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J Am Coll Cardiol, 2003; 42:201-208, doi:10.1016/S0735-1097(03)00572-2 © 2003 by the American College of Cardiology Foundation |
,*
||¶
* Section of Cardiovascular Medicine, Department of Medicine, Minneapolis, Minnesota, USA
Division of Epidemiology, University of Minnesota, Minneapolis, Minnesota, USA
Section of Cardiovascular Medicine, Department of Medicine, New Haven, Connecticut, USA
Section of Health Policy and Administration, Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, Connecticut, USA
|| Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut, USA
¶ Qualidigm, Middletown, Connecticut, USA
Manuscript received October 31, 2002; revised manuscript received February 7, 2003, accepted February 13, 2003.
* Reprint requests and correspondence: Dr. Alan K. Berger, Division of Epidemiology, University of Minnesota, 1300 South Second Street, Suite 300, Minneapolis, Minnesota 55454, USA.
berger1217{at}aol.com
OBJECTIVES: We sought to examine the use and impact of standard medical therapies in patients with end-stage renal disease (ESRD) faced with an acute myocardial infarction (AMI).
BACKGROUND: The poor prognosis of patients in this high-risk population has become increasingly well recognized.
METHODS: Using the ESRD database and the Cooperative Cardiovascular Project (CCP) database, we identified AMI patients who were receiving either peritoneal dialysis or hemodialysis before admission. The early administration of aspirin and beta-blockers was compared between ESRD and non-ESRD patients and the effect of these therapies on 30-day mortality was evaluated with logistic regression models.
RESULTS: The cohort consisted of 145,740 patients without ESRD and 1,025 patients with ESRD. Aspirin (67.0% vs. 82.4%, p < 0.001), beta-blockers (43.2% vs. 50.8%, p < 0.001), and angiotensin-converting enzyme (ACE) inhibitors (38.5% vs. 60.3%, p < 0.001) were less likely to be administered to ESRD patients than to non-ESRD patients. The benefit of these therapies on 30-day mortality was similar among ESRD patients (aspirin: relative risk [RR] 0.64; 95% confidence interval [CI] 0.50 to 0.80; beta-blocker: RR 0.78; 95% CI 0.60 to 0.99; ACE inhibitor: RR 0.58; 95% CI 0.42 to 0.77) and non-ESRD patients (aspirin: RR 0.57; 95% CI 0.55 to 0.58; beta-blocker: RR 0.70; 95% CI 0.68 to 0.72; ACE inhibitor: RR 0.64; 95% CI 0.63 to 0.66).
CONCLUSIONS: End-stage renal disease patients are far less likely than non-ESRD patients to be treated with aspirin, beta-blockers, and ACE inhibitors during an admission for AMI. The lower rates of usage for these medications, particularly aspirin, may contribute to the increased 30-day mortality. These findings demonstrate a marked opportunity to improve care in this population.
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