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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
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
Context
Contribution
Implications
–The Editors
Author and Article Information
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. ARTICLE
Acute Myocardial Infarction and Renal Dysfunction: A High-Risk Combination
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).
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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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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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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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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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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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J. M. Orlowski Update in Nephrology Ann Intern Med, January 20, 2004; 140(2): 106 - 111. [Full Text] [PDF]
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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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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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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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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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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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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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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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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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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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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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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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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. 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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I. Malik JournalScan Heart, January 1, 2003; 89(1): 119 - 120. [Full Text] [PDF]
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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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