Concomitant renal insufficiency and diabetes mellitus as prognostic factors for acute myocardial infarction

Long-Term Risk of Cardiovascular Death in Patients With Mildly Reduced Ejection Fraction After Acute Myocardial Infarction: A Multicenter, Prospective Registry Study

BACKGROUND

The prognostic implication of mildly reduced ejection fraction (mrEF) after acute myocardial infarction has not been clearly demonstrated. We investigated the long-term risk of cardiovascular death and its predictors in patients with mrEF following acute myocardial infarction.

METHODS AND RESULTS

A total of 18 668 patients who presented with acute myocardial infarction were included in 2 prospective, multicenter registries. The incidence of adverse cardiovascular events according to the left ventricular ejection fraction (EF) strata at index admission were evaluated. A score system consisting of clinical variables were developed to predict long-term cardiovascular death in the mrEF group. There were 2548 patients with reduced EF (EF ≤40%), 4266 patients with mrEF (EF 41%-49%), and 11 854 patients with preserved EF (EF ≥50%). During a median follow-up period of 37.9 months, the cardiovascular death rate was 22.3% in the reduced EF group, 10.3% in the mrEF group, and 7.3% in the preserved EF group (P<0.001). In the mrEF group, age>65 years, hypertension, stroke, severe renal insufficiency, and Killip class ≥3 were independent predictors for cardiovascular death. Presence of >2 predictors best discriminated the high-risk patients for cardiovascular death with an area under the curve of 0.746. Incidence of cardiovascular death in the high-risk mrEF group was comparable with the rEF group, while it was lower in the low-risk mrEF group than in the pEF group.

CONCLUSIONS

Patients with mrEF after acute myocardial infarction had a modest risk of cardiovascular death. Clinical predictors could help discriminate a high-risk subpopulation with cardiovascular death risks comparable with those in the reduced EF group.

Blood glucose fluctuation and in-hospital mortality among patients with acute myocardial infarction: eICU collaborative research database

BACKGROUND

To assess the relationship between glycemic variability, glucose fluctuation trajectory and the risk of in-hospital mortality in patients with acute myocardial infarction (AMI).

METHODS

This retrospective cohort study included AMI patients from eICU Collaborative Research Database. In-hospital mortality of AMI patients was primary endpoint. Blood glucose levels at admission, glycemic variability, and glucose fluctuation trajectory were three main study variables. Blood glucose levels at admission were stratified into: normal, intermediate, and high. Glycemic variability was evaluated using the coefficient of variation (CV), divided into four groups based on quartiles: quartile 1: CV≤10; quartile 2: 1030. Univariate and multivariate Cox regression models to assess the relationship between blood glucose levels at admission, glycemic variability, glucose fluctuation trajectory, and in-hospital mortality in patients with AMI.

RESULTS

2590 participants were eventually included in this study. There was a positive relationship between high blood glucose level at admission and in-hospital mortality [hazard ratio (HR) = 1.42, 95%confidence interval (CI): 1.06-1.89]. The fourth quartile (CV>30) of CV was associated with increased in-hospital mortality (HR = 2.06, 95% CI: 1.25-3.40). The findings indicated that only AMI individuals in the fourth quartile of glycemic variability, exhibited an elevated in-hospital mortality among those with normal blood glucose levels at admission (HR = 2.33, 95% CI: 1.11-4.87). Additionally, elevated blood glucose level was a risk factor for in-hospital mortality in AMI patients.

CONCLUSION

Glycemic variability was correlated with in-hospital mortality, particularly among AMI patients who had normal blood glucose levels at admission. Our study findings also suggest early intervention should be implemented to normalize high blood glucose levels at admission of AMI.

