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ARTICLE

Acute Myocardial Infarction and Renal Dysfunction: A High-Risk Combination

right arrow R. Scott Wright, MD; Guy S. Reeder, MD; Charles A. Herzog, MD; Robert C. Albright, DO; Brent A. Williams, MS; David L. Dvorak, RN; Wayne L. Miller, MD; Joseph G. Murphy, MD; Stephen L. Kopecky, MD; and Allan S. Jaffe, MD

1 October 2002 | Volume 137 Issue 7 | Pages 563-570

Background: Survival is poor in patients with acute myocardial infarction (MI) who also have severe renal disease. Less is known about the outcome of acute MI in patients with mild to moderate renal insufficiency.

Objective: To compare outcomes after acute MI in patients with varying levels of renal disease and in patients without renal failure.

Design: Retrospective cohort study.

Setting: Academic medical center.

Patients: 3106 total patients admitted with acute MI and end-stage renal disease (n = 44), severe renal insufficiency (creatinine clearance < 0.59 mL/s [<35 mL/min]) (n = 391), moderate renal dysfunction (creatinine clearance ≥ 0.59 mL/s [<35 mL/min] but ≤ 0.84 mL/s [≤ 50 mL/min]) (n = 491), mild chronic renal insufficiency (creatinine clearance > 0.84 mL/s [>50 mL/min] but ≤ 1.25 mL/s [≤ 75 mL/min]) (n = 860), or no renal disease (n = 1320).

Measurements: Clinical characteristics, treatment strategies, and short- and long-term survival were compared after patients were stratified by creatinine clearance.

Results: In-hospital mortality rates were 2% in patients with normal renal function, 6% in those with mild renal failure, 14% in those with moderate renal failure, 21% in those with severe renal failure, and 30% in those with end-stage renal disease (P < 0.001). Compared with patients without renal disease, similar adjusted trends were present for postdischarge death in patients with end-stage renal disease (hazard ratio, 5.4 [95% CI, 3.0 to 9.7]; P < 0.001), severe renal insufficiency (hazard ratio, 1.9 [CI, 1.2 to 3.0]; P = 0.006), moderate renal dysfunction (hazard ratio, 2.2 [CI, 1.5 to 3.3]; P < 0.001), and mild chronic renal insufficiency (hazard ratio, 2.4 [CI, 1.7 to 3.3]; P < 0.001). Patients with renal failure received adjunctive and reperfusion therapies less frequently than those with normal renal function (P < 0.001). Postdischarge death was less likely in patients who received acute reperfusion therapy (odds ratio, 0.7 [CI, 0.6 to 0.9]), aspirin (odds ratio, 0.7 [CI, 0.5 to 0.8]), and ß-blocker therapy (odds ratio, 0.7 [CI, 0.6 to 0.9]).

Conclusion: Patients with renal failure are at increased risk for death after acute MI and receive less aggressive treatment than patients with normal renal function.


Editors' Notes
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Context

  • Advanced renal failure worsens survival after myocardial infarction (MI). The effect of milder renal insufficiency on prognosis is unknown.

Contribution

  • Among 3106 patients with MI, those who also had renal insufficiency received less aggressive therapy than those with normal renal function and were twice as likely to die in the hospital. Even after adjustment for cardiovascular treatment differences, post-MI mortality rates increased as creatinine clearance decreased. Reperfusion therapy, aspirin, and ß-blockers were associated with better survival at all levels of renal function.

Implications

  • Even mild degrees of renal insufficiency confer poor MI outcomes. Clinicians should use reperfusion, aspirin, and ß-blockers aggressively in patients with renal dysfunction.

–The Editors

 

Author and Article Information
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From Mayo Clinic, Rochester, and University of Minnesota Medical School and Hennepin County Medical Center, Minneapolis, Minnesota.

Acknowledgment: The authors thank Amy Oeltjen for excellent administrative work.

Grant Support: By the Mayo Foundation and the Mayo Alliance for Clinical Trials.

