Double jeopardy of renal insufficiency and anemia in patients undergoing percutaneous coronary interventions

Anemia and renal insufficiency impart an increased risk of mortality in patients with congestive heart failure. There is a paucity of data on the mortality hazard associated with anemia and renal insufficiency in patients undergoing percutaneous coronary intervention in the setting of contemporary practice. We analyzed the short- and long-term outcomes among patients enrolled in EPIC, EPILOG and EPISTENT trials according to degree of kidney dysfunction (glomerular filtration rate [GFR] <60, 60 to 75, and >75 ml/min/1.73 m2) and by hematocrit (<35, 35 to 39 and 40). GFR was calculated as GFR = 186 x (serum creatinine-1.154) x (age-0.203) x 1.212 (if black) or x 0.742 (if female). There were 20 deaths (3.2%) among 638 patients with a hematocrit of <35, 41 deaths among 2,066 patients (2.0%) with a hematocrit of 35 to 39, and 43 deaths in 3,618 patients (1.2%) with a hematocrit >40 at 6 months (p <0.001). Similarly, a significant increase in mortality was seen with lower GFR [33 of 1,168 (2.9%) at GFR <60, 33 of 1,766 (1.9%) at GFR 60 to 75 and 37 of 3,317 (1.1%) at GFR >75, p <0.001)]. Further, GFR and anemia independently and in combination predicted mortality at 3 years. Thus, renal insufficiency and anemia are significant independent and additive predictors of short- and long-term complications in patients undergoing percutaneous coronary intervention.     

The impact of renal insufficiency on clinical outcomes in patients undergoing percutaneous coronary interventions

OBJECTIVES: We sought to determine the effect of varying degrees of renal insufficiency on death and cardiac events during and after a percutaneous coronary intervention (PCI). BACKGROUND: Patients with end-stage renal disease have a high mortality from coronary artery disease. Little is known about the impact of mild and moderate renal insufficiency on clinical outcomes after PCI. METHODS: Cardiac mortality and all-cause mortality were determined for 5,327 patients undergoing PCI from January 1, 1994, to August 31, 1999, at the Mayo Clinic, based on the estimated creatinine clearance or whether the patient was on dialysis. RESULTS: In-hospital mortality was significantly associated with renal insufficiency (p = 0.001). Even after successful PCI, one-year mortality was 1.5% when the creatinine clearance was > or =70 ml/min (n = 2,558), 3.6% when it was 50 to 69 ml/min (n = 1,458), 7.8% when it was 30 to 49 ml/min (n = 828) and 18.3% when it was < 30 ml/min (n = 141). The 18.3% mortality rate for the group with < 30 ml/min creatinine clearance was similar to the 19.9% mortality rate in patients on dialysis (n = 46). The mortality risk was largely independent of all other factors. CONCLUSIONS: Renal insufficiency is a strong predictor of death and subsequent cardiac events in a dose-dependent fashion during and after PCI. Patients with renal insufficiency have more baseline cardiovascular risk factors, but renal insufficiency is associated with an increased risk of death and other adverse cardiovascular events, independent of all other measured variables.     

Association of renal insufficiency with in-hospital mortality among Japanese patients with acute myocardial infarction undergoing percutaneous coronary interventions

It is not yet clear whether a difference in in-hospital morality between patients with and without renal insufficiency undergoing percutaneous coronary intervention (PCI) exists. Therefore, the aim of the present study was to investigate if such as association exists in Japan. Data from the Tokai Acute Myocardial Infarction Study II were used. This was a prospective study of all 3274 patients admitted with acute myocardial infarction (AMI) to the 15 participating hospitals from 2001 to 2003. We abstracted the baseline and procedural characteristics as well as in-hospital mortality from detailed chart reviews. Patients were stratified into 2 groups according to the estimated creatinine clearance on admission. The creatinine clearance values were available in 2116, 107 of whom had renal insufficiency. The patients with renal insufficiency were more likely to be older, female, not independent in their daily activities, have lower body mass index and higher heart rate values on admission, lower prevalences of hypercholesterolemia and peptic ulcers, greater prevalences of diabetes, angina, previous heart failure, previous renal failure, previous cerebrovascular disease, aortic aneurysm, worse clinical course such as bleeding, and a multivessel coronary disease. Vasopressors, an intra-aortic balloon pump, and mechanical ventilation were frequently used in the patients with renal insufficiency, while thrombolytics were used less frequently. The patients with renal insufficiency had a higher in-hospital mortality rate than those without. Multivariate analysis identified renal insufficiency as an independent predictor of in-hospital death. The results suggest that renal insufficiency is an independent predictor of in-hospital death among AMI patients undergoing PCI.     

