Decreased Glomerular Filtration Rate is an Independent Predictor of In-Hospital Mortality in Patients With ST-Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

MELD-XI score predict no-reflow phenomenon and short-term mortality in patient with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention

INTRODUCTION

No-reflow phenomenon (NRP) is one of the complications that mostly occur during percutaneous coronary intervention (PCI). In this study, we comprehensively examined the relationship between the model for end-stage liver disease-XI (MELD-XI) score and NRP. Moreover, we discussed whether the MELD-XI score could be considered as an accurate risk assessment score of patients with ST-segment elevation myocardial infarction (STEMI) who are candidates for PCI.

METHODS

This retrospective study involved 693 patients with acute STEMI and who underwent an emergency PCI. They were divided into a normal reflow group or a no-reflow group on the basis of the flow rate of post-interventional thrombolysis in myocardial infarction. Univariate, multivariate logistic regression, and Cox regression analyses were performed to identify the independent predictors of NRP in both groups. Receiver operator characteristic (ROC) curves and Kaplan-Meier curves were plotted to estimate the predictive values of the MELD-XI score.

RESULTS

MELD-XI score was found to be an independent indicator of NRP (odds ratio: 1.247, 95% CI: 1.144-1.360, P < 0.001). Multivariate Cox regression analysis also revealed that the MELD-XI score is an independent prognostic factor for 30-day all-cause mortality (hazard ratio: 1.155, 95% CI: 1.077-1.239, P < 0.001). Moreover, according to the ROC curves, the cutoff value of the MELD-XI score to predict NRP was 9.47 (area under ROC curve: 0.739, P < 0.001). The Kaplan-Meier curves for 30-day all-cause mortality revealed lower survival rate in the group with a MELD-XI score of > 9.78 (P < 0.001).

CONCLUSION

The MELD-XI score can be used to predict NRP and the 30-day prognosis in patients with STEMI who are candidates for primary PCI. It could be adopted as an inexpensive and a readily available tool for risk stratification.

Model for End-Stage Liver Disease Score Predicts the Mortality of Patients with Coronary Heart Disease Who Underwent Percutaneous Coronary Intervention

Background

Coronary heart disease (CHD) is caused by the blockage or spasm of coronary arteries. Evidence shows that liver disease is related to CHD. However, the correlation between the Model for End-Stage Liver Disease (MELD) score and outcomes in patients after percutaneous coronary intervention (PCI) was unclear.

Method

A retrospective cohort study involved 5373 patients with coronary heart disease after PCI was conducted from January 2008 to December 2016. Participants were classified to four groups according to the MELD score by quartiles. The primary endpoint was long-term mortality including all-case mortality (ACM) and cardiac mortality (CM). Secondary endpoints included bleeding events, readmission, major adverse cardiovascular events (MACE), major adverse cardiovascular, and cerebrovascular events (MACCE). The longest follow-up time was almost 10 years.

Results

There were significant differences in the incidences of ACM (p=0.038) and CM (p=0.027) among the four MELD groups, but there was no significant difference in MACEs (p=0.496), MACCEs (p=0.234), readmission (p=0.684), and bleeding events (p=0.232). After adjusting the age, gender, smoking, drinking status, and diabetes by a multivariable Cox regression analysis, MELD remains independently associated with ACM (HR:1.57, 95%CI 1.052–2.354, p=0.027) and CM (HR:1.434, 95% CI 1.003–2.050, p=0.048).

Conclusion

This study indicated that the MELD score had a strong prediction for long-term mortality in CHD patients who underwent PCI.

The Impact of Admission Serum Creatinine on Major Adverse Clinical Events in ST-Segment Elevation Myocardial Infarction Patients Undergoing Primary Percutaneous Coronary Intervention

Background

Impaired renal function has been shown in previous studies to be an independent predictor of cardiovascular adverse events amongst patients admitted for percutaneous coronary intervention (PCI) following ST-segment elevation myocardial infarction (STEMI). This study investigates the impact of admission serum creatinine (SCr) on major cardiovascular outcomes among STEMI patients undergoing PCI.

Methods

A retrospective study of patients admitted for PCI following STEMI was conducted using the National Cardiovascular Database Action Registry (NCDR) at Cleveland Clinic Akron General (CCAG) Hospital. The primary outcome was a composite of major clinical events: cardiogenic shock, atrial fibrillation, ventricular tachycardia/fibrillation, heart failure, bleeding and mechanical ventilation. SCr was an independent and continuous variable.

