Predictive power of ejection fraction and renal failure in patients admitted for chest pain without ST elevation in the troponin era

Influence of renal dysfunction on clinical outcomes in patients with congestive heart failure complicating acute myocardial infarction

The clinical course and medical treatment of patients with congestive heart failure (CHF) complicating acute myocardial infarction (AMI) are not well established, especially in patients with concomitant renal dysfunction. We performed a retrospective analysis of the prospective Korean Acute Myocardial Infarction Registry to assess the medical treatments and clinical outcomes of patients with CHF (Killip classes II or III) complicated by AMI, in the presence or absence of renal dysfunction. Of 13,498 patients with AMI, 2769 (20.5%) had CHF on admission. Compared to CHF patients with preserved renal function, in-hospital mortality and major adverse cardiac events were increased both at 1 month and at 1 year after discharge in patients with renal dysfunction (1154; 41.7%). Postdischarge use of aspirin, betablockers, calcium channel blockers, angiotensin-converting enzyme inhibitors, or angiotensin II receptor blockers and statins significantly reduced the 1-year mortality rate for CHF patients with renal dysfunction; such reduction was not observed for those without renal dysfunction, except in the case of aspirin. Patients with CHF complicating AMI, which is accompanied by renal dysfunction, are at higher risk for adverse cardiovascular outcomes than patients without renal dysfunction. However, they receive fewer medications proven to reduce mortality rates.

Troponin-positive, MB-negative patients with non-ST-elevation myocardial infarction: An undertreated but high-risk patient group: Results from the National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network-Get With The Guidelines (NCDR ACTION-GWTG) Registry

BACKGROUND

Despite the 2000 and 2007 redefinition of myocardial infarction (MI), patients who are troponin (Tn) positive ([+]) but MB negative ([-]) may not be considered to have MI, particularly in the absence of known coronary disease (prior MI or revascularization; coronary artery disease [CAD]). How this affects treatment and outcomes has not been well described.

METHODS

Direct arrival patients with non-ST elevation MI (NSTEMI) enrolled in the American College of Cardiology NCDR ACTION-GWTG Registry were included. Patients missing marker data who were Tn (-) and had CAD were excluded. Troponin (+) patients were categorized as MB (+) (n = 11,563) or MB (-) (n = 4,501). Treatments and in-hospital outcomes were compared between the 2 groups using logistic regression.

RESULTS

Of the 16,064 NSTEMI patients, 28% were MB (-). The MB (-) patients were older (median age 68 vs 65 years) and had more comorbidities (hypertension 71% vs 66%, diabetes 31% vs 27%, heart failure 22% vs 19%; all Ps < .01). After adjusting for baseline characteristics, MB (-) patients were significantly less likely to receive clopidogrel, antithrombins, glycoprotein IIb/IIIa antagonists, or angiography (all Ps < .001). In-hospital mortality was lower in MB (-) patients (3.8% vs 4.9%, P < .01), which remained significant after adjusting for baseline variables (odds ratio 0, 69, 95% CI 0.6-0.9, P = .002).

CONCLUSIONS

Patients without known CAD who have NSTEMI and are MB (-) have a higher risk profile but are less likely to receive guideline-recommended acute pharmacologic treatment than those who are MB (+). Given the relatively high mortality in this group, increased emphasis on improving quality of care in Tn (+)/MB (-) patients is warranted.

Renal impairment and heart failure with preserved ejection fraction early post-myocardial infarction

AIM

To study if impaired renal function is associated with increased risk of peri-infarct heart failure (HF) in patients with preserved ejection fraction (EF).

METHODS

Patients with occluded infarct-related arteries (IRAs) between 1 to 28 d after myocardial infarction (MI) were grouped into chronic kidney disease (CKD) stages based on estimated glomerular filtration rate (eGFR). Rates of early post-MI HF were compared among eGFR groups. Logistic regression was used to explore independent predictors of HF.

