CLINICAL STUDY: ACUTE CORONARY SYNDROME
Influence of concurrent renal dysfunction on outcomes of patients with acute coronary syndromes and implications of the use of glycoprotein IIb/IIIa inhibitors
Rosario V. Freeman, MD, MS*,*,
Rajendra H. Mehta, MD, MS, FACC ,
Wisam Al Badr, MD,
Jeanna V. Cooper, MS,
Eva Kline-Rogers, RN, MS and
Kim A. Eagle, MD, FACC
* Division of Cardiology, University of Washington, Seattle, Washington, USA
Division of Cardiology, University of Michigan, Ann Arbor, Michigan, USA
Manuscript received March 27, 2002;
revised manuscript received August 14, 2002,
accepted August 29, 2002.
* Reprint requests and correspondence: Dr. Rosario V. Freeman, University of Washington, Division of Cardiology, 1959 NE Pacific Street, Box 356422, Seattle, Washington 98195-6171, USA
rosariof{at}u.washington.edu
OBJECTIVES: The purpose of this study was to examine the in-hospital outcome and influence of glycoprotein (GP) IIb/IIIa antagonists on patients with acute coronary syndromes (ACS) across a range of renal function.
BACKGROUND: Recent studies demonstrate increasing cardiovascular risk with progressive renal dysfunction. Previous studies investigating GP IIb/IIIa antagonist use have excluded patients with renal dysfunction.
METHODS: Patients presenting with ACS between January 1999 and May 2000 were identified, and data on demographics, in-hospital management, and clinical events were collected using standardized definitions. Patients were stratified according to renal function assessed by calculated creatinine clearance (CrCl) at presentation. Primary outcome measures included in-hospital mortality and major bleeding events.
RESULTS: Renal insufficiency was present in 312 of 889 patients. There were 40 in-hospital deaths. In non-dialysis-dependent patients, as CrCl worsened, there was a decline in utilization of routine diagnostics and therapeutics, an increase in in-hospital mortality (p = 0.002), and an increase in major bleeding (p = 0.03). Although the use of GP IIb/IIIa antagonists was associated with an increase in major bleeding (p < 0.001), there was a protective effect on in-hospital mortality (p = 0.04) after controlling for CrCl.
CONCLUSIONS: Renal dysfunction is present in a substantial proportion of patients with ACS and is associated with increased in-hospital death. Although GP IIb/IIIa antagonist use in patients with ACS and renal insufficiency resulted in increased bleeding events, its administration was associated with a decreased risk of in-hospital mortality. These preliminary findings need to be confirmed in future randomized clinical trials.
|
Abbreviations and Acronyms
| | ACC/AHA | | American College of Cardiology/American Heart Association | | ACS | | acute coronary syndrome | | CI | | confidence interval | | CrCl | | creatinine clearance | | GP | | glycoprotein | | MI | | myocardial infarction | | OR | | odds ratio | | PCI | | percutaneous coronary intervention |
|
This article has been cited by other articles:
|
|
|
|
 
J. A. Wong, S. G. Goodman, R. T. Yan, R. Wald, A. J. Bagnall, R. C. Welsh, G. C. Wong, J. Kornder, K. A. Eagle, P. G. Steg, et al.
Temporal management patterns and outcomes of non-ST elevation acute coronary syndromes in patients with kidney dysfunction
Eur. Heart J.,
March 1, 2009;
30(5):
549 - 557.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
C. R. Parikh, S. G. Coca, Y. Wang, F. A. Masoudi, and H. M. Krumholz
Long-term Prognosis of Acute Kidney Injury After Acute Myocardial Infarction
Arch Intern Med,
May 12, 2008;
168(9):
987 - 995.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. K. Inrig, U. D. Patel, L. P. Briley, L. She, B. S. Gillespie, J. D. Easton, E. J. Topol, and L. A. Szczech
Mortality, kidney disease and cardiac procedures following acute coronary syndrome
Nephrol. Dial. Transplant.,
March 1, 2008;
23(3):
934 - 940.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
K. A.A. Fox, J.-P. Bassand, S. R. Mehta, L. Wallentin, P. Theroux, L. S. Piegas, V. Valentin, T. Moccetti, S. Chrolavicius, R. Afzal, et al.
