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Postconditioning with Lactate-enriched Blood for Cardioprotection in ST-segment Elevation Myocardial Infarction
Published on: May 28, 2019
Reperfusion in patients with renal dysfunction after presentation with ST-segment elevation or left bundle branch
Caroline Medi1, Gilles Montalescot, Andrzej Budaj
1Coronary Care Unit, Concord Hospital, Sydney, Australia.
Insights
Reperfusion strategies offer limited benefit for ST-segment elevation myocardial infarction with left bundle branch block in patients with renal dysfunction. Primary PCI may reduce mortality in moderate renal dysfunction, but outcomes remain poor in severe cases.
Area of Science:
- Cardiology
- Nephrology
- Acute Coronary Syndromes
Background:
- Limited data exist on treating ST-segment elevation myocardial infarction (STEMI) with left bundle branch block (LBBB) in patients with renal dysfunction.
- Renal dysfunction is a significant factor influencing outcomes in acute myocardial infarction.
Purpose of the Study:
- To investigate the comparative effectiveness of reperfusion strategies (fibrinolysis, primary percutaneous coronary intervention [PCI]) in patients with STEMI and LBBB, stratified by renal function.
- To assess the impact of renal dysfunction on mortality and treatment outcomes in this patient population.
Main Methods:
- Analysis of 12,532 patients from the Global Registry of Acute Coronary Events (GRACE) database.
- Patients with STEMI and LBBB were categorized based on renal function (glomerular filtration rate [GFR]) and reperfusion strategy received (fibrinolysis, primary PCI, or neither).
Main Results:
- Hospital mortality increased significantly as renal function declined (p < 0.001).
- Primary PCI showed a mortality benefit in normal renal function but not in moderate or severe renal dysfunction.
- Fibrinolysis was not associated with mortality reduction and was linked to increased mortality in moderate renal dysfunction.
- Primary PCI increased bleeding, while fibrinolysis increased stroke risk. In survivors with moderate renal dysfunction, primary PCI improved mortality; however, outcomes were poor in severe dysfunction regardless of treatment.
Conclusions:
- High mortality rates and lower reperfusion rates are observed in patients with STEMI/LBBB and renal dysfunction.
- Primary PCI demonstrates a mortality reduction in moderate renal dysfunction at 6 months.
- Severe renal dysfunction portends a poor prognosis despite reperfusion therapy.
Objectives:
We investigated the relative benefit of reperfusion strategies in renal dysfunction and ST-segment elevation/left bundle branch block (STE/LBBB).
Background:
Few data are available informing the treatment of STE myocardial infarction in the presence of renal dysfunction.
Methods:
Patients (N = 12,532) from the GRACE (Global Registry of Acute Coronary Events) presenting with STE/LBBB were stratified by renal function and receipt of fibrinolysis, primary percutaneous coronary intervention (PCI), or neither.
Results:
As renal function declined, hospital mortality increased and reperfusion decreased (both p < 0.001). Compared with no reperfusion, primary PCI was associated with lower hospital mortality in patients with normal renal function (1.9% vs. 3.7%, p = 0.001, adjusted) but no reduction in those with renal dysfunction (14% vs. 15% for glomerular filtration rate [GFR] 30 to 59 ml/min/1.73 m(2); 29% vs. 32% for GFR <30 ml/min/1.73 m(2)). Fibrinolysis was not associated with lower hospital mortality for normal (3.1% vs. 3.7%, p = NS) or low renal function (32% vs. 32%, p = NS) and with higher mortality with moderate renal dysfunction (adjusted odds ratio: 1.35, 95% confidence interval: 1.01 to 1.80). Primary PCI was associated with increased hospital bleeding and fibrinolysis with increased stroke in all patients. Among hospital survivors, primary PCI, but not fibrinolysis, was associated with lower mortality for moderate dysfunction. Both reperfusion strategies were associated with higher mortality for severe dysfunction.
Conclusions:
In STE/LBBB and renal dysfunction, mortality rates are high and reperfusion rates are lower. In moderate renal dysfunction, primary PCI is associated with mortality reduction at 6 months. Outcomes remain poor with severe renal dysfunction, despite receipt of reperfusion therapy.
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