RESULTS

Reduced eGFR was present in 71.1% of 2160 patients, with significant renal impairment (eGFR < 60 mL/min every 1.73 m(2)) in 14.8%. The prevalence of HF was higher with worsening renal function: 15.5%, 17.8% and 29.4% in patients with CKD stages 1, 2 and 3 or 4, respectively (P < 0.0001), despite a small absolute difference in mean EF across eGFR groups: 48.2 ± 10.0, 47.9 ± 11.3 and 46.2 ± 12.1, respectively (P = 0.02). The prevalence of HF was again higher with worsening renal function among patients with preserved EF: 10.1%, 13.6% and 23.6% (P < 0.0001), but this relationship was not significant among patients with depressed EF: 27.1%, 26.2% and 37.9% (P = 0.071). Moreover, eGFR was an independent correlate of HF in patients with preserved EF (P = 0.003) but not in patients with depressed EF (P = 0.181).

CONCLUSION

A significant proportion of post-MI patients with occluded IRAs have impaired renal function. Impaired renal function was associated with an increased rate of early post-MI HF, the association being strongest in patients with preserved EF. These findings have implications for management of peri-infarct HF.

Renal and cardiac function for long-term (10 year) risk stratification after myocardial infarction

Aims To determine whether combined renal and cardiac function after acute myocardial infarction (MI) predicts 10 year mortality and heart failure (HF). Methods and results Estimated glomerular filtration rate (eGFR), plasma amino terminal pro-brain natriuretic peptide (NT-proBNP), and radionuclide ventriculography were obtained in 1063 patients with MI between 24-96 h of symptom onset. Mortality and HF were documented over follow-up of 9.3 years. Estimated GFR, NT-proBNP, and left ventricular ejection fraction (LVEF) each independently predicted 10 year mortality. Reduced eGFR (below 60 mL/min/1.73 m(2)) combined with increased NT-proBNP (above 1000 pg/mL) was associated with higher mortality rate compared with preserved eGFR together with lower NT-proBNP (60 vs. 14%, P < 0.001). Similar results for mortality were identified for eGFR combined with LVEF (dichotomized about 50%) (58 vs. 17%, P < 0.001). Corresponding analysis combining eGFR and NT-proBNP to predict HF yielded rates of 34 and 7% for high- and low-risk groups, respectively (P < 0.001). Similar risk stratification for HF was observed when combining eGFR with LVEF (35 vs. 7%, P < 0.001). Conclusion Ten year rates of mortality and HF are 5-10 times higher when lower eGFR is present together with increased NT-proBNP or depressed LVEF.

A practical approach with outcome for the prognostic assessment of non-ST-segment elevation chest pain and normal troponin

Patients with non-ST-elevation chest pain constitute a heterogeneous population. Our aim is to compare the outcome of patients with chest pain, non-ST-segment deviation, and normal troponin, categorized using a risk score, with that of patients with ST depression or troponin increase. A total of 1,449 patients with non-ST-elevation chest pain were evaluated. A validated risk score (using pain characteristics and risk factors) was applied to patients without ST depression or troponin increase. Accordingly, 4 risk categories were defined: group 1, no troponin increase, no ST depression, and risk score <3 points (n = 633); group 2, no troponin increase, no ST depression, but risk score > or = 3 points (n = 158); group 3, no troponin increase, ST depression (n = 106); and group 4, troponin increase (n = 552). Median follow-up was 26 months, and the end point was death or myocardial infarction. Group 1 experienced fewer events at 30 days (1.7%, p = 0.0001) and long-term follow-up (9.4%, p = 0.0001) than groups 2 (10.8% and 26%), 3 (6.6% and 30%), and 4 (9.5% and 25%). Kaplan-Meier curves overlapped among groups 2, 3, and 4, whereas group 1 showed a flatter curve (p = 0.0001). Using multivariate analysis, risk group (group 1 vs remaining groups) predicted 30-day (p = 0.0003) and long-term (p = 0.0001) outcome. There were no differences among groups 2, 3, and 4. In conclusion, application of a risk score to patients without troponin increase or ST deviation identified a high-risk group with prognosis similar to that of patients with troponin increase or ST depression and affords a practical classification for the full spectrum of non-ST-elevation chest pain.