Requests for Single Reprints: R. Scott Wright, MD, Division of Cardiology, Mayo Clinic, Mayo Alliance for Clinical Trials, Stabile 5, 150 Third Street SW, Rochester, MN 55902; e-mail, wright.scott{at}mayo.edu.

Potential Financial Conflicts of Interest:Consultancies: C.A. Herzog, A.S. Jaffe; Grants received: R.S. Wright, C.A. Herzog, A.S. Jaffe; Grants pending: A.S. Jaffe.

Current Author Addresses: Drs. Wright and Kopecky and Mr. Dvorak: Division of Cardiology, Mayo Alliance for Clinical Trials, Mayo Clinic, Stabile 5, 150 Third Street SW, Rochester, MN 55902.

Drs. Reeder, Miller, Murphy, and Jaffe: Division of Cardiology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905.

Dr. Herzog: Hennepin County Medical Hospital—Cardiology, 701 Park Avenue, Mail Station 865A, Minneapolis, MN 55415.

Dr. Albright: Division of Nephrology, Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN 55905.

Mr. Williams: Division of Biostatistics, Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN 55905.

Author Contributions: Conception and design: R.S. Wright, C.A. Herzog, S.L. Kopecky.

Analysis and interpretation of the data: R.S. Wright, G.S. Reeder, R.C. Albright, B.A. Williams, W.L. Miller, J.G. Murphy, S.L. Kopecky, A.S. Jaffe.

Drafting of the article: R.S. Wright, G.S. Reeder, R.C. Albright, W.L. Miller, J.G. Murphy, A.S. Jaffe.

Critical revision of the article for important intellectual content: R.S. Wright, G.S. Reeder, C.A. Herzog, R.C. Albright, W.L. Miller, J.G. Murphy, S.L. Kopecky, A.S. Jaffe.

Final approval of the article: R.S. Wright, G.S. Reeder, R.C. Albright, B.A. Williams, W.L. Miller, J.G. Murphy, S.L. Kopecky, A.S. Jaffe.

Provision of study materials or patients: D.L. Dvorak, S.L. Kopecky.

Statistical expertise: B.A. Williams, A.S. Jaffe.

Obtaining of funding: R.S. Wright, S.L. Kopecky.

Collection and assembly of data: B.A. Williams, D.L. Dvorak, A.S. Jaffe.

 

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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]


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NEJMHome page
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]


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CirculationHome page
M. Tonelli, C. Isles, G. C. Curhan, A. Tonkin, M. A. Pfeffer, J. Shepherd, F. M. Sacks, C. Furberg, S. M. Cobbe, J. Simes, et al.
Effect of Pravastatin on Cardiovascular Events in People With Chronic Kidney Disease
Circulation, September 21, 2004; 110(12): 1557 - 1563.
[Abstract] [Full Text] [PDF]


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ANN INTERN MEDHome page
E. C. Keeley and C. L. Grines
Primary Percutaneous Coronary Intervention for Every Patient with ST-Segment Elevation Myocardial Infarction: What Stands in the Way?
Ann Intern Med, August 17, 2004; 141(4): 298 - 304.
[Abstract] [Full Text] [PDF]


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HeartHome page
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]


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J. Am. Soc. Nephrol.Home page
W. M. McClellan, R. D. Langston, and R. Presley
Medicare Patients with Cardiovascular Disease Have a High Prevalence of Chronic Kidney Disease and a High Rate of Progression to End-Stage Renal Disease
J. Am. Soc. Nephrol., July 1, 2004; 15(7): 1912 - 1919.
[Abstract] [Full Text] [PDF]


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Nephrol Dial TransplantHome page
P. J. Blankestijn
Sympathetic hyperactivity in chronic kidney disease
Nephrol. Dial. Transplant., June 1, 2004; 19(6): 1354 - 1357.
[Full Text] [PDF]


