Association of bleeding events and acute kidney failure in patients with ST-Elevation myocardial infarcation undergoing emergency percutaenous coronary intervention

Background

Acute kidney injury (AKI) is associated with a worse overall prognosis in patients with ST-elevation myocardial infarctions (STEMI). At the same time bleeding complications during emergency percutaneous interventions (PCI) in STEMI-patients are often associated with hemodynamic impairement, which might contribute to renal tissue damage. Aim of the present study was to investigate an association between bleeding complications and AKI and the interaction between bleedings events and other possible contributors to AKI.

Methods

All patients with STEMI admitted to a German heart center between 2006 and 2020 were analysed. AKI was defined as KDIGO stage ≥1. Bleedings were characterised by BARC criteria or by decrease in total hemoglobin (ΔHb = Hb(admission) − Hb(minimal).

Results

Of a total of 7381 patients, 6805 (92%) showed no or only minmal bleedings (BARC 0/1), in 300 (4%) a BARC 2 bleeding, in 200 (3%) a BARC 3a and in 76 (1%) a BARC 3b/c or 5-major-bleeding event was documented. In patients with bleeding events, higher age, female gender (BARC 0/1: 25%, BARC 3b/c+5: 41%) and cardiogenic shock (BARC 0/1: 11%, BARC 3b/c and 5: 38%) were more prevalent. Furthermore BARC was associated with higher rates of AKI (BARC 0/1: 13%, BARC 2: 24%, BARC 3a: 43%, BARC 3b/c+5: 57%, p (for trend) <0.01). Of the significant bleedings (≥BARC 2) 51% were femoral/retroperitoneal, 21% gastrointestinal, 2% intracerebral and 26% various. When estimating AKI-rates by decrease in Hemoglobin (ΔHb = Hb(admission) − Hb(minimal during the hospital stay in the PCI-center)), an association between any decrease in hemoglobin and AKI-rate was evident: ΔHb <1 g/dL: AKI-rate: 7%, ΔHb 3 to 3.9 g/dl: 29%, ΔHb ≥6 g/dl: 57%, p (for trend) <0.01. For every 1 g/dl decrease in hemoglobin, AKI-rates increased by on average the factor 1.44. When comparing the impact of the amount of contrast media (CM) used during emergency-PCI and Hb-decrease on AKI-rates it became evident that while higher CM-doses were associated with a modest rise in AKI-rates, the effect of an Hb-decrease on AKI-rates was more pronounced. A major decrease in Hemoglobin (≥4 g/dl) was associated with an at least 3.5 fold higher risk for AKI irrespective of amount of contrast media applied (Figure).

Conlusions

This registry data shows that bleeding events in STEMI-patients, classified by BARC-criteria or alternatively stratified by decrease in hemoglobin-levels are closely associated with incidence-rates of AKI. This indicates the importance of bleeding complications and its hemodynamic alterations in STEMI, which most likely contribute to renal tissue damage. Less access site complications might therefore result in renal protection.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): State of BremenStiftung Bremer Herzen Predictors of AKI in STEMI

Temporal trends in adverse ischemic events, bleedings, kidney injury and overall mortality for patients with ST-elevation myocardial infarctions and advanced kidney disease

Background

Although the negative effects of advanced chronic kidney disease (CKD) on the pathogenesis and prognosis of coronary artery disease (CAD) has been shown in prior studies, there is few data on the efficacy and safety of modern interventional therapies and medications in patients with advanced CKD. Aim of the present study was to analyse temporal trends in patients with ST-elevation myocardial infarctions (STEMI) and advanced CKD during the last 15 years.

Methods

All STEMI-Patients admitted to a German heart center between 2006–2019 were analysed. Advanced CKD, estimated with the CKD-EPI-equation, was defined as stage ≥G3b (glomerular filtration rate (GFR) <45 ml/min). Cumulative ischemic events at 1 year were defined as a combination of in-stent-thrombosis, myocardial re-infarction and repeat target-lesion-revascularisation

Results

Of a total of 9605 patients, 1013 (10.6%) showed a moderately or severely (G3b-G5) reduced renal function with a mean baseline Serum creatinine of 2.2±4.2 mg/dl and a GFR of 32.3±10 ml/min/1.73 m2. CKD-Patients were less likely to be treated with a primary percutaneous coronary interention (PCI): 84.1 vs. 94.1% (p<0.01) and showed higher all-cause-mortality (44.4 vs. 3.6%, p<0.01) and bleeding-rates (9.4 vs 3.7%, p<0.01) compared to non-CKD-patients at 1 year, while cumulative ischemic events did not differ (6.5 vs. 5.1%, p=0.12). Over time however, patients with advanced CKD were also more likely to be treated with primary PCI (2006–10: 75.8 to 2015–19: 90.1%, p<0.01), ticagrelor/prasugrel (1.7 to 59.6%, p<0.01) and drug eluting stents (DES: 1.3 to 90.7%, p<0.01). After adjustment for confounders (multivariate analysis of outcomes adjusted for age, gender, diabetes and cardiogenic shock) patients with advanced CKD showed a decline in ischemic events at 1 year, however offset by an increase in bleedings (table). Neither overall mortality nor rates of acute kidney injury changed over time (table), despite an increase in amount of contrast media used (132±62 ml to 152±73 ml, p<0.01). In patients with advanced CKD both ticagrelor/prasugrel (OR 0.48, 95% CI 0.2–0.98) and DES (OR 0.38, 95% CI 0.2–0.8) were associated with a decrease in ischemic-events.