Long-term mortality benefit with abciximab in patients undergoing percutaneous coronary intervention

OBJECTIVES

The goal of this study was to test: 1) if platelet glycoprotein IIb/IIIa (GP IIb/IIIa) blockade with abciximab bolus plus 12-h infusion reduces mortality after percutaneous coronary intervention (PCI); 2) if prevention of early myocardial infarction (MI) after PCI is a mechanism for reducing mortality; and 3) for risk factors for mortality after PCI.

BACKGROUND

Studies of PCI suggest that MI after intervention is predictive of mortality. Abciximab, a platelet GP IIb/IIIa receptor inhibitor, has consistently reduced the incidence of MI among PCI patients in several trials. The presumed mechanism is prevention of platelet thrombus associated with vessel wall injury and downstream embolization into the microcirculation.

METHODS

In eight trials, 5,154 patients were randomized to a regimen comprising conventional therapy plus a bolus of abciximab within 1 h before PCI followed by a 12-h infusion; 4,136 controls were randomized to conventional therapy alone. Patient follow-up from six months to three years was available. Survival differences are examined using proportional hazards regression and survival curves.

RESULTS

A hazard ratio of 0.71 (95% confidence interval 0.57 to 0.89; P = 0.003) suggests a mortality benefit with abciximab. The absolute reduction in mortality was estimated to be 0.5% through 30 days, 0.7% through six months, 0.9% through one year and 1.8% through three years. Early MI explained 18% of the observed mortality benefit at one year. Multivariate regression suggests that patients with advanced cardiovascular disease may derive the greatest mortality benefit from abciximab.

CONCLUSIONS

The evidence from 9,290 randomized PCI patients shows a mortality benefit provided by abciximab bolus plus 12-h infusion.     

Anxiety in patients undergoing percutaneous coronary interventions

Objective

Many patients undergoing percutaneous coronary intervention (PCI) experience symptoms of anxiety; however, it is unclear whether anxiety is an issue in the early recovery period and the types of factors and patient concerns that are associated. This study set out to determine the patterns of anxiety and concerns experienced by patients undergoing PCI and the contributing factors in the time period surrounding PCI.

Methods

A convenience sample of patients undergoing PCI (n = 100) were recruited, and anxiety was measured using the Spielberger State Anxiety Inventory immediately before the PCI, the first day postprocedure, and 1 week postdischarge. Patients were also asked to identify their most important concern at each time. Independent predictors of anxiety at each time were determined by multiple regression analysis.

Results

Anxiety scores were highest pre-procedure (35.72, standard deviation [SD] 11.75), decreasing significantly by the postprocedure time (31.8, SD 10.20) and further still by the postdischarge time (28.79, SD 9.78) (repeated-measures analysis of variance: F = 39.72, P < .001). The concerns patients identified most frequently as most important were the outcome of the PCI and the possibility of surgery pre-procedure (37%) and postdischarge (31%), and the limitations and discomfort arising from the access site wound and immobility postprocedure (25%). The predictor of anxiety at the pre-procedure time was taking medication for anxiety and depression (b = 7.12). The predictors of anxiety at the postprocedure time were undergoing first-time PCI (b = 4.44), experiencing chest pain (b = 7.63), and experiencing pre-procedural anxiety (b = .49). The predictors of anxiety at the postdischarge time were reporting their most important concern as the future progression of CAD (b = 7.51) and pre-procedural anxiety (b = .37).

Conclusion

Symptoms of anxiety were common, particularly before PCI. These symptoms are important to detect and treat because pre-procedural anxiety is predictive of anxiety on subsequent occasions. Patients who have had chest pain or their first PCI should be targeted for intervention during the early recovery period after PCI, and information on CAD should be provided postdischarge.     

Glycoprotein IIb/IIIa inhibitors in patients with renal insufficiency undergoing percutaneous coronary intervention

Glycoprotein IIb/IIIa receptor antagonists (GPRAs) are agents that block the final common pathway in platelet aggregation by inhibiting the binding of fibrinogen to the GPR on the surface of activated platelets, which then decreases crosslinking of platelets and thus platelet aggregation. Treatment guidelines recommend that patients undergoing percutaneous coronary intervention (PCI) be treated with a regimen of antithrombotic therapy that includes a GPRA to decrease the risk of ischemic events. Three GPRAs are currently available for use in the United States: abciximab (ReoPro), tirofiban (Aggrastat), and eptifibatide (Integrilin). Tirofiban and eptifibatide are renally cleared and thus must have dosage adjustment if used in patients with renal insufficiency (RI). Abciximab is not renally eliminated and does not require dosage adjustment in RI. Bleeding has been associated with worse outcomes after PCI and is the major risk associated with the use of GPRAs. Approximately 30% of PCI patients have RI, and RI increases the risk of bleeding. Unfortunately, clinical trials of GPRAs in PCI have excluded patients with moderate to severe RI. Several subgroup analyses and single center cohort analyses have analyzed the safety of GPRAs in patients with RI. These analyses have confirmed that bleeding is increased in patients with RI and in patients receiving GPRAs; however, the risk does not seem to be magnified by the combination of RI and GPRA therapy. These results are limited by the small study sample sizes and the varying definitions of RI and bleeding. An important finding of recent studies is that doses of eptifibatide and tirofiban are not always adjusted for RI, resulting in an increased risk of bleeding. The presence of RI in patients undergoing PCI should not preclude the use of GPRAs; however, the dose should be adjusted (eptifibatide and tirofiban) if pertinent and bleeding should be closely monitored.     