Results

A total of 656 patients included in the study with the diagnosis of STEMI who subsequently underwent primary PCI. Patients with eGFR < 60 mL/min/1.73 m² on admission had an increased incidence of cardiogenic shock (P = 0.001), bleeding (P < 0.001), heart failure (P < 0.0005) and higher mortality rates (P = 0.0005). Furthermore, in the setting of STEMI, elevated SCr was also associated with an increased risk of developing major adverse events like cardiogenic shock (P = 0.05), bleeding (P = 0.05), and heart failure (P = 0.005).

Conclusions

In the setting of STEMI, elevated SCr and eGFR < 60 mL/min/1.73 m² was associated with an increased risk of developing major adverse events including cardiogenic shock, bleeding and heart failure.

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

We aimed to investigate the dose-response associations between chronic kidney disease (CKD), and short and long-term cardiovascular outcomes, to characterize these associations by drawing dose-response curves based on a Chinese rural ST-segment elevation myocardial infarction (STEMI) population.In all, 1067 patients with STEMI were consecutively enrolled from 12 secondary hospitals of China's Liaoning province (from June 2009 to June 2010 and January 2015 to December 2015). The follow-up was regularly performed by telephone. Patients were grouped by estimated glomerular filter rate (eGFR): normal, eGFR ≥90 mL/min/1.73 m; mild CKD, 60 to 90 mL/min/1.73 m; CKD, <60 mL/min/1.73 m. Adjusted logistic or Cox regression models were employed to compare short and long-term cardiovascular outcomes across different eGFR groups. Dose-response curves were plotted using restricted cubic spline functions.About 18.46% of the STEMI patients had CKD. Patients with CKD were more likely to suffer from other comorbidities, but less likely to receive evidence-based therapies. CKD was independently associated with in-hospital mortality and major adverse cardiac events (MACE) as compared with patients with normal renal function (for in-hospital mortality, adjusted odds ratio [OR] 2.39, 95% confidence interval [CI] 1.18-4.85, P = .02; for in-hospital MACE, adjusted OR 2.01, 95% CI 1.09-3.70, P < .01). Likewise, CKD was significantly associated with long-term mortality as well (CKD vs normal, adjusted hazard ratio 2.55, 95% CI 1.17-5.57, P = .02). The dose-response associations between eGFR, and short and long-term cardiovascular outcomes were found to be linear (all with P values for nonlinear associations >.05).CKD is an independent predictor of worse in-hospital and long-term clinical outcomes. The assessment of eGFR is essential to enable risk stratification, tailored therapy, and early and aggressive management.

Long-term prognostic role of uric acid in patients with ST-elevation myocardial infarction and renal dysfunction

Patients with renal impairment have decreased excretion of uric acid, thus being particularly prone to having elevated serum uric acid concentrations. No data are available on the long-term prognostic role of uric acid in patients with ST-elevation myocardial infarction (STEMI) and renal dysfunction, submitted to percutaneous coronary intervention (PCI). We therefore prospectively assessed, in 329 patients with STEMI and renal dysfunction (admission estimated glomerular filtration rate <60 ml/min/1.73 m), all submitted to PCI, whether uric acid levels are associated with increased mortality at 1-year postdischarge follow-up.Patients in the third tertile of uric acid showed a higher BMI (P = 0.014), a higher incidence of hypertension (P = 0.029), and two or more comorbidities (P = 0.034). The highest incidence of bleeding and of acute kidney injury was detectable in patients in the third tertile (P = 0.011 and P < 0.001, respectively) who showed the highest mortality rate at 1-year postdischarge follow-up (P = 0.008). At Cox regression analysis, uric acid was an independent predictor of 1-year postdischarge mortality (hazard ratio 1.26, 95% confidence interval 1.06-1.51, P = 0.011).In STEMI patients with estimated glomerular filtration rate below 60 ml/min/1.73 m treated with PCI, uric acid helps in identifying a subset of patients at a higher risk of bleeding and acute kidney injury. Increased uric acid is an independent prognostic risk factor for 1-year mortality. Further studies performed in larger cohorts of patients are needed to confirm our findings and to evaluate whether lowering uric acid in these patients is beneficial.

The Impact of Admission Serum Creatinine Derived Estimated Glomerular Filtration Rate on Major Adverse Cardiac Events in ST-Segment Elevation Myocardial Infarction Patients Undergoing Primary Percutaneous Coronary Intervention

Background

The impact of Cockroft-Gault (C-G) derived estimated glomerular filtration rate (eGFR) on mortality and major adverse cardiac events (MACEs) in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) was assessed.

