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Measuring the Variation in the Prevention and Treatment of CI-AKI Among Interventional Cardiologists
Czarlota Valdenor1, Peter A McCullough2, David Paculdo1
1QURE Healthcare, San Francisco, CA.
Insights
Interventional cardiologists show significant gaps in recognizing and treating contrast-induced acute kidney injury (CI-AKI), highlighting a need for improved awareness and diagnostic tools to enhance patient care and reduce complications.
Area of Science:
- Cardiology
- Nephrology
- Medical Education
Background:
- Contrast-induced acute kidney injury (CI-AKI) complicates up to 10% of cardiac procedures, increasing morbidity, mortality, and healthcare costs.
- Under-recognition of CI-AKI risk and inadequate management of patients with renal impairment contribute to these adverse outcomes.
- Current care practices for CI-AKI present significant opportunities for improvement within interventional cardiology.
Purpose of the Study:
- To evaluate the ability of interventional cardiologists to assess CI-AKI risk, diagnose the condition, and implement appropriate management strategies.
- To identify specific areas of deficiency in the care pathway for patients undergoing procedures requiring contrast media.
- To determine the impact of procedural setting on the quality of CI-AKI care provided by cardiologists.
Main Methods:
- A simulation study involving 157 interventional cardiologists assessing three simulated patient scenarios (pre-procedural, during, post-procedure).
- Evaluation of cardiologists' performance in risk assessment, diagnosis, volume expansion, and avoidance of nephrotoxic medications.
- Analysis of quality-of-care scores, diagnostic accuracy for CI-AKI and chronic kidney disease, and adherence to treatment protocols.
Main Results:
- Overall quality-of-care scores averaged 46.0%, with significant variability (18%-78%).
- Diagnostic accuracy for CI-AKI risk was low (57.1%), and accuracy for pre-existing chronic kidney disease was 50.2%.
- Appropriate volume expansion occurred in only 30.7% of cases, with suboptimal use of nephrotoxic medication avoidance (14.2%) and creatinine testing (32.1%).
Conclusions:
- Interventional cardiologists demonstrate suboptimal performance in managing CI-AKI, indicating a critical need for enhanced awareness and diagnostic support.
- Deficiencies in risk assessment and treatment, particularly regarding nephrotoxic medication management and hydration, were observed across procedural settings.
- Improving CI-AKI care requires targeted educational interventions and the development of better diagnostic tools to guide clinical decision-making.
Abstract:
Contrast-induced acute kidney injury (CI-AKI) occurs in up to 10% of cardiac catheterizations and coronary interventions, resulting in increased morbidity, mortality, and cost. One main reason for these complications and costs is under-recognition of CI-AKI risk and under-treatment of patients with impaired renal status. 157 interventional cardiologists each cared for three simulated patients with common conditions requiring intravascular contrast media in three typical settings: pre-procedurally, during the procedure, and post-procedure. We evaluated their ability to assess the risk of developing CI-AKI, make the diagnosis, and treat CI-AKI, including proper volume expansion and withholding nephrotoxic medications. Overall, the quality-of-care scores averaged 46.0% ± 10.5, varying between 18% to 78%. The diagnostic scores for accurately assessing risk of CI-AKI were low at 57.1% ± 21.2% and the accuracy of diagnosis pre-existing chronic kidney disease was 50.2%. Poor diagnostic accuracy led to poor treatment: proper volume expansion done in only 30.7% of cases, in-hospital repeat creatinine evaluation performed in 32.1%, and avoiding nephrotoxic medications occurred in 14.2%. While volume expansion was relatively similar across the three settings (P = 0.287), the cardiologists were less likely to discontinue nephrotoxic medications in pre-procedurally (9.7%) compared to the other settings (27.0%), and to order in-hospital creatinine testing in peri-procedurally (18.8%) compared to post-procedure (57.8%) (P < 0.05 for both). The overall care of patients at risk for contrast-induced acute kidney injury varied widely and showed room for improvement. Improving care for this condition will require greater awareness by cardiologists and better diagnostic tools to guide them.
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