Influence of Renal Function on the Efficacy and Safety of Fondaparinux Relative to Enoxaparin in Non-ST-Segment Elevation Acute Coronary Syndromes
Ann Intern Med,
September 4, 2007;
147(5):
304 - 310.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. T. Yan, R. T. Yan, M. Tan, A. Casanova, M. Labinaz, K. Sridhar, D. H. Fitchett, A. Langer, and S. G. Goodman
Risk scores for risk stratification in acute coronary syndromes: useful but simpler is not necessarily better
Eur. Heart J.,
May 1, 2007;
28(9):
1072 - 1078.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
N.C. Edwards, R.P. Steeds, C.J. Ferro, and J.N. Townend
The treatment of coronary artery disease in patients with chronic kidney disease
QJM,
November 1, 2006;
99(11):
723 - 736.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
K. P. Alexander, A. Y. Chen, L. K. Newby, J. B. Schwartz, R. F. Redberg, J. S. Hochman, M. T. Roe, W. B. Gibler, E. M. Ohman, E. D. Peterson, et al.
Sex Differences in Major Bleeding With Glycoprotein IIb/IIIa Inhibitors: Results From the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines) Initiative
Circulation,
September 26, 2006;
114(13):
1380 - 1387.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
S. G. Coca, H. M. Krumholz, A. X. Garg, and C. R. Parikh
Underrepresentation of renal disease in randomized controlled trials of cardiovascular disease.
JAMA,
September 20, 2006;
296(11):
1377 - 1384.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. J. Kirtane, G. Piazza, S. A. Murphy, D. Budiu, D. A. Morrow, D. J. Cohen, E. Peterson, N. Lakkis, H. C. Herrmann, T. M. Palabrica, et al.
Correlates of Bleeding Events Among Moderate- to High-Risk Patients Undergoing Percutaneous Coronary Intervention and Treated With Eptifibatide: Observations From the PROTECT-TIMI-30 Trial
J. Am. Coll. Cardiol.,
June 20, 2006;
47(12):
2374 - 2379.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. G. Kingma Jr., C. Vincent, J. R. Rouleau, and I. Kingma
Influence of Acute Renal Failure on Coronary Vasoregulation in Dogs
J. Am. Soc. Nephrol.,
May 1, 2006;
17(5):
1316 - 1324.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
G. S. Hillis, B. L. Croal, K. G. Buchan, H. El-Shafei, G. Gibson, R. R. Jeffrey, C. G.M. Millar, G. J. Prescott, and B. H. Cuthbertson
Renal Function and Outcome From Coronary Artery Bypass Grafting: Impact on Mortality After a 2.3-Year Follow-Up
Circulation,
February 28, 2006;
113(8):
1056 - 1062.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. A. Brinker, C. J. Davidson, and W. Laskey
Preventing in-hospital cardiac and renal complications in high-risk PCI patients
Eur. Heart J. Suppl.,
August 1, 2005;
7(suppl_G):
G13 - G24.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. Vanholder, Z. Massy, A. Argiles, G. Spasovski, F. Verbeke, N. Lameire, and for the European Uremic Toxin Work Group (EUTox)
Chronic kidney disease as cause of cardiovascular morbidity and mortality
Nephrol. Dial. Transplant.,
June 1, 2005;
20(6):
1048 - 1056.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. Passauer, F. Pistrosch, E. Bussemaker, G. Lassig, K. Herbrig, and P. Gross
Reduced Agonist-Induced Endothelium-Dependent Vasodilation in Uremia Is Attributable to an Impairment of Vascular Nitric Oxide
J. Am. Soc. Nephrol.,
April 1, 2005;
16(4):
959 - 965.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. N. Foley, A. M. Murray, S. Li, C. A. Herzog, A. M. McBean, P. W. Eggers, and A. J. Collins
Chronic Kidney Disease and the Risk for Cardiovascular Disease, Renal Replacement, and Death in the United States Medicare Population, 1998 to 1999
J. Am. Soc. Nephrol.,
February 1, 2005;
16(2):
489 - 495.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
W. Koenig, D. Twardella, H. Brenner, and D. Rothenbacher
Plasma Concentrations of Cystatin C in Patients with Coronary Heart Disease and Risk for Secondary Cardiovascular Events: More than Simply a Marker of Glomerular Filtration Rate
Clin. Chem.,
February 1, 2005;
51(2):
321 - 327.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
C. M. Gibson, R. L. Dumaine, E. V. Gelfand, S. A. Murphy, D. A. Morrow, S. D. Wiviott, R. P. Giugliano, C. P. Cannon, E. M. Antman, E. Braunwald, et al.
