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Does renal function affect the efficacy or safety of a pharmacoinvasive strategy in patients with ST-elevation
Juan J Russo1, Shaun G Goodman2, Warren J Cantor3
1Terrence Donnelly Heart Centre, Michael's Hospital, Toronto, Ontario; University of Toronto, Toronto, Ontario; University of Ottawa Heart Institute, Ottawa, Ontario.
Insights
Pharmacoinvasive strategy is safe and effective for ST-elevation myocardial infarction (STEMI) patients with renal impairment. Renal dysfunction increases adverse event rates but does not alter treatment efficacy.
Area of Science:
- Cardiology
- Nephrology
- Clinical Trials
Background:
- Pharmacoinvasive strategy efficacy and safety post-fibrinolysis for ST-elevation myocardial infarction (STEMI) concerning renal function remain unclear.
- Renal impairment is a common comorbidity in STEMI patients, potentially affecting treatment outcomes.
Purpose of the Study:
- To evaluate the efficacy and safety of a pharmacoinvasive strategy compared to standard treatment after fibrinolysis for STEMI.
- To assess the impact of renal function, stratified by estimated glomerular filtration rate (eGFR), on treatment outcomes.
Main Methods:
- Analysis of patient-level data from 4 randomized controlled trials involving STEMI patients treated with fibrinolysis.
- Stratification of patients into two groups based on eGFR: <60 mL/min/1.73 m² (renal dysfunction) and ≥60 mL/min/1.73 m².
- Primary outcome: composite of death or reinfarction at 30 days. Secondary outcomes included 1-year death/reinfarction and in-hospital major bleeding.
Main Results:
- Patients with eGFR <60 mL/min/1.73 m² were older, had higher risk scores, and experienced higher rates of the primary outcome (11.8% vs 5.3%; P<.001).
- The pharmacoinvasive strategy demonstrated consistent efficacy and safety across both renal function groups, with no significant heterogeneity in treatment effect on the primary outcome or 1-year outcomes.
- Renal dysfunction was associated with increased in-hospital major bleeding (7.7% vs 4.3%; P=.004), but bleeding event rates did not differ between treatment arms in relation to eGFR.
Conclusions:
- Renal impairment is linked to worse outcomes in STEMI patients receiving fibrinolysis.
- The pharmacoinvasive strategy maintains its safety and efficacy profile even in STEMI patients presenting with renal impairment.
Background:
The efficacy and safety of pharmacoinvasive strategy following fibrinolysis for ST-elevation myocardial infarction (STEMI) in relation to renal function have not been established.
Methods:
Using patient-level data from 4 randomized controlled trials, we examined the efficacy and safety of pharmacoinvasive versus standard treatment after fibrinolysis for STEMI. Patients were stratified based on the estimated glomerular filtration rate (eGFR) on presentation (<60 mL/min/1.73 m2 vs ≥60 mL/min/1.73 m2). The primary outcome was the composite of death or reinfarction at 30 days.
Results:
Of 2,029 patients, 457 (23%) had an eGFR<60 mL/min/1.73 m2. Patients with eGFR<60 mL/min/1.73 m2 were older and had higher Thrombolysis in Myocardial Infarction risk scores. Compared with patients with eGFR≥60 mL/min/1.73 m2, patients with renal dysfunction had higher rates of the primary outcome (5.3% vs 11.8%, respectively; P<.001). There was no significant heterogeneity in the treatment effect of pharmacoinvasive strategy on the primary outcome (P heterogeneity=.73) or the rate of death or reinfarction at 1 year (P heterogeneity=.64) in relation to eGFR. Patients with renal dysfunction had higher rates of in-hospital major bleeding compared with patients with eGFR ≥60 mL/min/1.73 m2 (7.7% vs 4.3%, respectively; P=.004); however, there was no difference in bleeding events between treatment arms in the overall cohort or in relation to eGFR (P heterogeneity=.67).
Conclusions:
Renal impairment is associated with increased rates of adverse events in STEMI patients treated with fibrinolysis. However, the safety and efficacy of pharmacoinvasive strategy are preserved in patients with renal impairment on presentation.
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