Diabetes Mellitus with Mild or Moderate Kidney Dysfunction is Associated with Poor Prognosis in Patients with Coronary Artery Disease: A Large-Scale Cohort Study

AIM

Both kidney dysfunction and diabetes mellitus (DM) predict long-term poor prognosis in patients with coronary artery disease (CAD). We aimed to evaluate the clinical outcomes according to the combined status of DM and different stages of kidney dysfunction in CAD patients.

METHODS

From January 2013 to December 2013, 9293 eligible patients hospitalized for percutaneous coronary intervention (PCI) at Fuwai hospital were followed up for major adverse cardiovascular and cerebrovascular events (MACCEs), a composite of all-cause mortality, myocardial infarction and stroke. Baseline kidney function was considered as stage I: normal or high kidney function; stage II: mild dysfunction and stage III: moderate dysfunction according to estimated glomerular filtration rate (eGFR). Upon baseline kidney function, diabetic and non-diabetic patients were divided into six groups.

RESULTS

During a median follow-up of 2.4 years, 326 (3.5%) MACCEs occurred. Compared to patients in the stage I/non-DM group, patients in the stage II/DM and stage III/DM groups had significantly increased MACCE risk [adjusted hazard ratio (aHR), 1.53; 95% confidence interval (CI), 1.09-2.15; P = 0.014; aHR, 3.00; 95%CI, 1.74-5.18; P<0.002, respectively]. Additionally, there were J-shaped associations of eGFR with MACCE risk regardless of glycemic metabolism status after adjusted for confounders. Furthermore, moderate kidney dysfunction conferred an increased MACCE risk in diabetic patients with uncontrolled glycemia (aHR, 2.93; 95%CI, 1.48-5.78; P=0.002).

CONCLUSIONS

DM with mild or moderate kidney dysfunction is associated with poor prognosis in CAD patients. Categorical classification of patients with DM and kidney dysfunction could provide prognostic information for risk stratification of CAD patients.

Effect of Calcium Dobesilate in Preventing Contrast-Induced Nephropathy in Patients with Diabetes and Chronic Kidney Disease

OBJECTIVES

This study assessed the protective effect of calcium dobesilate against contrast-induced nephropathy (CIN) after coronary angiography (CAG) or percutaneous coronary intervention (PCI) in patients with diabetes and chronic kidney disease (CKD).

METHODS

A total of 130 patients with diabetes and CKD estimated glomerular filtration rate: 30-90 mL/min/1.73m2 were enrolled and included in the analysis. They were divided into experimental (n=65) and control groups (n=65). Patients in the experimental group were administered oral calcium dobesilate (500 mg) three times daily for 2 days before and 3 days after the procedure. The serum creatinine (SCr), cystatin C (Cys C), and neutrophil gelatinase-associated lipocalin (NGAL) levels were measured before and after the procedure.

RESULTS

The mean SCr level at 24h after the procedure was found to be significantly lower in the experimental group than in the control group (79.1±19.6 μmol/L vs. 87.0±19.3 μmol/L, p=0.023). However, the Cys C and NGAL levels were not significantly different between the two groups at all measurement time points (all p>0.05). The incidence of CIN defined by the SCr level was significantly lower in the experimental group than in the control group (3 [4.6%] vs. 13 [20.0%], p=0.017). However, the incidence of CIN defined by the Cys C level was not statistically different between the two groups (7 [10.8%] vs. 7 [10.8%], p=1.000).

CONCLUSIONS

This study revealed that calcium dobesilate has no preventive effect against CIN in patients with diabetes and CKD.

Higher Long-Term Mortality in Patients with Non-ST-Elevation Myocardial Infarction than ST-Elevation Myocardial Infarction after Discharge

PURPOSE

This study aimed to compare mortality rates after discharge between the patients with non-ST-elevation myocardial infarction (NSTEMI) and those with ST-elevation myocardial infarction (STEMI), and identify each mortality risk factors in these two types of myocardial infarction.