Conclusions

This registry data shows, that during the last 15 years STEMI-patients with advanced CKD were more likely to be treated with primary PCI and are in their majority now treated with ticagrelor, prasugrel and modern DES. These changes in therapeutic strategies probably have contributed to the decline in adverse ischemic events, while overall mortality was not affected.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): State of BremenStiftung Bremer Herzen Multivariate outcome analysis over time

Development of 1- and 5-year outcomes between 2006 and 2018 in patients with uncomplicated ST-elevation myocardial infarctions and successful percutaneous coronary intervention

Introduction

While modern P2Y12-inhibitors and drug eluting stents (DES) have changed therapeutic options in patients with ST-elevation mycoardial infarctions (STEMI) during the last decade, there is few data on their impact in real world registries. Aim of the present study was to analyze changes in mortality and major adverse cardiac and cererobrovascular event rates (MACCE: death, reinfarction,stroke) during the last 13 years in patients with uncomplicated STEMI after successful percutaneous coronary intervention (PCI).

Methods

All consecutive STEMI-patients, admitted between 2006 and 2018 and successfully treated with PCI (TIMI flow ≥2) in a large German heart center entered analysis. To reduce confounding pts. with STEMI complicated by heart failure and pts. >70 yrs. of age were excluded.

Results

A STEMI-cohort of 5016 pts. was analysed, with a mean age of 55.9±8 yrs., 19% females, 16% diabetics and 59% smokers. At the beginning of the study period (2006) no patient was treated with ticagrelor/prasugrel and only 5% had a DES implanted. In 2018 92% were treated with prasugrel or ticagrelor and 96% with a DES. The reduction in 1-year-mortality during the study period was not significant: 2006–11: 3.4%, 2012–19: 3.1%, p=0.4, however the reduction in 1-year-MACCE was: 2006–11: 8.3%, 2012–18: 5.7%, p<0.01. This could mainly be attributed to a reduction in reinfarctions: 2006–11: 4.9%, 2012–18: 2.8%, p<0.01. Subgroup analysis revealed that with the exception of diabetics all subgroups showed a significant decline in MACCE-rates during the study period. It was more pronounced in women, non-smokers and patients with a high socioeconomic status (SES) (Table). Analysis of 5-year-data revealed a significant reduction in both 5-year-mortality (2006–09: 9.1%, 2010–13: 6.8%, p<0.01) and 5-year-MACCE-rates: 2006–09: 19.3%, 2010–13: 14.5%, p<0.01.

Conclusions

This analysis of registry data over a study period of 13 years reveals, that for patients with uncomplicated STEMI and successful PCI a significantly better 1- and 5-year-outcome could be achieved during the last years. This improvement of prognosis was more pronounced in specific subgroups, such as women, non-diabetics and patients with higher SES.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Stiftung Bremer Herzen, Gesundheit Nord

P2660Definition of clinically relevant thresholds of acute kidney injury in patients with ST-elevation myocardial infarctions undergoing primary percutaneous coronary interventions

Background

Although the clinical importance of deteriorating kidney function in patients with ST-elevation-myocardial infarctions (STEMI) on overall prognosis is generally accepted, there is conflicting evidence on the importance of small changes in renal function. Aim of the present study was to calculate clincially relevant thresholds for deterioration of renal function after STEMI.

Methods

From a large registry of patients with STEMI renal function was estimated calculating the glomerular filtration rate (GFR in ml/min/1.73 m2) with the CKD-EPI-equation. To assess acute kidney injury the ratio GFR (at peak creatinine))/ GFR (at admission) was calculated for each patient (with 1 representing no change). Patients were graded by GFR-reduction and assigned to 11 groups (G1 to G11) each representing 5% intervals.