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J. Am. Soc. Nephrol.Home page
R. Dikow, L. P. Kihm, M. Zeier, J. Kapitza, J. Tornig, K. Amann, C. Tiefenbacher, and E. Ritz
Increased Infarct Size in Uremic Rats: Reduced Ischemia Tolerance?
J. Am. Soc. Nephrol., June 1, 2004; 15(6): 1530 - 1536.
[Abstract] [Full Text] [PDF]


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J. Am. Soc. Nephrol.Home page
K. Amann, M.-L. Gross, and E. Ritz
Pathophysiology Underlying Accelerated Atherogenesis in Renal Disease: Closing in on the Target
J. Am. Soc. Nephrol., June 1, 2004; 15(6): 1664 - 1666.
[Full Text] [PDF]


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J. Am. Soc. Nephrol.Home page
D. E. Weiner, H. Tighiouart, M. G. Amin, P. C. Stark, B. MacLeod, J. L. Griffith, D. N. Salem, A. S. Levey, and M. J. Sarnak
Chronic Kidney Disease as a Risk Factor for Cardiovascular Disease and All-Cause Mortality: A Pooled Analysis of Community-Based Studies
J. Am. Soc. Nephrol., May 1, 2004; 15(5): 1307 - 1315.
[Abstract] [Full Text] [PDF]


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J. Am. Soc. Nephrol.Home page
E. Ritz and W. M. McClellan
Overview: Increased Cardiovascular Risk in Patients with Minor Renal Dysfunction: An Emerging Issue with Far-Reaching Consequences
J. Am. Soc. Nephrol., March 1, 2004; 15(3): 513 - 516.
[Abstract] [Full Text] [PDF]


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J. Am. Soc. Nephrol.Home page
T. Pinkau, K. F. Hilgers, R. Veelken, and J. F. E. Mann
How Does Minor Renal Dysfunction Influence Cardiovascular Risk and the Management of Cardiovascular Disease?
J. Am. Soc. Nephrol., March 1, 2004; 15(3): 517 - 523.
[Abstract] [Full Text] [PDF]


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J. Am. Soc. Nephrol.Home page
H. A. Koomans, P. J. Blankestijn, and J. A. Joles
Sympathetic Hyperactivity in Chronic Renal Failure: A Wake-up Call
J. Am. Soc. Nephrol., March 1, 2004; 15(3): 524 - 537.
[Abstract] [Full Text] [PDF]


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J. Am. Soc. Nephrol.Home page
A. M. O'Hare, J. Feinglass, G. E. Reiber, R. A. Rodriguez, J. Daley, S. Khuri, W. G. Henderson, and K. L. Johansen
Postoperative Mortality after Nontraumatic Lower Extremity Amputation in Patients with Renal Insufficiency
J. Am. Soc. Nephrol., February 1, 2004; 15(2): 427 - 434.
[Abstract] [Full Text] [PDF]


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ANN INTERN MEDHome page
J. M. Orlowski
Update in Nephrology
Ann Intern Med, January 20, 2004; 140(2): 106 - 111.
[Full Text] [PDF]


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J. Am. Soc. Nephrol.Home page
M. Trovati and F. Cavalot
Optimization of Hypolipidemic and Antiplatelet Treatment in the Diabetic Patient with Renal Disease
J. Am. Soc. Nephrol., January 1, 2004; 15(90010): S12 - 20.
[Abstract] [Full Text]


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CirculationHome page
H. M. Sadeghi, G. W. Stone, C. L. Grines, R. Mehran, S. R. Dixon, A. J. Lansky, M. Fahy, D. A. Cox, E. Garcia, J. E. Tcheng, et al.
Impact of Renal Insufficiency in Patients Undergoing Primary Angioplasty for Acute Myocardial Infarction
Circulation, December 2, 2003; 108(22): 2769 - 2775.
[Abstract] [Full Text] [PDF]