MATERIALS AND METHODS

Between 2011 and 2015, 13105 consecutive patients were enrolled in the Korea Acute Myocardial Infarction-National Institute of Health registry (KAMIR-NIH); 12271 patients with acute myocardial infarction met the inclusion criteria and were further stratified into the STEMI (n=5828) and NSTEMI (n=6443) groups. The occurrence of mortality and cardiac mortality at 3 years were compared between groups, and the factors associated with mortality for NSTEMI and STEMI were evaluated.

RESULTS

The comparison between these two groups and long-term follow-up outcomes showed that the cumulative rates of all-cause and cardiac mortality were higher in the NSTEMI group than in the STEMI group [all-cause mortality: 10.9% vs. 5.8%; hazards ratio (HR), 0.464; 95% confidence interval (CI), 0.359-0.600, p<0.001; cardiac mortality: 6.6% vs. 3.5%, HR, 0.474; 95% CI, 0.344-0.654, p<0.001, respectively). In the NSTEMI group, low left ventricular ejection fraction (LVEF; <40%), no percutaneous coronary intervention (PCI), old age (≥65 years), and low hemoglobin level (<12 g/dL) were identified as risk factors for 3-year mortality. In the STEMI group, old age, low glomerular filtration rate (<60 mL/min/1.73 m²), low LVEF, high heart rate (>100 beats/min), no PCI, and low hemoglobin level were identified as the risk factors for 3-year mortality.

CONCLUSION

The NSTEMI group had higher mortality compared to the STEMI group during the 3-year clinical follow-up after discharge. Low LVEF and no PCI were the main risk factors for mortality in the NSTEMI group. In contrast, old age and renal dysfunction were the risk factors for long-term mortality in the STEMI group.

Does Diabetes Mellitus Increase the Short- and Long-Term Mortality in Patients With Critical Acute Myocardial Infarction? Results From American MIMIC-III and Chinese CIN Cohorts

BACKGROUND

The harmful effect of diabetes mellitus (DM) on mortality in patients with acute myocardial infarction (AMI) remains controversial. Furthermore, few studies focused on critical AMI patients. We aimed to address whether DM increases short- and long-term mortality in this specific population.

METHODS

We analyzed AMI patients admitted into coronary care unit (CCU) with follow-up of ≥1 year from two cohorts (MIMIC-III, Medical Information Mart for Intensive Care III; CIN, Cardiorenal ImprovemeNt Registry) in the United States and China. Main outcome was mortality at 30-day and 1-year following hospitalization. Kaplan-Meier curves and Cox proportional hazards models were constructed to examine the impact of DM on mortality in critical AMI patients.

RESULTS

1774 critical AMI patients (mean age 69.3 ± 14.3 years, 46.1% had DM) were included from MIMIC-III and 3380 from the CIN cohort (mean age 62.2 ± 12.2 years, 29.3% had DM). In both cohorts, DM group was older and more prevalent in cardio-renal dysfunction than non-DM group. Controlling for confounders, DM group has a significantly higher 30-day mortality (adjusted odds ratio (aOR) (95% CI): 2.71 (1.99-3.73) in MIMIC-III; aOR (95% CI): 9.89 (5.81-17.87) in CIN), and increased 1-year mortality (adjusted hazard ratio (aHR) (95% CI): 1.91 (1.56-2.35) in MIMIC-III; aHR (95% CI): 2.62(1.99-3.45) in CIN) than non-DM group.

CONCLUSIONS

Taking into account cardio-renal function, critical AMI patients with DM have a higher 30-day mortality and 1-year mortality than non-DM group in both cohorts. Further studies on prevention and management strategies for DM are needed for this population.

CLINICAL TRIAL REGISTRATION

clinicaltrials.gov, NCT04407936.

The prevalence of 30-day readmission after acute myocardial infarction: A systematic review and meta-analysis

Objective

The 30‐day readmission is associated with increased medical costs, which has become an important quality metric in several medical institutions. This current study is aimed at clarifying the prevalence, the underlying risk factors, and reasons of the 30‐day readmission after acute myocardial infarction (AMI).

