Combination therapy improves survival after acute myocardial infarction in the elderly with chronic kidney disease.
BACKGROUND
Individuals with chronic kidney disease have a high mortality rate after acute myocardial infarction. It is not known how frequently these individuals are prescribed combination cardioprotective therapy and if survival is affected by such therapy after acute myocardial infarction.


METHODS
A retrospective cohort study of 1,342 Medicare recipients with acute myocardial infarction. Data were collected by medical chart abstraction as part of the Cooperative Cardiovascular Project in 60 hospitals in North Carolina during 5/30/1996-12/28/1997. We categorized cardioprotective medication use as aspirin alone, aspirin with beta-blockers, and aspirin with beta-blockers and ace-inhibitors. Chronic kidney disease was defined as a derived glomerular filtration rate (GFR) ranging from 15-89 mL/min/1.73 m2. Cox proportional hazards regression analyses were performed to determine the effect of cardioprotective medication use on survival while controlling for potential explanatory variables.


RESULTS
The prevalence of cardioprotective medication use differed among levels of chronic kidney disease. Those with severe kidney disease (GFR 15-29 mL/min/1.73 m2) were less frequently prescribed aspirin with beta-blockers, 27.1%, and only 8.6% were prescribed aspirin with beta-blockers and ace-inhibitors. Survival was improved with prescribed cardioprotective medication use. In severe kidney disease (GFR 15-29 mL/min/1.73 m2), the hazards risk for death was 0.21 (0.08, 0.53) for aspirin alone, 0.17 (0.06, 0.51) for aspirin with beta-blockers, and 0.35 (0.09, 1.42) for aspirin with beta-blockers and ace-inhibitors.


CONCLUSIONS
Individuals with chronic kidney disease benefit from combination cardioprotective therapy, but are less likely to be prescribed them after acute myocardial infarction. Further investigation is warranted to identify possible reasons for these observed treatment disparities.
Krause
Michelle W
MW
Division of Nephrology and Hypertension, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA. krausemichellew@uams.edu
Massing
Mark
M
Kshirsagar
Abhijit
A
Rosamond
Wayne
W
Simpson
Ross J
RJ
D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use; D000368:Aged; D000369:Aged, 80 and over; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use; D001241:Aspirin / Q000627:therapeutic use; D002316:Cardiotonic Agents / Q000627:therapeutic use*; D015331:Cohort Studies; D016001:Confidence Intervals; D004359:Drug Therapy, Combination; D005260:Female; D015577:Geriatric Assessment; D006801:Humans; D007676:Kidney Failure, Chronic / Q000175:diagnosis / Q000453:epidemiology* / Q000628:therapy; D008297:Male; D009203:Myocardial Infarction / Q000175:diagnosis / Q000188:drug therapy* / Q000401:mortality*; D011379:Prognosis; D012042:Registries; D006435:Renal Dialysis / Q000009:adverse effects / Q000379:methods; D012189:Retrospective Studies; D018570:Risk Assessment; D016019:Survival Analysis; D016896:Treatment Outcome
D000319:Adrenergic beta-Antagonists; D000806:Angiotensin-Converting Enzyme Inhibitors; D002316:Cardiotonic Agents; D001241:Aspirin