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J Am Coll CardiolHome page
C. M. Gibson, D. S. Pinto, S. A. Murphy, D. A. Morrow, H.-P. Hobbach, S. D. Wiviott, R. P. Giugliano, C. P. Cannon, E. M. Antman, E. Braunwald, et al.
Association of creatinine and creatinine clearance on presentation in acute myocardial infarction with subsequent mortality
J. Am. Coll. Cardiol., November 5, 2003; 42(9): 1535 - 1543.
[Abstract] [Full Text] [PDF]


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J Am Coll CardiolHome page
W. J. French and R. S. Wright
Renal insufficiency and worsened prognosis with STEMI: A call for action
J. Am. Coll. Cardiol., November 5, 2003; 42(9): 1544 - 1546.
[Full Text] [PDF]


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HypertensionHome page
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]


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CirculationHome page
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]


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Nephrol Dial TransplantHome page
R. Dikow and E. Ritz
Cardiovascular complications in the diabetic patient with renal disease: an update in 2003
Nephrol. Dial. Transplant., October 1, 2003; 18(10): 1993 - 1998.
[Full Text] [PDF]


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J. Am. Soc. Nephrol.Home page
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]


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HeartHome page
E Ritz
Minor renal dysfunction: an emerging independent cardiovascular risk factor
Heart, September 1, 2003; 89(9): 963 - 964.
[Full Text] [PDF]


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HeartHome page
J J Santopinto, K A A Fox, R J Goldberg, A Budaj, G Pinero, A Avezum, D Gulba, J Esteban, J M Gore, J Johnson, et al.
Creatinine clearance and adverse hospital outcomes in patients with acute coronary syndromes: findings from the global registry of acute coronary events (GRACE)
Heart, September 1, 2003; 89(9): 1003 - 1008.
[Abstract] [Full Text] [PDF]


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J. Am. Soc. Nephrol.Home page
K. C. Abbott, C. M. Yuan, A. J. Taylor, D. F. Cruess, and L. Y. C. Agodoa
Early Renal Insufficiency and Hospitalized Heart Disease after Renal Transplantation in the Era of Modern Immunosuppression
J. Am. Soc. Nephrol., September 1, 2003; 14(9): 2358 - 2365.
[Abstract] [Full Text] [PDF]


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CirculationHome page
D. A. Morrow and E. Braunwald
Future of Biomarkers in Acute Coronary Syndromes: Moving Toward a Multimarker Strategy
Circulation, July 22, 2003; 108(3): 250 - 252.
[Full Text] [PDF]


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J Am Coll CardiolHome page
C. R. Conti
Management of patients with acute myocardial infarction and end-stage renal disease
J. Am. Coll. Cardiol., July 16, 2003; 42(2): 209 - 210.
[Full Text] [PDF]


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J Am Coll CardiolHome page
J. S. Zebrack, J. L. Anderson, S. Beddhu, B. D. Horne, T. L. Bair, A. Cheung, J. B. Muhlestein, and Intermountain Heart Collaborative Study Group
Do associations with C-Reactive protein and extent of coronary artery disease account for the increased cardiovascular risk of renal insufficiency?
J. Am. Coll. Cardiol., July 2, 2003; 42(1): 57 - 63.
[Abstract] [Full Text] [PDF]


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HeartHome page
I. Malik
JournalScan
Heart, January 1, 2003; 89(1): 119 - 120.
[Full Text] [PDF]


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Journal Watch CardiologyHome page
Learning More About MI Patients with Renal Disease
Journal Watch Cardiology, November 29, 2002; 2002(1129): 5 - 5.
[Full Text]


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JWatch GeneralHome page
Renal Disease Is Associated with Poor Post-MI Prognosis
Journal Watch (General), November 1, 2002; 2002(1101): 3 - 3.
[Full Text]


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ANN INTERN MEDHome page
R. R. Townsend
Cardiac Mortality in Chronic Kidney Disease: A Clearer Perspective
Ann Intern Med, October 1, 2002; 137(7): 615 - 616.
[Full Text] [PDF]




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