Relation of subclinical serum creatinine elevation to adverse in-hospital outcomes among myocardial infarction patients

Emerging Biomarkers for Predicting Clinical Outcomes in Patients with Heart Disease

Cardiovascular disease is most frequently caused by the development and progression of atherosclerosis. When coronary arteries are afflicted, and the stenoses caused by atherosclerotic plaques are severe enough, the metabolic supply-and-offer balance is disturbed, leading to myocardial ischemia. If atherosclerotic plaques become unstable and local thrombosis develops, a myocardial infarction occurs. Sometimes, myocardial ischemia and infarction may result in significant and irreversible heart failure. To prevent severe complications, such as acute coronary syndromes and ischemia-related heart failure, extensive efforts have been made for developing biomarkers that would help identify patients at increased risk for cardiovascular events. In this two-part study, we attempted to provide a review of existing knowledge of blood biomarkers that may be used in this setting. The first part of this work was dedicated to conventional biomarkers, which are already used in clinical practice. In the second part, here presented, we discuss emerging biomarkers which have not yet become mainstream.

A Small Increase in Serum Creatinine within 48 h of Hospital Admission Is an Independent Predictor of In-Hospital Adverse Outcomes in Patients with ST-Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention: Findings from the Improving Care for Cardiovascular Disease in the China Project

Background

Acute kidney injury (AKI) is a common complication of percutaneous coronary intervention (PCI) that has been associated with high morbidity and mortality in patients with STEMI. Acute tubular damage may be reflected by serum creatinine (Scr) values that do not meet the criteria for AKI.

Methods

This analysis included 19,424 patients from the Improving Care for Cardiovascular Disease in China, Acute Coronary Syndrome Project (n = 5,221 (36.8%), patients with a small increase in Scr within 48 h of hospitalization; n = 14,203 patients with no increase in Scr). The primary outcome was the incidence of major adverse cardiovascular events (MACE). Secondary outcomes included the incidence of massive hemorrhage, in-hospital death, atrial fibrillation, heart failure, cardiogenic shock, cardiac arrest, and stroke. Logistic regression analysis was used to evaluate associations between a small increase in Scr within 48 h of hospitalization (>0.1 to <0.3 mg/dl) and MACE or massive hemorrhage during hospitalization.

Results

Patients with a small increase in Scr within 48 h of hospitalization were significantly more likely to experience MACE (11.2% vs. 9.1%; P < 0.001) or massive hemorrhage (3.2% vs. 2.2%; P < 0.001) compared to patients with no increase in Scr, but there was no significant difference in in-hospital mortality (0.8% vs. 0.9%; P=0.301). Logistic regression analysis showed that a small increase in Scr within 48 h of hospital admission was a risk factor for MACE (OR, 1.168; 95% CI, 1.044-1.306; P=0.006) or massive hemorrhage (OR, 1.413; 95% CI, 1.164-1.715; P < 0.001). Other risk factors included age ˃65 years, history of heart failure, use of glycoprotein IIb/IIIa inhibitors, aspirin or ACEI/ARB, LVEF <40%, Killip class III-IV, and increased SBP and heart rate.

Conclusion

A small increase in Scr during hospitalization in patients with STEMI undergoing primary PCI that does not meet the criteria for AKI is a risk factor for in-hospital adverse outcomes. This effect is maintained in patients with normal Scr at hospitalization. Trial Registration. Clinical trial registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02306616.

Predictive value of elevated alanine aminotransferase for in-hospital mortality in patients with acute myocardial infarction

Background and aims

Liver enzymes, including alanine aminotransferase (ALT) and aspartate aminotransferase (AST), are markers of hepatic dysfunction and fatty liver disease. Although ALT and AST have been suggested as risk factors for cardiovascular disease, their role as predictors of mortality after acute myocardial infarction (AMI) has not been established. The objective of this study was to investigate the predictive value of ALT and AST for mortality in patients with AMI.

Methods

We analyzed records of 712 patients with AMI and no known liver disease treated at the Department of Cardiovascular Center in the First Hospital of Jilin University. The primary outcome was all-cause in-hospital mortality. Relationships between primary outcome and various risk factors, including serum transaminase levels, were assessed using multivariate logistic regression analysis.