Methods

A total of 884 patients were classified into four categories according to admission creatine derived eGFR: < 60, 60 - < 90, 90 - < 120, and ≥ 120 mL/min/1.73 m².

Results

In-hospital and long-term MACEs were significantly higher in eGFR < 60 mL/min/1.73 m² subgroup (P < 0.001 and P = 0.028). Multivariate analysis demonstrated 7.78-fold (95% CI: 0.91 - 66.8) higher mortality risk in eGFR < 60 mL/min/1.73 m² subgroup.

Conclusion

As an easily applicable bedside method, C-G derived eGFR could be important for prediction of in-hospital and long-term mortality and MACE in STEMI patients undergoing primary PCI.

Renal insufficiency was correlated with 2-year mortality for rural female patients with ST-segment elevation acute myocardial infarction after reperfusion therapy: a multicenter, prospective study

BACKGROUND

Renal insufficiency (RI) following ST-segment elevation acute myocardial infarction (STEMI) is associated with a worse clinical prognosis. We investigated the impact of RI on long-term mortality in rural female patients with STEMI and evaluated prognostic factors.

METHODS

A prospective cohort study of 436 consecutive rural female patients who were successfully treated with reperfusion therapy for STEMI between May 2009 and August 2011 in secondary care hospitals in Liaoning province northeastern China and followed up for 2 years. Patients were divided into three groups by estimated glomerular filtration rate (eGFR): Normal group, eGFR ≥90 mL/min/1.73 m(2) (n = 233). Moderate group, eGFR 60-90 mL/min/1.73 m(2) (n = 108). RI group, eGFR <60 mL/min/1.73 m(2) (n = 95). The primary outcome was 2-year mortality.

RESULTS

During follow-up (mean 741 ± 118 days), the RI group had a significantly higher mortality than the other groups (24.21 % vs. 6.87 % and 10.19 %, p < 0.001). The RI group had significantly higher hospital mortality (7.37 % p = 0.045 vs. Normal group). RI increased the risk of hospital mortality (hazard ratio (HR) 1.832, 95 % CI 1.017-3.091, p = 0.033), and increased the risk of 2-year mortality (HR 3.872, 95 % CI 2.004-6.131, p < 0.001). Multivariate analysis showed eGFR <90 ml/min/1.73 m(2) and age ≥75 years as independent predictors of mortality at 2 years. In detail these were eGFR 60-90 ml/min/1.73 m(2) with HR 2.081, 95%CI 1.250-2.842, p < 0.001; eGFR <60 ml/min/1.73 m(2) with HR 3.872, 95%CI 2.004-6.131, p < 0.001; age ≥75 with HR 1.461, 95%CI 1.011-1.952, p = 0.024.

CONCLUSIONS

RI had a powerful correlation with long-term mortality for rural female patients with STEMI after reperfusion therapy.

Renal Dysfunction and hsCRP Predict Long-term Outcomes of Percutaneous Coronary Intervention in Acute Myocardial Infarction

BACKGROUND

This study assessed the combined utility of estimated glomerular filtration rate (eGFR) and serum high-sensitivity C-reactive protein (hsCRP) levels to predict long-term mortality and cardiovascular outcomes of patients with acute ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). Elevated CRP levels and renal dysfunction have both been shown to independently and jointly predict mortality and cardiovascular outcomes after PCI in the short term. However, long-term results in patients with acute STEMI undergoing PCI have not been reported.

METHODS

A total of 262 patients with acute STEMI undergoing primary PCI were classified at admission into quartiles according to eGFR (<60, 60-70, 70-80 and ≥80 mL·min·1.73 m) and hsCRP (<3 and ≥3 mg/L). Mortality, nonfatal myocardial infarction (MI) and major adverse cardiac events (MACEs) were compared among the groups.

RESULTS

During a median follow-up of 48.3 months, the composite of all-cause mortality and nonfatal MI (mortality + MI) was significantly higher (35.09%) in the group with the lowest eGFR compared with that of the other 3 eGFR groups (14.29%, 3.77% and 9.43%, respectively, P < 0.0001) and the group with elevated hsCRP (34.29%) versus that with hsCRP <3 mg/L (4.41%, P < 0.0001). A combined analysis showed an exaggerated hazard in patients with the lowest eGFR and highest hsCRP (hazard ratio: 44.658; 95% confidence interval: 5.955-111.890).

