIN. Symptoms, EF, and LVESV at 6 months improved in both CIN and non‐CIN patients, and the rate of responders to CRT was similar. Among responders, at 6 months, those with CIN had significantly lower EF (28.5% vs. 35.7% P = 0.003).

At a median follow‐up of 112 weeks, 43% of patients experienced a clinical event with similar incidence in CIN and non‐CIN patients, and likewise survival was similar. Non‐responders to CRT had worse survival while among responders those with CIN had worse survival than non‐CIN patients (71% vs. 90%, P = 0.0035).

Conclusions

The incidence of CIN is rather high. Although CIN does not influence response to CRT overall, however among responders impairs the recovery of EF and survival.

Long-term prognostic role of uric acid in patients with ST-elevation myocardial infarction and renal dysfunction

Patients with renal impairment have decreased excretion of uric acid, thus being particularly prone to having elevated serum uric acid concentrations. No data are available on the long-term prognostic role of uric acid in patients with ST-elevation myocardial infarction (STEMI) and renal dysfunction, submitted to percutaneous coronary intervention (PCI). We therefore prospectively assessed, in 329 patients with STEMI and renal dysfunction (admission estimated glomerular filtration rate <60 ml/min/1.73 m), all submitted to PCI, whether uric acid levels are associated with increased mortality at 1-year postdischarge follow-up.Patients in the third tertile of uric acid showed a higher BMI (P = 0.014), a higher incidence of hypertension (P = 0.029), and two or more comorbidities (P = 0.034). The highest incidence of bleeding and of acute kidney injury was detectable in patients in the third tertile (P = 0.011 and P < 0.001, respectively) who showed the highest mortality rate at 1-year postdischarge follow-up (P = 0.008). At Cox regression analysis, uric acid was an independent predictor of 1-year postdischarge mortality (hazard ratio 1.26, 95% confidence interval 1.06-1.51, P = 0.011).In STEMI patients with estimated glomerular filtration rate below 60 ml/min/1.73 m treated with PCI, uric acid helps in identifying a subset of patients at a higher risk of bleeding and acute kidney injury. Increased uric acid is an independent prognostic risk factor for 1-year mortality. Further studies performed in larger cohorts of patients are needed to confirm our findings and to evaluate whether lowering uric acid in these patients is beneficial.

Contrast-induced acute kidney injury in patients undergoing cardiac resynchronization therapy-incidence and prognostic importance. Sub-analysis of data from randomized TRUST CRT trial

Introduction

Because data on contrast-induced acute kidney injury (CI-AKI) in patients undergoing cardiac resynchronization therapy (CRT-D) are scarce, we aimed to assess the incidence, natural course and prognostic importance of this syndrome in CRT recipients.

Methods

Study population consisted of 100 consecutive patients enrolled into the Triple Site Versus Standard Cardiac Resynchronization (TRUST CRT) trial, who were treated with CRT-D. Two patients were excluded up to 3 months after randomization and not analysed further. CI-AKI was defined as a rise in serum creatinine of at least 26.5 μmol/L (0.3 mg/dL) within 48 h after contrast exposure, or at least 50 % increase from the baseline value during index hospital stay with CRT-D implantation according to KDIGO Clinical Practice Guideline for Acute Kidney Injury.

Results

Among 98 subjects of TRUST CRT trial, 10 patients (10.2 %) developed CI-AKI after CRT-D implantation. In patients with glomerular filtration rate (GFR) <60 mL/min/1.73 m² on admission, the incidence of CI-AKI was almost twofold (15.4 %) higher than in subjects with GFR ≥60 (8.3 %). CRT-D recipients with CI-AKI had significantly higher mortality rate (50.0 %) compared to those without CI-AKI (17.0 %) during 30 months of follow-up (logrank p = 0.012). Multivariate Cox regression analysis showed CI-AKI as significant and independent risk factor for death in CRT-D recipients (hazard ratio 5.71; 95 % CI 5.16–6.26; p = 0.001).

Conclusions

Contrast-induced acute kidney injury is a serious and frequent procedural complication of CRT-D implantation with a significant negative influence on long-term survival. The results suggest that clinical evaluation regarding renal function should be considered in CRT-D recipients, both before and after device implantation.

Does estimated glomerular filtration rate have an effect on left ventricular function after ST-elevation myocardial infarction?

OBJECTIVES

Little is known about whether estimated glomerular filtration rates (eGFR) affect left ventricular (LV) function and gain benefit with antiremodeling treatment in patients with ST-elevation myocardial infarction (STEMI). We investigated the effect of eGFR on LV function using tissue Doppler imaging (TDI) parameters. In addition, we sought to evaluate the antiremodeling effect of standard treatment at follow-up in patients with renal insufficiency (RI) after STEMI.

METHODS AND RESULTS

A retrospective analysis of 579 patients with STEMI was performed. Patients were divided into 3 groups according to eGFR (Group 1: eGFR > 90 mL/min per 1.73 m(2); Group 2: eGFR = 60-89 mL/min per 1.73 m(2); Group 3: eGFR < 60 mL/min per 1.73 m(2)). Conventional echocardiography and TDI were performed within 48-72 hours after STEMI and at 6-month follow-up. The mean left ventricular ejection fraction (LVEF) was significantly lower in Group 3 than in Group 1 (P = 0.021). The mean peak systolic velocity (Sm) was significantly lower in Group 3 than in Group 1 and Group 2 (P = 0.002 and 0.006, respectively). The estimated GFR had a linear association with Sm and LVEF (P = 0.001, r = 0.161; P = 0.005, r = 0.132, respectively). Multivariate analysis showed that an eGFR < 60 mL/min per 1.73 m(2) was an independent predictor of lower Sm and in-hospital mortality. In addition, an antiremodeling effect of standard treatment was seen in all groups at 6-month follow-up.

CONCLUSIONS

Estimated glomerular filtration rate of <60 mL/min per 1.73 m(2) was associated with lower LV function after STEMI, and may gain an antiremodeling effect with standard treatment at follow-up.