Results

Age (P < 0.001), hypertension (P = 0.034), prior myocardial infarction (P < 0.001), AST (P < 0.001), ALT (P < 0.001), creatinine (P = 0.007), blood urea nitrogen (P = 0.006), and troponin I (P < 0.001) differed significantly between ST-segment elevation myocardial infarction (STEMI) and non-STEMI. The following factors were associated with an increased risk of in-hospital all-cause mortality in patients with AMI: ALT ≥ 2ULN (adjusted odds ratio [AOR] 2.240 [95% confidence interval (CI), 1.331–3.771]; P = 0.002); age ≥ 65 year (AOR 4.320 [95% CI 2.687–6.947]; P < 0.001); increased fasting plasma glucose (FPG) (AOR 2.319 [95% CI 1.564–3.438]; P < 0.001); elevated D-dimer (AOR 2.117 [95% CI 1.407–3.184]; P < 0.001); elevated fibrinogen (AOR 1.601 [95% CI 1.077–2.380]; P = 0.20); and reduced estimated glomerular filtration rate (eGFR) (AOR 2.279 [95% CI 1.519–3.419]; P < 0.001).

Conclusions

Our findings demonstrated that elevated ALT was independently associated with increased in-hospital all-cause mortality in patients with AMI. Other risk factors were increased age, FPG, D-dimer, and fibrinogen and decreased eGFR.

Prediction Factors of 6-Month Poor Prognosis in Acute Myocardial Infarction Patients

Background: Acute myocardial infarction (AMI) is among the leading causes of death worldwide. Patients with AMI may have the risk of developing recurrent cardiovascular events leading to rehospitalization or even death. The present study aimed to investigate the prediction factors of poor prognosis (mortality and/or readmission) after AMI during a 6-month follow-up.

Methods: A total of 206 consecutive patients hospitalized for the first visit with AMI were enrolled. Data collection included demographic characteristics, medical history, clinical information, laboratory results, and oral medications within 24 h of admission. At 1, 3, and 6 months after discharge, AMI patients were followed up to assess the occurrence of composite endpoint events including in-hospital and out-of-hospital death and/or readmission due to recurrent myocardial infarction (MI) or exacerbated symptoms of heart failure following MI.

Results: After 6-month follow-up, a total of 197 AMI patients were available and divided in two groups according to good prognosis (n = 144) and poor prognosis (n = 53). Our data identified serum myoglobin ≥651 ng/mL, serum creatinine ≥96 μM, Killip classification 2–4, and female gender as independent predictors of 6-month mortality and/or readmission after AMI. Moreover, we demonstrated that Killip classification 2–4 combined with either myoglobin (AUC_{Killip class 2−4+myoglobin} = 0.784, sensitivity = 69.8%, specificity = 79.9%) or creatinine (AUC_{Killip class 2−4+creatinine} = 0.805, sensitivity = 75.5%, specificity = 77.1%) could further enhance the predictive capacity of poor 6-month prognosis among AMI patients.

Conclusions: Patients with AMI ranked in the higher Killip class need to be evaluated and monitored with attention. Multibiomarker approach using Killip classification 2–4 and myoglobin or creatinine may be an effective way for 6-month prognosis prediction in AMI patients.

Editor's Choice- What do small serum creatinine changes tell us about outcomes after acute myocardial infarction?

Acute kidney injury (AKI), mostly defined as a rise in serum creatinine concentration of more than 0.5 mg/dl, is a common, serious, and potentially preventable complication of percutaneous coronary intervention and is associated with adverse outcomes including an increased risk of inhospital mortality. Recent data from the National Cardiovascular Data Registry/Cath-PCI registry including 985,737 consecutive patients undergoing percutaneous coronary intervention suggest that approximately 7% experienced AKI with a reported incidence of 3-19%. In patients undergoing primary percutaneous coronary intervention for acute myocardial infarction (AMI), AKI occurs more frequently with rates up to 20% depending on patient and procedural characteristics. However, varying definitions of AKI limit comparisons of AKI rates across different studies. Recently, most studies have adopted the Acute Kidney Injury Network (AKIN) criteria for definition and classification of AKI. Beyond the AKIN criteria for AKI, other classifications such as the risk, injury, failure, loss and end-stage kidney disease (RIFLE) and kidney disease: improving global outcomes (KDIGO) criteria are used to define AKI. Notably, even small increases in serum creatinine beyond AKI may be associated with adverse outcomes including increased hospital length of stay and excess. Acute kidney injury (AKI) is a serious and potentially preventable complication of percutaneous coronary intervention (PCI). Worsening renal function is associated with adverse outcomes including a higher rate of in-hospital mortality. In patients undergoing primary PCI for acute myocardial infarction (AMI), AKI occurs up to 20% of such individuals. Varying definitions of AKI limit comparisons of AKI rates across different studies. Additionally, even small increases in serum creatinine beyond lavels meeting AKI definitions may be associated with adverse outcomes including increased hospital length of stay.