Methods

PubMed, Cochrane Library, and EMBASE were systematically searched to identify eligible studies. Random‐effect models were employed to perform pooled analyses. Means and 95% confidence intervals (CIs) were used to estimate prevalence and reasons for 30‐day readmission. We also used Odds ratios (ORs) to explore the potential significant predictors of risk factors of 30‐day readmission after AMI. Potential publication bias was assessed using funnel plot and Begg'test.

Results

A total of 14 relevant studies were included in this systematic review and meta‐analysis. The pooled 30‐day readmission rate of AMI was 12% (95% CI 0.11‐0.14). Acute coronary syndrome (ACS), angina and acute ischemic heart disease, and heart failure (HF) were the principal cardiovascular reasons of 30‐day readmission. Meanwhile, non‐specific chest pain was regarded as the significant cause among non‐cardiovascular reasons. The common co‐morbidities kidney disease, HF and diabetes mellitus were significant risk factors for 30‐day readmission. No significant publication bias was found by funnel plot and statistical tests.

Conclusions

The 30‐day readmission rate of post‐AMI ranged from 11% to 14% and can be mainly attributed to cardiovascular and non‐cardiovascular events. The common co‐morbidities, such as kidney disease, HF, and diabetes mellitus were significant risk factors for 30‐day readmission.

Effect of trimetazidine on preventing contrast-induced nephropathy in diabetic patients with renal insufficiency

BACKGROUND

Our study sought to assess the effect of trimetazidine (TMZ) on preventing contrast-induced nephropathy (CIN) in diabetic patients with renal insufficiency.

MATERIALS AND METHODS

106 diabetic patients with renal insufficiency who were undergoing coronary angiography (CAG) and/or percutaneous coronary intervention (PCI) were enrolled in this study. Standard hydration was administered to both groups (the TMZ group and the control group). In the TMZ group, patients were orally administered TMZ for 48 hours before and 24 hours after CAG and/or PCI. Serum creatinine (Scr), cystatin C and the glomerular filtration rate (eGFR) were measured before as well as 24 hours, 48 hours and 72 hours after contrast media injection. The incidence of CIN and major cardiovascular events (MACE) was also evaluated in both groups.

RESULTS

Scr, cystatin C and the eGRF in the TMZ group were better than those in the control group after 24 hours (OR: 0.78, 95% CI: 0.54-0.82; OR: 0.66, 95% CI: 0.62-0.73; OR: 1.2, 95% CI: 1.02-1.53, respectively), 48 hours (OR: 0.69, 95% CI: 0.52-0.73; OR: 0.76, 95% CI: 0.69-0.84; OR: 1.5, 95% CI: 1.25-1.68, respectively) and 72 hours (OR: 0.82, 95% CI: 0.77-0.91; OR: 0.85, 95% CI: 0.71-0.92; OR: 1.67, 95% CI: 1.33-1.72, respectively). The incidence of CIN (9.26% vs 16.67%) and MACE (7.41% vs 18.51%) in the TMZ group was significantly lower than that in the control group (P < 0.05).

CONCLUSIONS

Our study suggests that TMZ could reduce the incidence of CIN and MACE in diabetic patients with renal insufficiency who are undergoing CAG and/or PCI.

Metabolic syndrome and abdominal fat are associated with inflammation, but not with clinical outcomes, in peritoneal dialysis patients

Background

In the general population, metabolic syndrome (MetS) is correlated with visceral fat and a risk factor for cardiovascular disease (CVD); however, little is known about the significance of abdominal fat and its association with inflammation and medication use in peritoneal dialysis (PD) patients. We investigated the relationship of visceral fat area (VFA) with C-reactive protein (CRP) levels and medication use in PD patients and followed their clinical outcomes.

