Association of Renal Insufficiency with Treatment and Outcomes after Myocardial Infarction in Elderly Patients

  1. Michael G. Shlipak, MD, MPH;
  2. Paul A. Heidenreich, MD, MS;
  3. Haruko Noguchi, PhD;
  4. Glenn M. Chertow, MD, MPH;
  5. Warren S. Browner, MD, MPH; and
  6. Mark B. McClellan, MD, PhD
  1. From San Francisco Veterans Affairs Medical Center and University of California, San Francisco, San Francisco, California; Palo Alto Veterans Affairs Medical Center and Stanford University, Palo Alto, California; and Toyo-Eiwa University, Kanagawa, Japan.

    Abstract

    Background: Patients with end-stage renal disease are known to have decreased survival after myocardial infarction, but the association of less severe renal dysfunction with survival after myocardial infarction is unknown.

    Objectives: To determine how patients with renal insufficiency are treated during hospitalization for myocardial infarction and to determine the association of renal insufficiency with survival after myocardial infarction.

    Design: Cohort study.

    Setting: All nongovernment hospitals in the United States.

    Patients: 130 099 elderly patients with myocardial infarction hospitalized between April 1994 and July 1995.

    Measurements: Patients were categorized according to initial serum creatinine level: no renal insufficiency (creatinine level < 1.5 mg/dL [<132 µmol/L]; n = 82 455), mild renal insufficiency (creatinine level, 1.5 to 2.4 mg/dL [132 to 212 µmol/L]; n = 36 756), or moderate renal insufficiency (creatinine level, 2.5 to 3.9 mg/dL [221 to 345 µmol/L]; n = 10 888). Vital status up to 1 year after discharge was obtained from Social Security records.

    Results: Compared with patients with no renal insufficiency, patients with moderate renal insufficiency were less likely to receive aspirin, β-blockers, thrombolytic therapy, angiography, and angioplasty during hospitalization. One-year mortality was 24% in patients with no renal insufficiency, 46% in patients with mild renal insufficiency, and 66% in patients with moderate renal insufficiency (P < 0.001). After adjustment for patient and treatment characteristics, mild (hazard ratio, 1.68 [95% CI, 1.63 to 1.73]) and moderate (hazard ratio, 2.35 [CI, 2.26 to 2.45]) renal insufficiency were associated with substantially elevated risk for death during the first month of follow-up. This increased mortality risk continued until 6 months after myocardial infarction.

    Conclusions: Renal insufficiency was an independent risk factor for death in elderly patients after myocardial infarction. Targeted interventions may be needed to improve treatment for this high-risk population.

    Article and Author Information

    • Acknowledgments: The authors thank Dr. Eric Vittinghoff for his contributions to this manuscript.

    • Grant Support: By the Centers for Medicare & Medicaid Services (formerly the Health Care Financing Administration) (500-96-P535) and the National Institute on Aging. Dr. Shlipak and Dr. Heidenreich are Research Career Development Awardees from the Health Research and Development Division of the Veterans Administration. Dr. Shlipak is also supported by the National Heart, Lung, and Blood Institute (RO3 HL68099-01).

    • Requests for Single Reprints: Michael G. Shlipak, MD, MPH, General Internal Medicine Section, Veterans Affairs Medical Center (111A1), 4150 Clement Street, San Francisco, CA 94121; e-mail, shlip{at}itsa.ucsf.edu.

    • Current Author Addresses: Dr. Shlipak: General Internal Medicine Section, Veterans Affairs Medical Center (111A1), 4150 Clement Street, San Francisco, CA 94121.

    • Dr. Heidenreich: Veterans Affairs Palo Alto Health Care System, 3801 Miranda Avenue, Palo Alto, CA 94304.

    • Dr. Noguchi: Toyo-Eiwa University, 32 Miho-cho, Midoritau, Yokohama, Kanagawa, Japan 226-0015.

    • Dr. Chertow: Division of Nephrology, University of California, San Francisco, 3333 California Street, Suite 430, San Francisco, CA 94118.

    • Dr. Browner: California Pacific Medical Center, 2340 Clay Street, Room 114, San Francisco, CA 94115.

    • Dr. McClellan: Council of Economics Advisor, The White House, Eisenhower Executive Building, Room 320, Washington, DC 20502.

    • Author Contributions: Conception and design: M.G. Shlipak, W.S. Browner, M.B. McClellan.

    • Analysis and interpretation of the data: M.G. Shlipak, P.A. Heidenreich, H. Noguchi, G.M. Chertow, W.S. Browner.

    • Drafting of the article: M.G. Shlipak, W.S. Browner.

    • Critical revision of the article for important intellectual content: M.G. Shlipak, P.A. Heidenreich, G.M. Chertow, W.S. Browner.

    • Final approval of the article: M.G. Shlipak, P.A. Heidenreich, G.M. Chertow, W.S. Browner, M.B. McClellan.

    • Provision of study materials or patients: M.B. McClellan.

    • Statistical expertise: M.G. Shlipak, H. Noguchi, W.S. Browner, M.B. McClellan.

    • Obtaining of funding: M.B. McClellan.

    • Collection and assembly of data: H. Noguchi.

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    1. Ann Intern Med October 1, 2002 vol. 137 no. 7 555-562
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