Previous studies have shown that patients with end-stage renal disease (on dialysis replacement therapy) experience increased cardiovascular death and morbidity in the setting of an acute ST-elevation myocardial infarction (STEMI).1–4 In the United States, approximately 44% of all deaths in these patients can be related to cardiovascular disease, and more than one in five cardiac deaths can be attributed to acute myocardial infarction (AMI). However, less is known of patients with different degrees of renal dysfunction who undergo primary percutaneous coronary intervention (PCI) in the acute phase of an AMI. One of the seminal works in this area by Wright and colleagues revised the outcomes of 1,786 patients with different degrees of renal insufficiency and compared them to 1,320 patients with normal renal function who were admitted between 1988 and 2000 to the Mayo Clinic with an AMI.5 As seen in previous studies, baseline clinical characteristics differed significantly among the groups, with older and more comorbid disease in patients with renal dysfunction. However, this study showed that patients with renal insufficiency are not treated as aggressively as patients with normal renal function. Only 7% of patients with end-stage renal disease were treated with any type of reperfusion therapy versus 11% in patients with severe renal insufficiency, and 30% in patients with normal renal function. In-hospital mortality rates increased with worsened renal function (30%, 21% and 2%, respectively), even after adjustment (Figure 1). However, patients with renal insufficiency admitted with a STEMI and who received reperfusion therapy had better outcomes with reduced in-hospital mortality rates.
The largest study to date that assessed the impact of renal function in patients undergoing primary PCI in the setting of an AMI was a subgroup analysis of the Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC) trial.6 In this analysis by Sadeghi and colleagues, the outcomes of 350 AMI patients with at least moderate chronic kidney disease (creatinine clearance ≤ 60 mL/minute) were compared to 1,583 AMI patients with normal renal function. The 30-day and 1-year mortality rates were markedly elevated in patients with at least moderate chronic kidney disease, with a > 9-fold increase in mortality at 30 days and a 5-fold increase in mortality at 1 year. For every decline of 10 mL/minute in creatinine clearance, mortality increased incrementally, up to a 45% 1-year mortality rate in patients with a creatinine clearance of 2.0 mg/dL) was an exclusion criteria to participate in the study, limiting the power of these results. Similar results were observed in an analysis of 17 Japanese hospitals that participated in the Heart Institute of Japan Acute Myocardial Infarction registry.7 In this analysis by Yamaguchi and colleagues, 1,451 patients underwent primary PCI between 1999 and 2001. The majority of these patients had normal renal function, and only 29 patients had a serum creatinine ≥ 2.0 mg/dl. In-hospital mortality rate in these patients was 34.5% compared to 3.9% in patients with a serum creatinine level 2.5 mg/dL had worse outcomes.10 Of the 9,015 patients who underwent primary PCI in the State of New York between 1997 and 1999 in the acute phase of an AMI, 94 patients (1%) had a baseline serum creatinine > 2.5 mg/dL. The in-hospital unadjusted mortality rate was 23.4% in patients with elevated creatinine levels compared to 4.2% (p From the Division of Cardiology, Stony Brook University Medical Center, Stony Brook, New York.
The author reports no conflicts of interest regarding the content herein.
Address for correspondence: Luis Gruberg, MD, FACC, Professor of Medicine, Department of Medicine, Division of Cardiology, Stony Brook University Medical Center, Stony Brook, NY 11794. E-mail: luis.gruberg@stonybrook.edu
1. Herzog CA. How to manage the renal patient with coronary heart disease: the agony and the ecstasy of opinion-based medicine. J Am Soc Nephrol 2003;14:2556–2572.
2. Herzog CA, Ma JZ, Collins AJ. Poor long-term survival after acute myocardial infarction among patients on long-term dialysis. N Engl J Med 1998;339:799–805.
3. Chertow GM, Normand SL, Silva LR, McNeil BJ. Survival after acute myocardial infarction in patients with end-stage renal disease: Results from the cooperative cardiovascular project. Am J Kidney Dis 2000;35:1044–1051.
4. Iseki K, Fukiyama K. Long-term prognosis and incidence of acute myocardial infarction in patients on chronic hemodialysis: The Okinawa Dialysis Study Group. Am J Kidney Dis 2000;36:820–825.
5. Wright RS, Reeder GS, Herzog CA, et al. Acute myocardial infarction and renal dysfunction: A high-risk combination. Ann Intern Med 2002;137:563–570.
6. Sadeghi HM, Stone GW, Grines CL, et al. Impact of renal insufficiency in patients undergoing primary angioplasty for acute myocardial infarction. Circulation 2003;108:2769–2775.
7. Yamaguchi J, Kasanuki H, Ishii Y, et al; HIJC Study Group. Prognostic significance of serum creatinine concentration for in-hospital mortality in patients with acute myocardial infarction who underwent successful primary percutaneous coronary intervention (from the Heart Institute of Japan Acute Myocardial Infarction [HIJAMI] Registry). Am J Cardiol 2004;93:1526–1528.
8. Marenzi G, Moltrasio M, Assanelli E, et al. Impact of cardiac and renal dysfunction on in-hospital morbidity and mortality of patients with acute myocardial infarction undergoing primary angioplasty. Am Heart J 2007;153:755–762.
9. Gruberg L, Lawson WE, Mani A, et al. The impact of glomerular filtration rate on the outcomes of primary percutaneous coronary intervention in ST-elevation myocardial infarction. J Am Coll Cardiol 2007;49(Suppl B):24B.
10. Vasu S, Gruberg L, Brown DL. The impact of advanced chronic kidney disease on in-hospital mortality following percutaneous coronary intervention for acute myocardial infarction. Catheter Cardiovasc Interv 2007;70:701–705.
11. Zhao L, Wang L, Zhang Y. Elevated admission serum creatinine predicts poor myocardial blood flow and more one-year mortality in ST-segment elevation myocardial infarction patients undergoing primary percutaneous coronary intervention. J Invasive Cardiol 2009;21:493–496.
12. Celik T, Iyisoy A, Yuksel CU, et al. Impact of admission glomerular filtration rate on the development of poor myocardial perfusion after primary percutaneous intervention in patients with acute myocardial infarction. Coron Artery Dis 2008;19:543–549.
13. French WJ, Wright RS. Renal insufficiency and worsened prognosis with STEMI: A call for action. J Am Coll Cardiol 2003;42:1544–1546.