Association of glomerular filtration rate on presentation with subsequent mortality in non-ST-segment elevation acute coronary syndrome; observations in 13307 patients in five TIMI trials
Eur. Heart J.,
November 2, 2004;
25(22):
1998 - 2005.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
G. Marenzi, G. Lauri, E. Assanelli, J. Campodonico, M. De Metrio, I. Marana, M. Grazi, F. Veglia, and A. L. Bartorelli
Contrast-induced nephropathy in patients undergoing primary angioplasty for acute myocardial infarction
J. Am. Coll. Cardiol.,
November 2, 2004;
44(9):
1780 - 1785.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. Ezekowitz, F. A. McAlister, K. H. Humphries, C. M. Norris, M. Tonelli, W. A. Ghali, M. L. Knudtson, and APPROACH Investigators
The association among renal insufficiency, pharmacotherapy, and outcomes in 6,427 patients with heart failure and coronary artery disease
J. Am. Coll. Cardiol.,
October 19, 2004;
44(8):
1587 - 1592.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. Gupta, Y. Birnbaum, and B. F. Uretsky
The renal patient with coronary artery disease: Current concepts and dilemmas
J. Am. Coll. Cardiol.,
October 6, 2004;
44(7):
1343 - 1353.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
N. S. Anavekar, J. J.V. McMurray, E. J. Velazquez, S. D. Solomon, L. Kober, J.-L. Rouleau, H. D. White, R. Nordlander, A. Maggioni, K. Dickstein, et al.
Relation between Renal Dysfunction and Cardiovascular Outcomes after Myocardial Infarction
N. Engl. J. Med.,
September 23, 2004;
351(13):
1285 - 1295.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
M W Yerkey, S J Kernis, B A Franklin, K R Sandberg, and P A McCullough
Renal dysfunction and acceleration of coronary disease
Heart,
August 1, 2004;
90(8):
961 - 966.
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. Manhapra
Why is chronic kidney disease the "spoiler" for cardiovascular outcomes: an alternate take from a generalist
J. Am. Coll. Cardiol.,
March 3, 2004;
43(5):
924 - 924.
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. J. Sarnak, A. S. Levey, A. C. Schoolwerth, J. Coresh, B. Culleton, L. L. Hamm, P. A. McCullough, B. L. Kasiske, E. Kelepouris, M. J. Klag, et al.
Kidney Disease as a Risk Factor for Development of Cardiovascular Disease: A Statement From the American Heart Association Councils on Kidney in Cardiovascular Disease, High Blood Pressure Research, Clinical Cardiology, and Epidemiology and Prevention
Hypertension,
November 1, 2003;
42(5):
1050 - 1065.
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. J. Sarnak, A. S. Levey, A. C. Schoolwerth, J. Coresh, B. Culleton, L. L. Hamm, P. A. McCullough, B. L. Kasiske, E. Kelepouris, M. J. Klag, et al.
Kidney Disease as a Risk Factor for Development of Cardiovascular Disease: A Statement From the American Heart Association Councils on Kidney in Cardiovascular Disease, High Blood Pressure Research, Clinical Cardiology, and Epidemiology and Prevention
Circulation,
October 28, 2003;
108(17):
2154 - 2169.
[Full Text]
[PDF]
|
|
|
|
|
|
|
C. A. Herzog
How to Manage the Renal Patient with Coronary Heart Disease: The Agony and the Ecstasy of Opinion-Based Medicine
J. Am. Soc. Nephrol.,
October 1, 2003;
14(10):
2556 - 2572.
[Full Text]
[PDF]
|
|
|
|
|
|
|
Does GPIIb/IIIa Inhibition Improve Survival in ACS Patients with Renal Dysfunction?
Journal Watch Cardiology,
April 25, 2003;
2003(425):
5 - 5.
[Full Text]
|
|
|
|