Methods

In a prospective study from February 2009 to February 2012, we assessed diabetes mellitus (DM) status, clinical and PD-associated characteristics, medication use, CRP levels, components of MetS, and VFA in 183 PD patients. These patients were categorized into 3 groups based on MetS and DM status: non-MetS (group 1, n = 73), MetS (group 2, n = 65), and DM (group 3, n = 45). VFA was evaluated by computed tomography (CT) and corrected for body mass index (BMI).

Results

Patients in group 1 had smaller VFAs than patients in groups 2 and 3 (3.2 ± 1.8, 4.6 ± 1.9, and 4.9 ± 2.0 cm²/[kg/m²], respectively, P < 0.05) and lower CRP levels (0.97 ± 2.31, 1.27 ± 2.57, and 1.11 ± 1.35 mg/dL, respectively, P < 0.05). VFA increased with the number of criteria met for MetS. After adjusting for age, body weight, and sex, CRP and albumin levels functioned as independent positive predictors of VFA; on other hand, the use of renin-angiotensin system blockers was inversely correlated with VFA in PD patients without DM. In the survival analysis, DM patients (group 3) had the poorest survival among the 3 groups, but no significant differences were found between groups 1 and 2.

Conclusion

This study showed that VFA and MetS are associated with CRP levels but cannot predict survival in PD patients without DM. The complex relationship of nutritional parameters to VFA and MetS may explain these results. The type of antihypertensive medication used was also associated with the VFA. The mechanisms behind these findings warrant further investigation.

Glomerular filtration rate and albuminuria predict mortality independently from coronary artery calcified plaque in the Diabetes Heart Study

Background

Risk stratification in individuals with type 2 diabetes (T2D) remains an important priority in the management of associated morbidity and mortality, including from cardiovascular disease (CVD). The current investigation examined whether estimated glomerular filtration rate (eGFR) and urine albumin:creatinine ratio (UACR) were independent predictors of CVD-mortality in European Americans (EAs) with T2D after accounting for subclinical CVD.

Methods

The family-based Diabetes Heart Study (DHS) cohort (n=1,220) had baseline measures of serum creatinine, eGFR, UACR and coronary artery calcified plaque (CAC) assessed by non-contrast computed tomography scan. Cox proportional hazards regression was performed to determine risk for all-cause mortality and CVD-mortality associated with indices of kidney disease after accounting for traditional CVD risk factors and CAC as a measure of subclinical CVD.

Results

Participants were followed for 8.2±2.6 years (mean±SD) during which time 247 (20.9%) were deceased, 107 (9.1%) from CVD. Univariate analyses revealed positive associations between serum creatinine (HR:1.56; 95% CI:1.37–1.80; p<0.0001) and UACR (1.59; 1.43–1.77; p>0.0001) and negative associations between serum albumin (0.74; 0.65–0.84; p<0.0001) and eGFR (0.66; 0.58–0.76; p<0.0001) with all-cause mortality. Associations remained significant after adjustment for traditional CVD risk factors, as well as for CAC. Similar trends were noted when predicting risk for CVD-mortality.

Conclusions

The DHS reveals that kidney function and albuminuria are independent risk factors for all-cause mortality and CVD-mortality in EAs with T2D, even after accounting for CAC.

New horizons of acute myocardial infarction: from the Korea Acute Myocardial Infarction Registry