Results

Of 6583 patients admitted with STEMI between 2006–2017 3518 (53%) had no change or a change <5% during hospital stay (G1) while 161 (3%) showed a decrease in GFR of ≥50% (G11). The rest of the patients could be attributed to G2- G10 (table). There was a pronounced correlation between extent of GFR-reduction and peak creatine kinase (indicating size of STEMI, r2=0.785; G1: 1521±1684 U/l vs. G11: 2885±2943 U/l, p<0.01) as well as left-ventricular ejection fraction (LVEF) (r2=0.79; G1: 50.9±9% vs. G11: 41.4±10%, p<0.01). However, no such correlation could be detected between GFR-reduction and amount of contrast media (CM) applied (r2=0.05, G1: 141±60 ml vs. G11: 139±61 ml, p=0.5). Analysis of outcome-data (1-year-mortality and major adverse cardiovascular and cerebrovascular events (MACCE: death, stroke, re-infarction)) revealed, that beneath a threshold of 25% deterioration of renal function did not significantly impact prognosis, while higher degrees of deterioration led to a 7-fold increase in mortality and a 5-fold increase in MACCE-rates (table).

Impact of GFR-reduction on outcome Group G1 G2 G3 G4 G5 G6 G7 G8 G9 G10 G11 GFR-reduction (in %) 0–4 5 to 9 10 to 14 15 to 19 20 to 24 25 to 29 30 to 34 35 to 39 40 to 44 45 to 49 ≥50 Patients, n (%) 3518 (53) 881 (13) 717 (11) 492 (7) 327 (5) 196 (3) 119 (2) 88 (1) 48 (1) 36 (1) 161 (3) 1 year mortality (%) 7 4 5 8 7 15 20 22 39 43 50 1-year-MACCE (%) 12 8 8 12 10 19 27 27 49 49 52

Conclusions

These data from a large STEMI-registry show that small changes (less than 25%) in GFR did not significantly impact long-term outcome, while the impact was pronounced for all patients beyond that threshold. The degree of renal deterioration furthermore correlated with size of STEMI as well as reduction of LV-function after STEMI while no correlation to amount of contrast media could be found.

465Benefit of modern P2Y12-inhibitors on long-term prognosis in patients with ST-elevation myocardial infarction with and without advanced chronic kidney disease

Background

Current guidelines on the management of patients with ST-elevation myocardial infarction (STEMI) recommend the preferred use of the modern P2Y12-inhibitors ticagrelor or prasugrel regardless of the presence of chronic kidney disease (CKD), although patients with advanced stages of CKD were excluded from randomized trials. Aim of the present study was therefore to evaluate the potential benefit of modern P2Y12-inhibitors in patients with and without advanced renal disease at admission.

Methods

All patients admitted with STEMI between 2006–2017 from a large german heart center treated with primary percutaneous coronary intervention (PCI) entered analysis. Initial CKD was estimated with the initial glomerular filtration rate (GFR), calculated with the CKD-EPI-equation, assigning them to the groups G1-G5.

Results

Of 7227 patients with STEMI and primary PCI 2669 (37%) showed no relevant reduction in GFR at admission (≥90 ml/min/1.73 m2, G1), 2976 pts. (41%), a slight reduction (GFR 60–89 ml/min/1.73 m2, G2), 880 pts. (12%) a moderate reduction (GFR 45–59 ml/min/1.73 m2, G3a) and 702 pts. (10%) a moderate to severe reduction (GFR<45 ml/min 1.73 m2, G3b-G5). Pts. with more advanced stages of CKD were on average older (G1: 55±11 years, G2: 66±12 years, G3a: 72±12 years, G3b-G5: 75±11 years, p<0.01) and more likely to be female (G1: 19%, G2: 26%, G3a: 40%, G3b-G5: 48%, p<0.01). Prasugrel/ticagrelor were less often given instead of clopidogrel in patients with advanced CKD (G1: 70%, G2: 45%, G3a: 31%, G3b-G5: 32%, p<0.01). The use of ticagrelor/prasugrel was associated with a reduction in 1-year-MACCE (major adverse cardio- and cerebrovascular events)-rates in patients with no/low-grade-CKD (G1-G2), while no significant reduction in MACCE could be observed for patients with moderate to severe CKD (table). Furthermore, CKD was associated with an elevation in severe bleeding events within 1 year (G1: 1%, G2: 3%, G3a: 5%, G3b-G5: 6%, p<0.01).

Impact of CKD-stage on outcome CKD-stage G1 CKD-stage G2 CKD-stage G3a CKD-stage G3b-G5 1-year-MACCE-rate (%) Ticagrelor/prasugrel 4.5 11.0 27.4 47.3 Clopidogrel 9.9 15.6 26.6 50.4 Significance <0.01 <0.01 0.6 0.7

Conclusions

These data from a large STEMI-registry demonstrate, that modern P2Y12-inhibitors were less often used in patients with CKD and their benefit regarding MACCE disappeared in advanced stages of CKD while bleeding rates increased. These results underline the special role of patients with advanced stage-CKD in STEMI and the necessity of specialized randomized trials for these patients.