Optimizing the Outcomes of Percutaneous Coronary Intervention in Patients with Chronic Kidney Disease

Higher inpatient mortality following percutaneous coronary intervention in patients with advanced chronic kidney disease

BACKGROUND

Advanced chronic kidney disease (ACKD) is common in patients undergoing percutaneous coronary intervention (PCI) and is associated with adverse outcomes. These patients are often excluded from revascularization studies. The goal of this study was to evaluate the impact of ACKD in patients undergoing PCI.

METHODS

We analyzed the national inpatient sample database to compare the inpatient mortality rate for ACKD patients [chronic kidney disease (CKD) stage 3 and above] who underwent PCI between 2006 and 2011 to patients without ACKD. Specific ICD-9 CM codes were used to identify these patients.

RESULTS

A total of 1 826 536 PCIs were performed during the study period, of which 113 018 (6.2%) were patients with advanced CKD. The age-adjusted inpatient mortality rates were significantly higher in the ACKD group in all years studied compared to the no CKD group. For the first year studied in 2006, the age-adjusted mortality rate for patients undergoing PCI was 149 per 100 000 vs. 48 per 100 000 in patients without ACKD (P < 0001). In the last year studied in 2011, age-adjusted mortality was 124.1 per 100 000 vs. 40.4 per 100 000 in patients with no ACKD, (P < 0.0001). The presence of ACKD remained independently associated with higher mortality despite multivariate adjustment (odds ratio: 1.32, confidence interval: 1.27-1.36, P < 0.001).

CONCLUSION

ACKD is independently associated with higher mortality in patients undergoing PCI. Therefore, PCI in these patients should be performed with more caution.

A Simple Strategy to Reduce Contrast Media Use and Risk of Contrast-Induced Renal Injury during PCI: Introduction of an "Optimal Contrast Volume Protocol" to Daily Clinical Practice

Contrast-induced acute kidney injury is the leading cause of iatrogenic acute nephropathy. Development of contrast-induced nephropathy (CIN) increases the risk of adverse long- and short-term patients outcomes, the hospital costs, and length of hospitalization. There are a couple of methods described for CIN prevention (statin prescription, prehydration, contrast media (CM) clearance from the blood system, and decrease amounts of contrast volume). The CM volume to patient's creatinine clearance ratio is the main factor to predict the risk of CIN development. The safe CM to creatinine clearance ratio limits have been established. The usage of CM amount depends on personal operators habits and inside center regulations. There is no standardized contrast usage protocol worldwide. The aim of this study was to establish an easy to use, cheap, and efficient protocol to estimate a personalized safe CM dose limit for every patient based on their kidney function. These limits are announced during the "Time Out" before the procedure. Our study included 519 patients undergoing interventional coronary procedures: 207 patients into the "Optimal Contrast Volume" arm and 312 into the control group. Applying the protocol into a daily clinical practice leads to a significant reduction in CM volume used for all type of procedures and the development of CIN in comparison with a control group.

Risk Factors of Suboptimal Coronary Blood Flow after a Percutaneous Coronary Intervention in Patients with Acute Anterior Wall Myocardial Infarction

BACKGROUND AND AIMS

Primary percutaneous coronary intervention (PCI) is regarded as the most preferred strategy in ST-segment elevation myocardial infarction (STEMI). Thrombolysis in Myocardial Infarction (TIMI) flow grade has been an important and cohesive predictor of outcomes in STEMI patients. We sought to evaluate potential variables associated with the risk of suboptimal TIMI flow after PCI in patients with anterior wall STEMI.

METHODS

We evaluated 107 patients admitted to our hospital between 1 January 2019 and 31 December 2021 with a diagnosis of anterior wall STEMI treated with primary PCI.

RESULTS

Suboptimal TIMI flow grade (≤2) after PCI occurred in 14 (13%) patients while grade 3 was found in 93 (87%) of them presenting with anterior wall STEMI. Failure to achieve optimal TIMI 3 flow grade after PCI was associated with lower TIMI grade prior to PCI (OR 0.5477, 95% CI 0.2589-0.9324, p = 0.02), greater troponin concentration before (OR 1.0001, 95% CI 1-1.0001, p = 0.0028) and after PCI (OR 1.0001, 95% CI 1-1.0001, p = 0.0452) as well as lower mean minimal systolic blood pressure (OR 0.9653, 95% CI 0.9271-0.9985, p = 0.04).

CONCLUSIONS

Among predictors of suboptimal TIMI flow grade after PCI, we noted lower TIMI grade flow pre-PCI, greater serum troponin concentrations in the periprocedural period and lower mean minimal systolic blood pressure.

Cardiovascular and bleeding risks of inactive cancer in patients with acute myocardial infarction who received primary percutaneous coronary intervention using drug-eluting stent and dual/triple antithrombotic therapy

Background

Active cancer associates with increased cardiovascular and bleeding risks in patients with acute myocardial infarction (AMI). Recent chemotherapeutic agents have improved survival rate which enables to induce inactive status of cancer. However, whether cardiovascular and bleeding risks still exist in AMI patients with inactive cancer remains unknown.

Methods

The current study is a retrospective cross-sectional study including 712 AMI patients receiving primary percutaneous coronary intervention (PCI) with drug-eluting stent between 2007 and 2017. Primary PCI in ST-segment elevation myocardial infarction and non-ST-segment elevation myocardial infarction subjects was defined as PCI performed within 48 and 72 hours of symptom onset, respectively. Cardiovascular (= all-cause death + non-fatal MI + stroke) and bleeding events were compared in AMI patients with and without inactive cancer.

Results

Inactive cancer was identified in 11.1% of study subjects. Patients with inactive cancer were older (P<0.001) with atrial fibrillation (P<0.001), chronic kidney disease (P<0.001), anemia (P<0.001) and a higher prevalence of Killip class IV (P<0.001). Dual (82.3% vs. 86.7%) and triple (17.7% vs. 13.3%, P=0.34) antithrombotic therapies were commenced. Nearly 80% of subjects switched to single antithrombotic therapy around 1.5 years after dual/triple antithrombotic therapies (77.2% vs. 77.3%, P=0.994). During the 2.9-year observational period, inactive cancer was associated with 3.59-fold elevated risk for experiencing a composite of cardiovascular and bleeding events (95% CI: 2.13-6.04, P<0.001). Furthermore, after adjusting clinical characteristics, inactive cancer was an independent predictor for bleeding events (HR: 3.98, 95% CI: 1.90-8.34, P<0.001). Of particular interests, even after switching to single antithrombotic therapy, an elevated bleeding risk was still observed in inactive cancer subjects (P<0.001).

Conclusions

Inactive cancer worsened clinical outcome, especially bleeding risks in AMI subjects, underscoring to further optimize their antithrombotic managements.