title: Underuse of standard care and outcome of patients with acute myocardial infarction and chronic renal insufficiency.
abstract: OBJECTIVE
  To investigate characteristics, management and outcome of patients with acute myocardial infarction (AMI) and chronic renal insufficiency (CRI).
  
  
  BACKGROUND
  Patients with AMI and CRI are considered to be at high risk of complications and death. Physicians may be reluctant to prescribe life-saving medications to patients with concomitant CRI.
  
  
  METHODS
  We compared clinical characteristics, management and outcome of 1,683 consecutive AMI patients in three categories of renal function: (1) normal renal function (<1.5 mg/dl) (n = 1,559), (2) mild to moderate CRI (1.5-3.5 mg/dl) (n = 77), and (3) severe CRI (>3.5 mg/dl) (n = 47).
  
  
  RESULTS
  CRI patients were older and were more likely to have other co-morbidities such as hypertension, diabetes mellitus, prior AMI, stroke, angina and heart failure. Compared with patients with normal renal function, standard therapy for AMI including thrombolysis, aspirin, angiotensin-converting-enzyme inhibitors, beta-blockers and lipid lowering agents was underutilized in CRI patients and these patients were more likely to have in-hospital complications such as heart failure, atrial or ventricular fibrillation, cardiogenic shock, sepsis, worsening of renal function and death within 30 days [odds ratio (OR) = 3.3; 95% confidence interval (CI) = 2.0-4.8]. After adjustment for age and co-morbidities, the association between mild to moderate CRI and 30-days mortality declined, whereas severe CRI remained an independent determinant of mortality (OR = 4.8; 95% CI = 2.0-11.4). Adjustment for aspirin, angiotensin-converting-enzyme inhibitors and beta-blocker therapy weakened the association between CRI and death within 30 days after AMI.
  
  
  CONCLUSIONS
  CRI patients are more likely to experience serious complications and death early after AMI. Underutilization of standard care, particularly beta-blocker therapy, contributes to increased mortality risk in these patients.
authors.affiliation: Neufeld Cardiac Research Institute, Tel-Aviv University, Tel-Hashomer, Israel.
authors.forename: Ariel
authors.initials: A
authors.lastname: Tessone
authors.forename: Shmuel
authors.initials: S
authors.lastname: Gottlieb
authors.forename: Israel M
authors.initials: IM
authors.lastname: Barbash
authors.forename: Moshe
authors.initials: M
authors.lastname: Garty
authors.forename: Avi
authors.initials: A
authors.lastname: Porath
authors.forename: Alexander
authors.initials: A
authors.lastname: Tenenbaum
authors.forename: Hanoch
authors.initials: H
authors.lastname: Hod
authors.forename: Valentina
authors.initials: V
authors.lastname: Boyko
authors.forename: Lori
authors.initials: L
authors.lastname: Mandelzweig
authors.forename: Solomon
authors.initials: S
authors.lastname: Behar
authors.forename: Jonathan
authors.initials: J
authors.lastname: Leor
mesh_terms: 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; D003404:Creatinine / Q000097:blood; D004363:Drug Utilization; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D017052:Hospital Mortality; D006801:Humans; D000960:Hypolipidemic Agents / Q000627:therapeutic use; D007676:Kidney Failure, Chronic / Q000150:complications / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000150:complications / Q000628:therapy*; D005791:Patient Care / Q000592:standards*; D016896:Treatment Outcome
chemical_list: D000319:Adrenergic beta-Antagonists; D000806:Angiotensin-Converting Enzyme Inhibitors; D005343:Fibrinolytic Agents; D000960:Hypolipidemic Agents; D003404:Creatinine; D001241:Aspirin