Is kidney function affecting the management of myocardial infarction? A retrospective cohort study in patients with normal kidney function, chronic kidney disease stage III–V, and ESRD

Abstract

Patients with chronic kidney disease (CKD) are three times more likely to have myocardial infarction (MI) and suffer from increased morbidity and higher mortality. Traditional and unique risk factors are prevalent and constitute challenges for the standard of care. However, CKD patients have been largely excluded from clinical trials and little evidence is available to guide evidence-based treatment of coronary artery disease in patients with CKD. Our objective was to assess whether a difference exists in the management of MI (ST-segment elevation myocardial infarction and non-ST-segment elevation myocardial infarction) among patients with normal kidney function, CKD stage III–V, and end-stage renal disease (ESRD) patients. We conducted a retrospective cohort study on patients admitted to Staten Island University Hospital for the diagnosis of MI between January 2005 and December 2012. Patients were assigned to one of three groups according to their kidney function: Data collected on the medical management and the use of statins, platelet inhibitors, beta-blockers, and angiotensin converting enzyme inhibitors/angiotensin receptor blockers were compared among the three cohorts, as well as medical interventions including: catheterization and coronary artery bypass graft (CABG) when indicated. Chi-square test was used to compare the proportions between nominal variables. Binary logistic analysis was used in order to determine associations between treatment modalities and comorbidities, and to account for possible confounding factors. Three hundred and thirty-four patients (mean age 67.2±13.9 years) were included. In terms of management, medical treatment was not different among the three groups. However, cardiac catheterization was performed less in ESRD when compared with no CKD and CKD stage III–V (45.6% vs 74% and 93.9%) ( P <0.001). CABG was performed in comparable proportions in the three groups and CABG was not associated with the degree of CKD ( P =0.078) in binary logistics regression. Cardiac catheterization on the other hand carried the strongest association among all studied variables ( P <0.001). This association was maintained after adjusting for other comorbidities. The length of stay for the three cohorts (non-CKD, CKD stage III–V, and ESRD on hemodialysis) was 16, 17, and 15 days, respectively and was not statistically different. Many observations have reported discrimination of care for patients with CKD considered suboptimal candidates for aggressive management of their cardiac disease. In our study, medical therapy was achieved at high percentage and was comparable among groups of different kidney function. However, kidney disease seems to affect the management of patients with acute MI; percutaneous coronary angiography is not uniformly performed in patients with CKD and ESRD when compared with patients with normal kidney function.

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

“…Several possible explanations for the detrimental clinical outcomes are coexisting coronary risk factors (including advanced age, high percentage of female, diabetes mellitus, and hypertension), advanced Killip class, high burden of coronary atherosclerosis, low left ventricular ejection fraction, inadequate reperfusion therapy, insufficient guideline recommended pharmacotherapy treatment, increased oxidative stress, and decreased nitric oxide activity. [6,18,20,39,40] Furthermore, as compared with patients with preserved renal function, CKD patients tend to have larger infarct size and left ventricular remodeling that result from excessive inflammatory response, oxidative stress, and activation of sympathetic nervous and rennin-angiotensin systems. [41] These factors may act synergistically to increase the risk of adverse cardiovascular events among CKD patients.…”

Kidney Cell Cycle Arrest and Cardiac Biomarkers and Acute Kidney Injury Following Angiography: The Prevention of Serious Adverse Events Following Angiography (PRESERVE) Study

“…Our finding of association between preangiography cardiac biomarkers and risk of major adverse kidney events suggests that the risk of adverse outcomes is more likely attributable to underlying cardiovascular disease and patient comorbidities rather than CA-AKI. Our findings are relevant because registry-based studies 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 have documented lower utilization of angiography among patients with CKD than among patients without CKD, which may relate to physician concern for precipitating CA-AKI among those with CKD. However, such underutilization of potentially life-saving contrast enhanced procedures in high-risk patients may be potentially deleterious because the risk of poor outcomes exist even before contrast exposure and that contrast exposure does not significantly increase the risk of CA-AKI in most patients.…”

Radiographic Contrast Media and the Kidney

“…Among those who underwent angiography, revascularization was performed less frequently in patients with CKD than those without CKD (55% versus 62%, P <0.001). Numerous other studies have documented that patients with CKD who are hospitalized with acute coronary syndrome, including ST segment elevation myocardial infarction, are considerably less likely to undergo invasive coronary care than those without CKD (Table 3) (38–54). Although less well studied than in the setting of atherosclerotic cardiac disease, utilization of contrast-enhanced procedures has also been studied in patients with peripheral vascular disease and CKD.…”