As the first nationwide Korean prospective multicenter data collection registry, the Korea Acute Myocardial Infarction Registry (KAMIR) launched in November 2005. Through a number of innovative approaches, KAMIR suggested new horizons about acute myocardial infarction (AMI) which contains unique features of Asian patients from baseline characteristics to treatment strategy. Obesity paradox was existed in Korean AMI patients, whereas no gender differences among them. KAMIR score suggested new risk stratifying method with increased convenience and an enhanced accuracy for the prediction of adverse outcomes. Standard loading dose of clopidogrel was enough for Asian AMI patients. Triple antiplatelet therapy with aspirin, clopidogrel and cilostazol could improve clinical outcomes than dual antiplatelet therapy with aspirin and clopidogrel. Statin improved clinical outcomes even in AMI patients with very low LDL-C levels. The rate of percutaneous coronary intervention was higher and door-to-balloon time was shorter than the previous reports. Zotarolimus eluting stents as the 2nd generation drug-eluting stent (DES) was not superior to the 1st generation DES, in contrast to the western AMI studies. KAMIR made a cornerstone in the study of Korean AMI and expected to be new standards of care for AMI with the renewal of KAMIR design to overcome its pitfalls.

The prognostic value of different glucose abnormalities in patients with acute myocardial infarction treated invasively

Background

Diabetes (DM) deteriorates the prognosis in patients with coronary heart disease. However, the prognostic value of different glucose abnormalities (GA) other than DM in subjects with acute myocardial infarction (AMI) treated invasively remains unclear.

Aims

To assess the incidence and impact of GA on clinical outcomes in AMI patients treated with percutaneous coronary intervention (PCI).

Methods

A single-center, prospective registry encompassed 2733 consecutive AMI subjects treated with PCI. In all in-hospital survivors (n = 2527, 92.5%) without the history of DM diagnosed before or during index hospitalization standard oral glucose tolerance test (OGTT) was performed during stable condition before hospital discharge and interpreted according to WHO criteria. The mean follow-up period was 37.5 months.

Results

The incidence of GA was as follows: impaired fasting glycaemia - IFG (n = 376, 15%); impaired glucose tolerance - IGT (n = 560, 22%); DM (n = 425, 17%); new onset DM (n = 384, 15%); and normal glucose tolerance – NGT (n = 782, 31%). During the long-term follow-up, death rate events for previously known DM, new onset DM and IGT were significantly more frequent than those for IFG and NGT (12.3; 9.6 and 9.4 vs. 5.6 and 6.4%, respectively, P < 0.05). The strongest and common independent predictors of death in GA patients were glomerular filtration rate < 60 ml/min/1,73 m^2 (HR 2.0 and 2.8) and left ventricle ejection fraction < 35% (HR 2.5 and 1.8, all P < 0.05) respectively.

Conclusions

Glucose abnormalities are very common in AMI patients. DM, new onset DM and IGT increase remote mortality. Impaired glucose tolerance bears similar long-term prognosis as diabetes.

Right intra-atrial catheter placement for hemodialysis in patients with multiple venous failure

The purpose of this study is to evaluate the efficacy and safety of direct right atrial catheter insertion for hemodialysis in patients with multiple venous access failure. We retrospectively evaluated the charts of 27 patients with multiple venous access failure who had intra-atrial dialysis catheter placement between October 2005 and October 2010 in our clinic. Permanent right atrial dialysis catheters were placed through a right anterior mini-thoracotomy under intratracheal general anesthesia in all patients. Demographics of the cases, the patency rates of hemodialysis via atrial catheterization, existence of any catheter thrombosis, and catheter-related infections were documented and used in statistical analysis. Seventeen women (63%) and 10 men (37%) with the mean age of 59.0 ± 7.1 years (47-71) were enrolled in this study. Chronic renal failure was diagnosed for the mean of 78.9 ± 24.3 months (33-130). Five patients (18.5%) died. Ventricular fibrillation and myocardial infarction were the causes of death in the early postoperative period in two patients. Two of the remaining three patients died because of cerebrovascular events, and one patient died because of an unknown cause. Ten patients (37%) had been using anticoagulate agents (warfarin) because of concomitant disorders such as deep vein thrombosis, operated valve disease, and arrhythmias. Catheter thrombosis and malfunction was determined in three cases (11.1%). Intra-atrial hemodialysis catheterization is a safe and effective life-saving measure for the patients with multiple venous failure and without any possibility of peritoneal dialysis or renal transplantation.