Clinical outcome following percutaneous coronary interventions in patients with chronic renal failure.

The clinical outcome of patients with chronic renal failure (CRF) who undergo percutaneous coronary intervention (PCI) has not been systematically evaluated in a large cohort of patients. We retrospectively analyzed the in-hospital and 1-year clinical outcomes of 10,076 consecutive patients who underwent PCI between January 1994 and December 1997. A total of 95 patients (0.9%) had end-stage renal disease (ESRD) on dialysis, 786 patients (7.8%) had CRF, and 9,125 patients (90.6%) had normal renal function. Despite an angiographic success rate of 97% in all three groups, in-hospital mortality was significantly higher among patients with renal disease, whether they were on dialysis or not, when compared to patients without renal dysfunction (6.8% vs. 4.2% vs. 0.9%; P < 0.0001). At 1-year follow-up, mortality rate was 48.8% for ESRD, 25.7% for patients with CRF, and 5.5%, for patients without renal dysfunction (P < 0.0001). By multivariate analysis, high left ventricular ejection fraction and creatinine clearance were associated with decreased late mortality (OR = 0.84 and 0.95; P < 0.0001), whereas ESRD (OR = 3.65; P = 0.0002), non-Q-wave myocardial infarction (OR = 2.21; P < 0.0001), diabetes mellitus (OR = 1.99; P < 0.0001), and CRF (OR = 1.74; P = 0.003) were independent correlates of increased late mortality. Therefore, PCI in patients with impaired renal function, whether on dialysis or not, is associated with poor in-hospital and 1-year survival.     

Comparison of abciximab with "high-dose" tirofiban in patients undergoing percutaneous coronary intervention

BACKGROUND: The TARGET study has been criticised for sub-optimal platelet inhibition with tirofiban. We aimed to compare a high-dose bolus regimen of tirofiban (hd-tirofiban) to standard dose of abciximab for patients undergoing percutaneous coronary intervention (PCI). METHODS: We assessed consecutive patients who received either hd-tirofiban (25 mcg/kg bolus followed by 0.15 mcg/kg/min infusion for 18 h) or standard dose abciximab. In-hospital and 6-month outcomes were obtained in all cases. RESULTS: Over an 18-month period, 109 patients who received hd-tirofiban were compared with 110 patients who received abciximab. Both hd-tirofiban and abciximab groups had acute coronary syndromes in 86% and 80% and diabetes in 10% and 13% respectively. Most patients had coronary stent implantation (96% vs. 98%). Thrombocytopenia (platelet count< 100,000) developed in 0.9% of patients receiving hd-tirofiban and 2% of patients receiving abciximab (p = 0.566). Bleeding requiring transfusion occurred in 7.3% and 3% of patients respectively (p = 0.118). Peri-procedural troponin rise was 0.9% in patients receiving hd-tirofiban and 5.5% in patients receiving abciximab (p = 0.07). MACE (Myocardial infarction, Stroke, Revascularisation and Death) at 6 months was 23% in the hd-tirofiban group and 20% in the abciximab group (p = 0.711). The pharmaceutical costs were AUD 322 for hd-tirofiban (one ampoule) and AUD 1,350 for abciximab (3 ampoules). CONCLUSION: There was a small increase in bleeding requiring transfusion and a lower rate of peri-procedural troponin rise in the hd-tirofiban group however, the overall 6-month MACE rates were similar in both groups. There was a considerable cost-saving with the use of hd-tirofiban. A prospective randomised trial of hd-tirofiban vs. abciximab is warranted.     

Haemoglobin-related mortality in patients undergoing percutaneous coronary interventions.

