Iso-osmolar contrast media and adverse renal and cardiac events after percutaneous cardiovascular intervention

Abstract

Aim: To assess the relationship between type of contrast media (CM), iso-osmolar contrast media (IOCM) or low-osmolar contrast media (LOCM), and major adverse renal and cardiovascular events (MARCE). Materials & methods: Coronary or peripheral angioplasty visits were stratified into CM cohorts: IOCM or LOCM. Multivariable regression analysis used hospital fixed effects to assess the relationship between MARCE events and type of CM. Results: Among 333,533 visits (357 hospitals), the incidence of MARCE was 7.41%. After controlling for observable and unobservable time invariant within-hospital characteristics, administration of IOCM versus LOCM was associated with a 0.69% absolute and 9.32% relative risk reduction in MARCE rate. Conclusion: Our study indicates that as compared with LOCM, IOCM may be associated with reduction of MARCE events in coronary or peripheral angioplasty patients. Arterial angiography and percutaneous intervention require administration of iodinated contrast media (CM) to render the blood vessels radiographically opaque. Contrast-induced acute kidney injury (CI-AKI) is one of the major adverse events associated with administration of iodinated CM [1,2]. The most common definition of CI-AKI is a rise in serum creatinine levels by ≥0.3 mg/dl within 48 h of contrast administration. CI-AKI has been associated with progression to advanced stages of chronic kidney disease (CKD) and with increased risk for major adverse cardiac events (MACE) [3,4].CI-AKI is the third most common cause of hospital-acquired renal failure and is associated with increased morbidity, prolonged hospitalization and higher rates of in-hospital and long-term mortality [5,6]. The incidence of CI-AKI varies from 2% in the general population to over 50% in high-risk groups [7]. In studies of the impact of the osmolality of iodinated CM, the use of low-osmolar contrast media (LOCM) has been shown to substantially reduce the risk of nephropathy when compared with high-osmolar CM [8][9][10][11].In several studies, iodixanol, iso-osmolar contrast media (IOCM) have been associated with lower risk for CI-AKI when compared with LOCM [12][13][14][15][16]. In a meta-analysis of 16 randomized controlled trials, McCullough et al. found that CI-AKI occurred less frequently for all patients in the iodixanol group when compared with the LOCM group [15]. Similar findings were reported for the subgroup of patients with CKD and for patients with CKD and diabetes mellitus. More recent meta-analysis concluded that iodixanol use was associated with less nephrotoxicity compared with LOCM and that use of iodixanol was associated with significantly fewer contrast-induced nephropathy events compared with LOCM [12]. Both meta-analyses concluded that intra-arterial

Major Adverse Renal and Cardiovascular Events following Intra-Arterial Contrast Media Administration in Hospitalized Patients with Comorbid Conditions

“…In comparison to LOCM, IOCM use resulted in a significantly lower risk of MARCE in subgroups of patients with diabetes, heart failure, CKD, patients undergoing CTO procedures, and the combined group including those with CKD stages 3–4 having diabetes. These outcomes further support prior studies evaluating IOCM and LOCM in patients undergoing angiography or other procedures associated with intra-arterial administration of contrast media [8-13]. Given the large volume of procedures done at most medical centers, the NNT values are clinically and institutionally meaningful.…”

“…Iso-osmolar contrast media (IOCM) has been associated with reduced adverse renal and cardiovascular outcomes compared with low-osmolar contrast media (LOCM) in prior randomized controlled trials [8, 9] and meta-analyses [10-12], and particularly in at-risk patients with pre-existing renal dysfunction [8, 9] and diabetes [12]. In addition to randomized controlled trials and meta-analyses, a recent analysis of real-world data [13] from the Premier Healthcare Database performed on 333,533 inpatient “all-comers” undergoing coronary, peripheral or carotid angioplasty showed significantly lower rates of major adverse renal and cardiovascular events (MARCE) with IOCM than multiple LOCM pooled together, with 9.32% lower relative risk of MARCE associated with the use of IOCM. However, this association has not been studied via large-scale real-world data analyses in patients with comorbid conditions including one or more risk factors for post-procedural AKI undergoing intra-arterial contrast-enhanced procedures.…”

Incidence of Major Adverse Cardiovascular and Cerebrovascular Events in Chinese Patients Undergoing Percutaneous Coronary Intervention with Iodixanol: An Observational Postauthorization Study

“…A real-world study with similar endpoints to ours examining major adverse renal and cardiovascular events (MARCEs) conducted at 357 hospitals in the United States over a given period reported an overall incidence rate of MARCEs of 7.41%; moreover, compared to low-osmolar CM, iso-osmolar CM was associated with a 0.69% absolute and 9.32% relative risk reduction in MARCE rate, although only iodixanol was evaluated as a CM. [34]…”

“…A real-world study with similar endpoints to ours examining major adverse renal and cardiovascular events (MARCEs) conducted at 357 hospitals in the United States over a given period reported an overall incidence rate of MARCEs of 7.41%; moreover, compared to low-osmolar CM, iso-osmolar CM was associated with a 0.69% absolute and 9.32% relative risk reduction in MARCE rate, although only iodixanol was evaluated as a CM. [34] 5. Limitations There were some limitations inherent to the observational nature of the study such as the lack of randomization/blinding and absence of a reference standard or uniform standard for assessing baseline risk factors and AEs at participating centers.…”

Hemorrhagic Transformation Rates following Contrast Media Administration in Patients Hospitalized with Ischemic Stroke

“…21 Iodinated intravascular contrast media have long been a staple of radiographic diagnosis and interventions. The safety of contrast agents continues to be carefully studied with largely familiar adverse events, including renal, [22][23][24] cardiovascular, 23,25 hemodynamic, 26 injection site discomfort, 27 and acute allergic reactions. 28 Given that many patients undergoing interventional procedures are in at-risk categories, the reduction of complications from contrast becomes even more important and the choice of an appropriate agent is an important consideration along with other frequently used periprocedural mitigation measures such as patient risk assessments, optimal periprocedural hydration, contrast volume management, and necessary premedication or withholding of medications.…”