CONCLUSIONS

Renal dysfunction and elevated hsCRP predict a high long-term incidence of MACE in patients with acute STEMI undergoing primary PCI, with the combination being of prognostic significance for long-term mortality and MI in these patients.

Association of beta-blocker therapy at discharge with clinical outcomes in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention

OBJECTIVES

This study sought to investigate the association of beta-blocker therapy at discharge with clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI) after primary percutaneous coronary intervention (PCI).

BACKGROUND

Limited data are available on the efficacy of beta-blocker therapy for secondary prevention in STEMI patients.

METHODS

Between November 1, 2005 and September 30, 2010, 20,344 patients were enrolled in nationwide, prospective, multicenter registries. Among these, we studied STEMI patients undergoing primary PCI who were discharged alive (n = 8,510). We classified patients into the beta-blocker group (n = 6,873) and no-beta-blocker group (n = 1,637) according to the use of beta-blockers at discharge. Propensity-score matching analysis was also performed in 1,325 patient triplets. The primary outcome was all-cause death.

RESULTS

The median follow-up duration was 367 days (interquartile range: 157 to 440 days). All-cause death occurred in 146 patients (2.1%) of the beta-blocker group versus 59 patients (3.6%) of the no-beta-blocker group (p < 0.001). After 2:1 propensity-score matching, beta-blocker therapy was associated with a lower incidence of all-cause death (2.8% vs. 4.1%, adjusted hazard ratio: 0.46, 95% confidence interval: 0.27 to 0.78, p = 0.004). The association with better outcome of beta-blocker therapy in terms of all-cause death was consistent across various subgroups, including patients with relatively low-risk profiles such as ejection fraction >40% or single-vessel disease.

CONCLUSIONS

Beta-blocker therapy at discharge was associated with improved survival in STEMI patients treated with primary PCI. Our results support the current American College of Cardiology/American Heart Association guidelines, which recommend long-term beta-blocker therapy in all patients with STEMI regardless of reperfusion therapy or risk profile.

Impact of family history on the presentation and clinical outcomes of coronary heart disease: data from the Korea Acute Myocardial Infarction Registry

BACKGROUND/AIMS

Family history (FHx) of coronary heart disease (CHD) is a well-known risk factor for CHD. However, the prognostic implication of FHx has not been established clearly in patients with acute myocardial infarction (AMI).

METHODS

In total, 11,612 patients (8,132 males [70%], age 63 ± 13 years) with first-onset AMI between November 2005 and June 2008 in a nationwide, prospective, multicenter, online registry (the Korea AMI Registry) were analyzed. Clinical characteristics and outcomes (cardiac death and major adverse cardiac events [MACEs]) were assessed according to the presence of FHx.

RESULTS

The patients with FHx were younger and included more males. Male patients with FHx included more current smokers and individuals with poor lipid profiles. In all patients, after adjustment using the Cox proportional hazard model, FHx was related to the risk of MACEs (hazard ratio [HR], 1.41; p = 0.009) and cardiac death (HR, 1.56; p = 0.080). The poor prognostic implication of FHx was further augmented in females and a low risk subset of patients. A significant interaction was only found between male and female patients for composite MACEs (p for interaction = 0.057), and between patients with more risk factors (≥ 2 risk factors) and fewer risk factors for cardiac deaths (p for interaction = 0.008).

CONCLUSIONS

FHx may be an independent prognostic predictor, especially in female patients and patients with low-risk profile.

Renal dysfunction in STEMI-patients undergoing primary angioplasty: higher prevalence but equal prognostic impact in female patients; an observational cohort study from the Belgian STEMI registry

Background

Mortality in female patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary angioplasty (pPCI) is higher than in men. We examined gender differences in the prevalence and prognostic performance of renal dysfunction at admission in this setting.

Methods

A multicenter retrospective sub-analysis of the Belgian STEMI-registry identified 1,638 patients (20.6% women, 79.4% men) treated with pPCI in 8 tertiary care hospitals (January 2007-February 2011). The estimated glomerular filtration rate (eGFR) was calculated using the CKD-EPI equation. Main outcome measure was in-hospital mortality.

