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CLINICAL STUDY: CORONARY ARTERY DISEASE

Renal insufficiency and cardiovascular events in postmenopausal women with coronary heart disease

Michael G. Shlipak, MD, MPH^* , Joel A. Simon, MD, MPH^* , Deborah Grady, MD, MPH^* , Feng Lin, MS, Nanette K. Wenger, MD, FACC, Curt D. Furberg, MD, PhD^|| for the Heart and Estrogen/progestin Replacement Study (HERS) Investigators

^* General Internal Medicine Section, Veterans Affairs Medical Center, San Francisco, California, USA
Department of Medicine, University of California, San Francisco, California, USA
Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA
Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
^|| Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA

Manuscript received December 31, 2000; revised manuscript received May 1, 2001, accepted June 1, 2001.

Reprint requests and correspondence: Dr. Michael G. Shlipak, General Internal Medicine Section (111A-1), Veterans Affairs Medical Center, 4150 Clement Street, San Francisco, California 94121
shlip{at}itsa.ucsf.edu

OBJECTIVES

This study sought to determine the independent association of renal insufficiency with cardiovascular risk among women with known coronary heart disease (CHD).

BACKGROUND

Although patients with end-stage renal disease and proteinuria are at high risk for cardiovascular events, little is known about the cardiovascular risk associated with moderate renal insufficiency.

METHODS

The Heart and Estrogen/progestin Replacement Study (HERS) was a clinical trial among 2,763 women with coronary disease who were randomized to conjugated estrogen plus progestins or identical placebo and followed for a mean of 4.1 years. Women were categorized as having normal renal function (creatinine < 1.2 mg/dl; n = 2,012), mild renal insufficiency (1.2 mg/dl to 1.4 mg/dl; n = 567) and moderate renal insufficiency (>1.4 mg/dl; n = 182). We examined the independent association of renal function with incident cardiovascular events including CHD death, nonfatal myocardial infarction, hospitalization for unstable angina, stroke and transient ischemic attacks.

RESULTS

Compared with women with normal renal function, those with mild and moderate renal insufficiency were older, more likely to be black, have a history of hypertension and diabetes and have higher serum levels of triglycerides and lipoprotein(a). After multivariate adjustment, both mild (relative hazards [RH] = 1.24; 95% confidence interval [CI]: 1.0 to 1.5) and moderate renal insufficiency (RH = 1.57; 95% CI: 1.2 to 2.1) were independently associated with increased risk for cardiovascular events compared with women with normal renal function.

CONCLUSIONS

Renal insufficiency is an independent risk factor for cardiovascular events in postmenopausal women with known coronary artery disease. Renal function may add helpful information to CHD risk stratification.

Abbreviations and Acronyms   ACE = angiotensin-converting enzyme   CABG = coronary artery bypass graft surgery   CHD = coronary heart disease   CI = confidence interval   ECG = electrocardiogram   HERS = Heart and Estrogen/progestin Replacement Study   MI = myocardial infarction   PTCA = percutaneous transluminal coronary angioplasty   RH = relative hazards   TIA = transient ischemic attack

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