The prognostic impact of in-hospital worsening of renal function in patients with acute coronary syndrome

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Abstract

Background

Renal impairment is strongly linked to adverse cardiovascular (CV) events. Baseline renal dysfunction is a strong predictor of CV mortality and morbidity in patients admitted with acute coronary syndrome (ACS). However, the prognostic importance of worsening renal function (WRF) in these patients is not well characterized.

Methods

ACS patients enrolled in the SPACE (Saudi Project for Assessment of Coronary Events) registry who had baseline and pre-discharge serum creatinine data available were eligible for this study. WRF was defined as a 25% reduction from admission estimated glomerular filtration rate (eGFR) within 7 days of hospitalization. Baseline demographics, clinical presentation, therapies, and in-hospital outcomes were compared.

Results

Of the 3583 ACS patients, WRF occurred in 225 patients (6.3%), who were older, had more cardiovascular risk factors, were more likely to be female, have past vascular disease, and presented with more non-ST-segment elevation myocardial infarction than patients without WRF (39.5% vs. 32.8%; p = 0.042). WRF was associated with an increased risk of in-hospital death, heart failure, cardiogenic shock, and stroke. After adjusting for potential confounders, WRF was an independent predictor of in-hospital death (adjusted odd ratio 28.02, 95% CI 13.2–60.28, p < 0.0001). WRF was more predictive of mortality than baseline eGFR.

Conclusion

These results indicate that WRF is a powerful predictor for in-hospital mortality and CV complications in ACS patients.

Introduction

The association between cardiovascular disease and chronic kidney disease (CKD) has been extensively explored [1], [2]. Numerous studies have documented renal insufficiency as an independent predictor of both short- and long-term cardiovascular morbidity and mortality [3], [4], [5], [6], [7], [8], [9], [10]. Moderate renal dysfunction at baseline in a broad range of patients with acute coronary syndrome (ACS) is associated with an at least 2-fold increase in mortality [4], [5], [6]. In contrast with CKD, information about the effect of in-hospital worsening of renal function (WRF) on clinical outcomes after ACS is limited. Therefore, our primary aim was to explore the prognostic impact of WRF developed during hospitalization in ACS patients enrolled in the SPACE (Saudi Project for Assessment of Coronary Events) registry.

Section snippets

Materials and methods

The SPACE registry is a prospective, multicenter, observational study, and a quality improvement initiative for all consecutive ACS patients admitted to the participating hospitals. The registry is comprised of two phases from December 2005 to December 2007. The phase I design was described in full previously [11]. Phase II, which included more hospitals, was conducted from December 2006 to the end of December 2007. Seventeen hospitals across Saudi Arabia participated in the SPACE registry.

Results

A total of 5062 patients were enrolled in the two phases of the SPACE registry. Of these patients, 3583 (70.8%) had two readings of serum creatinine within 7 days of hospitalization. Two hundred and twenty five patients (6.3%) had WRF compared to 3358 (93.7%) without WRF. Fig. 1 shows the proportion of patients with a < 25%, 25–50%, and > 50% reduction in eGFR from baseline.

Baseline characteristics

Table 1 presents the baseline characteristics of the two groups. Patients with WRF were generally similar in baseline characteristics compared to patients with no WRF except for a few exceptions. Fifteen patients were with end-stage renal disease. Patients with WRF were older, had a lower baseline eGFR, were more likely to be woman, and hypertensive, and were more likely to have a previous history of cerebrovascular accidents (stroke or transient ischemic attacks). Upon hospital admission,

Hospital therapies

With regard to in-hospital pharmacological therapies, both groups were treated equally, with the exception of a lower use of β blockers in patients with WRF (Table 2). The rate of diagnostic coronary angiography and subsequent coronary revascularization procedures (PCI or CABG) were similar between both groups.

Hospital outcomes

With the exception of re-infarction and major bleeding rates, patients with WRF were at a strikingly increased risk of all in-hospital adverse cardiovascular outcomes (Fig. 2). Fig. 3 shows significant correlation between baseline renal function and percent change in GFR (r =  0.29, 95% CI, to 1.34; p < 0.01). The frequency of worsening of renal function was higher among patients with lower baseline GFR.

The in-hospital mortality for patients with WRF was more than 18 times greater than that of

Discussion

In this study of 3583 patients with a broad spectrum of ACS, a ≥ 25% reduction in eGFR from baseline was a powerful predictor of in-hospital adverse cardiovascular outcomes. Poor prognosis was independent from baseline renal function, and did not appear to be related to the initial clinical presentation, baseline risk profile, or therapies received, including the performance of coronary angiography. Moreover, patients with WRF were treated the same as those with stable renal function, including

Conclusions

Our data suggest that WRF during hospitalization is a powerful predictor of short-term adverse outcomes in ACS patients. Future studies should focus on prospectively validating these findings, as well as assessing the utility of aggressive and early management in this high-risk group.

Acknowledgments

The SPACE registry is managed under the auspices of the Saudi Heart Association and financially sponsored by Sanofi-Aventis, which had no role in data extraction or analyses, the writing of the manuscript, or the decision to submit the manuscript for publication. The College of Medicine Research Center at King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia, provided ethical approval and partial funding. None of the authors have any conflict of interest to report. We

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