Results

More women than men suffered from renal dysfunction at admission (42.3% vs. 25.3%, p < 0.001). Mortality in women was doubled as compared to men (9.5 vs. 4.7%, OR (95% CI) = 2.12 (1.36-3.32), p<0.001). In-hospital mortality for men and women with vs. without renal dysfunction was much higher (10.7 and 15.3 vs. 2.3 and 2.4%, p < 0.001). In a multivariable regression analysis, adjusting for age, gender, peripheral artery disease (PAD), coronary artery disease (CAD), hypertension, diabetes and low body weight (<67 kg), female gender was associated with renal dysfunction at admission (OR (95% CI) 1.65 (1.20-2.25), p = 0.002). In a multivariable model including TIMI risk score and renal dysfunction, renal dysfunction was an independent predictor of in-hospital mortality in both men (OR (95% CI) = 2.39 (1.27-4.51), p = 0.007) and women (OR (95% CI) = 4.03 (1.26-12.92), p = 0.02), with a comparable impact for men and women (p for interaction = 0.69).

Conclusions

Female gender was independently associated with renal dysfunction at admission in pPCI treated patients. Renal dysfunction was equally associated with higher in-hospital mortality in both men and women.

Predictors of long-term survival in acute coronary syndrome patients with left ventricular dysfunction after percutaneous coronary intervention

Background and Objectives

Predictive factors of mortality in acute coronary syndrome (ACS) patients with left ventricular dysfunction were analyzed during 5-year clinical follow-up after percutaneous coronary intervention (PCI).

Subjects and Methods

A total of 329 ACS consecutive patients (64.6±11.3 years, 227 males) who underwent PCI from January 2001 to March 2006 were followed for 5 years. All patients had lower than 40% of left ventricular ejection fraction (LVEF). Patients were divided into Group I (survived longer than 5-years: n=130, 101 males) and Group II (survived shorter than 5 years: n=199, 126 males).

Results

The cumulative survival rate was 88.0% at 1 month, 78.0% at 6 months, 75.0% at 1 year, 67.0% at 2 years, 62.0% at 3 years, 57.0% at 4 years and 40% at 5-years. Group II was older (61.6±11.2 years vs. 66.4±11.4 years, p<0.001), and showed higher prevalence of female gender (28.4% vs. 36.7%, p=0.006) and lower LVEF (35.3±5.2 vs. 33.6±5.6) than Group I. The independent predictors for mortality were LVEF <30% {odds ratio (OR)=1.793, 95% confidence interval (CI): 1.234-2.452, p=0.002}, serum creatinine >3.0 mg/dL (OR=2.455, 95% CI: 1.306-4.614, p=0.005), older than 65 years (OR=1.594, 95% CI: 1.152-2.206, p=0.005), and female gender (OR=1.524, 95% CI: 1.090-2.130, p=0.014).

Conclusion

Five-year survival rate was 40% in ACS patients with left ventricular dysfunction, and the predictors for mortality were low LVEF, high serum creatinine, old age, and female gender.

Renal Dysfunction was an Independent Predictor of In-Hospital Death and Ventricular Rupture in Patients With Acute Myocardial Infarction

BACKGROUND

Apart from the severity of myocardial infarction and coronary artery disease, several predictors of in-hospital death (In-HD) are suggested in patients with acute myocardial infarction (AMI).

METHODS

We investigated predictors of In-HD and ventricular rupture (VR) including ventricular septal rupture (VSR) and free wall rupture (FWR) with stepwise multivariable logistic regressions in 1,042 patients admitted to our Cardiovascular Center within 48 hours from symptom onset for the first attack of AMI.

RESULTS

In-HD, VSR, and FWR were observed in 78 cases (7.5%), 14 cases of which 13 cases were In-HD, and 13 cases of which 6 cases were In-HD, respectively. Apart from the disease severity, age and renal dysfunction (RD) defined by estimated glomerular filtration rate of lower than 60 mL/min/ 1.73 m² were independent positive predictors of In-HD (the odds ratios (ORs) (95% confidence interval (CI)): 1.04 (1.01 - 1.06) P = 0.0069 and 5.75 (3.12 - 10.59) P < 0.0001, respectively) and hypercholesterolemia was an independent negative predictor for In-HD (OR (95% CI): 0.34 (0.17 - 0.67) P = 0.0017). After including the categories of coronary disease, ventricular rupture, and ejection fraction in predictors, RD remained an independent predictor of In-HD (OR (95% CI): 6.65 (2.67 - 16.60) P < 0.0001). Age (OR (95% CI): 1.07 (1.02 - 1.12) P = 0.0064), RD (OR (95% CI): 2.77 (1.18 - 6.49) P = 0.019), and diabetes (OR (95% CI): 2.52 (1.12 - 5.71) P = 0.026) were independent predictors of VR.

CONCLUSIONS

RD was an independent predictor of In-HD and VR in patients with initial AMI.