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Reperfusion strategy and mortality in ST-elevation myocardial infarction among patients with and without impaired
Mark Y Chan1, Richard C Becker, Ling-Ling Sim
1National University Heart Centre, Singapore, Singapore. chanyymark@gmail.com
Insights
Primary percutaneous coronary intervention (PCI) improves survival for ST-segment elevation myocardial infarction (STEMI) patients with normal kidney function. However, PCI did not show a significant survival benefit over fibrinolytic therapy in STEMI patients with impaired renal function.
Area of Science:
- Cardiology
- Nephrology
- Interventional Cardiology
Background:
- Primary percutaneous coronary intervention (PCI) is superior to fibrinolytic therapy for ST-segment elevation myocardial infarction (STEMI) in patients with normal renal function.
- The benefit of primary PCI versus fibrinolysis in STEMI patients with impaired renal function remains uncertain.
Purpose of the Study:
- To investigate the impact of reperfusion strategy on 30-day mortality in STEMI patients with normal versus impaired renal function.
- To compare the efficacy of primary PCI and fibrinolytic therapy based on renal function.
Main Methods:
- A study of 1672 STEMI patients admitted within 12 hours of symptom onset between 2000-2002.
- Patients received either primary PCI or fibrinolytic therapy. Glomerular filtration rate (GFR) was determined using the Modification of Diet in Renal Disease equation.
- The impact of reperfusion strategy on 30-day mortality was analyzed for patients with GFR ≥60 mL/min/1.73 m² (normal) and GFR <60 mL/min/1.73 m² (impaired).
Main Results:
- Primary PCI was associated with significantly lower 30-day mortality in patients with normal renal function (OR, 0.41; 95% CI, 0.19-0.89).
- In patients with impaired renal function, primary PCI did not show a significant reduction in 30-day mortality compared to fibrinolysis (OR, 0.70; 95% CI, 0.31-1.60).
- Unadjusted 30-day mortality rates were higher in the impaired renal function group (29.4% for fibrinolysis vs. 17.9% for PCI) compared to the normal renal function group (5.4% for fibrinolysis vs. 3.1% for PCI).
Conclusions:
- Primary PCI improves 30-day survival in STEMI patients with normal renal function.
- The survival benefit of primary PCI over fibrinolysis was not demonstrated in STEMI patients with impaired renal function.
- Randomized trials are necessary to determine the relative efficacy of reperfusion strategies in STEMI patients with impaired renal function.
Introduction:
Several randomised controlled trials have demonstrated better outcomes with primary percutaneous coronary intervention (PCI) over fibrinolytic therapy in the treatment of patients with ST-segment elevation myocardial infarction (STEMI) and normal renal function. Whether this benefit extends to patients with impaired renal function is uncertain.
Materials And Methods:
We studied 1672 patients with STEMI within 12 hours of symptom onset who were admitted to 2 major public hospitals in Singapore from 2000 to 2002. All patients received either upfront fibrinolytic or PCI as determined by the attending cardiologist. Serum creatinine was measured on admission and the glomerular filtration rate (GFR) was determined using the Modification of Diet in Renal Disease equation. The impact of reperfusion strategy on 30-ay mortality was then determined for patients with GFR > or =60 mL min-(1) 1.73 m-(2) and GFR <60 mL min-(1) 1.73 m-(2).
Results:
The mean age was 56 +/- 12 years (85% male) and mean GFR was 81 +/- 30 mL min-(1) 1.73 m-(2). Unadjusted 30-day mortality rates for fibrinolytic-treated vs primary PCI-treated patients were 29.4% vs 17.9%, P <0.05, in the impaired renal function group and 5.4% vs 3.1%, P <0.05, in the normal renal function group. After adjusting for covariates, primary PCI was associated with a significantly lower mortality in the normal renal function group [odds ratio (OR), 0.41; 95% confidence interval (CI), 0.19-0.89] but not in the impaired renal function group [OR, 0.70; 95% CI, 0.31-1.60].
Conclusions:
Primary PCI was associated with improved 30-day survival among patients with normal renal function but not among those with impaired renal function. Randomised trials are needed to study the relative efficacy of both reperfusion strategies in patients with impaired renal function.
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