AIMS: It has recently been proposed that anaemia is an independent risk factor for development of cardiovascular disease in the general population. The impact of anaemia on long-term survival of patients with manifest coronary heart disease (CHD) has not been assessed so far. In this study, we examined the influence of haemoglobin concentrations on the outcome after percutaneous coronary interventions (PCI). METHODS AND RESULTS: In a retrospective cohort study, we analysed in-hospital and long-term mortality in all male patients admitted to our institution for elective PCI from 1998 to 1999. In 689 cases, complete follow-up information could be obtained (98.4%). Depending on their baseline haemoglobin, patients were divided in quintiles. In all subgroups, angiographic success after PCI (90-94%) was comparably high and in-hospital mortality was low (0-0.7%). During follow-up (median 697 days), patients in the lowest haemoglobin quintile (相似文献   

慢性肾功能不全患者经皮冠状动脉介入治疗的疗效观察

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Aspirin desensitization in patients undergoing percutaneous coronary interventions with stent implantation

The aim of this study was to test the safety and efficacy of a novel rapid desensitization procedure in patients with acetylsalicylic acid sensitivity and coronary artery disease who underwent cardiac catheterization and coronary stent implantation. Aspirin plays a key role in the secondary prevention of atherothrombotic events and thrombotic complications after stent implantation. Aspirin sensitivity not only limits patients to benefit from the long-term use of this antiplatelet agent but is also often an impediment to the implantation of bare-metal and drug-eluting coronary stents. Of 1,014 patients admitted for cardiac catheterization, 26 (2.6%) had histories of aspirin sensitivity characterized by respiratory or cutaneous manifestations (none had previous anaphylactic reactions); of these, 61.5% presented with acute coronary syndromes. All patients underwent a novel rapid desensitization challenge procedure before cardiac catheterization, except for those presenting with ST-elevation myocardial infarctions (n = 4), who underwent desensitization before hospital discharge. The desensitization procedure involved the oral administration of 6 sequential doses of aspirin (1, 5, 10, 20, 40, and 100 mg) over 5.5 hours without the use of corticosteroids or antihistamines. Patients were followed for 1 year to assess compliance with aspirin therapy and adverse events. The desensitization procedure was successful in 23 patients (88.5%). Percutaneous coronary intervention with stent implantation was performed in 22 patients (1.8 stents/patient). Drug-eluting stents were used in all patients except those who underwent primary percutaneous coronary intervention (n = 3), in whom bare-metal stents were used. Multivessel percutaneous coronary intervention was performed in 30.7% of patients. At follow-up, all patients who successfully responded to the desensitization procedure tolerated aspirin well, without developing allergic reactions. Aspirin was withdrawn in only 1 patient, because of a peptic ulcer. In conclusion, rapid desensitization is safe and highly effective in patients with aspirin sensitivity and coronary artery disease who undergo coronary stent implantation, including those who receive drug-eluting stents.     

Impact of chronic renal insufficiency on clinical outcomes in patients undergoing percutaneous coronary intervention with sirolimus-eluting stents versus bare metal stents

Patients with chronic renal insufficiency (CRI) have higher rates of target vessel revascularization and mortality. The efficacy of sirolimus-eluting stents (SESs) to improve the clinical outcomes of these patients is unknown. We investigated the effect of SESs versus bare metal stents (BMSs) on outcomes of patients with CRI. Among the first 1,522 patients treated with SESs, 76 were identified with CRI and 1,446 without CRI. In-hospital and 1- and 6-month clinical outcomes were compared with 153 patients with CRI who were treated with BMSs. Patients with CRI were older, hypertensive, and diabetic and had more previous myocardial infarctions, revascularizations, and decreased left ventricular function (p <0.001). These patients had more saphenous vein graft lesions, were treated with more debulking devices (p <0.003), and had higher rates of in-hospital complications and mortality (p <0.001) compared with those without CRI. Among patients with CRI, treatment with SESs did not affect clinical outcomes at 1 month and was associated with lower incidences of target vessel revascularization (7.1% vs 22.1%, p = 0.02) at 6 months but did not affect other events, including mortality (16.7% vs 14.7% p = 0.89), compared with BMSs. However, treatment with SESs in patients without CRI was associated with significantly lower rates of major adverse cardiac events at 6 months (p <0.001). In conclusion, percutaneous coronary intervention with SESs in patients with CRI is associated with low rates of repeat revascularization compared with BMSs but has no effect on mortality at 6 months.     

Outcomes of tubeless percutaneous nephrolithotomy in patients with chronic renal insufficiency

We evaluated the outcomes of percutaneous nephrolithotomy in patients with chronic renal insufficiency. A total of 60 patients with a creatinine level greater than 1.5 mg/dL who underwent PCNL were included. Serum creatinine level, as a kidney function index, was assessed before and after the operation. The mean calculus size was 31.13 ± 9.38 mm. The mean pre-operative and 2-week postoperative serum creatinine levels were 2.43 ± 0.75 mg/dL and 2.08 ± 0.78 mg/dL, respectively. There was a significant difference between the pre-operative and postoperative creatinine levels in all postoperative days (days 1, 2, and 14). Fifty of the 60 patients (83.3%) were stone free. Ten patients (16.6%) developed postoperative fever. We can conclude that percutaneous nephrolithotomy seems to be a safe and effective therapeutic option for kidney calculi in patients with chronic kidney disease.