Aspirin, beta-blocker, and angiotensin-converting enzyme inhibitor therapy in patients with end-stage renal disease and an acute myocardial infarction
Alan K. Berger, MD* ,*,
Sue Duval, PhD and
Harlan M. Krumholz, MD, FACC  ||¶
* 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
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Figure 1 Aspirin, beta-blockers, and angiotensin-converting enzyme (ACE) inhibitors were less likely to be provided to patients with end-stage renal disease (ESRD) than those without ESRD. In an analysis of patients considered ideal for the individual therapies, the overall administration rates were higher, but patients with ESRD still remained less likely to receive the therapy than those without ESRD. The p value for each comparison between ESRD and non-ESRD patients was <0.001.
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Figure 2 Thirty-day mortality was dramatically reduced by the administration of aspirin (ASA) during the hospitalization. The p value for each mortality comparison between patients taking ASA and those not receiving ASA was <0.001. The relative risk reduction in mortality was significantly greater for patients without end-stage renal disease (ESRD) than for those with ESRD in the entire cohort (63% vs. 50%, p = 0.01). After restricting the cohort to patients ideal for ASA, the reduction in mortality provided by aspirin therapy remained greater in the non-ESRD group, although it was no longer statistically significant (65% vs. 53%, p = 0.10).
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Figure 3 Thirty-day mortality was dramatically reduced by the administration of beta-blockers during the hospitalization. The p value for each mortality comparison between patients taking beta-blockers and those not receiving beta-blockers was <0.001. The relative reduction in mortality was significantly greater for patients without end-stage renal disease (ESRD) than for those with ESRD (56% vs. 40%, p = 0.02). After restricting the cohort to patients ideal for beta-blockers, the relative reduction in mortality provided by beta-blocker therapy was still significantly greater in the non-ESRD group (53% vs. 34%, p = 0.03).
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Figure 4 Thirty-day mortality was reduced by the administration of angiotensin-converting enzyme (ACE) inhibitors during the hospitalization. The p value for each mortality comparison between patients taking ACE inhibitors and those not receiving them was <0.001. The relative reduction in mortality was significantly greater for patients with end-stage renal disease (ESRD) than for those without ESRD (48% vs. 27%, p = 0.02). After restricting the cohort to patients ideal for ACE inhibitors, the relative reduction in mortality provided by ACE inhibitor therapy was still significantly greater in the ESRD group (47% vs. 33%, p = 0.43).
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Figure 5 Effects are illustrated for the entire cohort as well as patients deemed ideal for each of the therapies. The mortality models showed good discrimination; the area under the receiver operating characteristic curve ranged from 0.75 to 0.78 for the 30-day mortality models. In assessing the goodness of fit in both models, there was less than a 10% difference between observed and expected mortality within each decile of probability for each model. The Pearson coefficient was <0.30 between the treatment variables and all other covariates. Triangles = patients with end-stage renal disease (ESRD); circles = patients without ESRD. ACE = angiotensin-converting enzyme; ASA = aspirin; BB = beta-blocker.
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