title: Reperfusion in patients with renal dysfunction after presentation with ST-segment elevation or left bundle branch block: GRACE (Global Registry of Acute Coronary Events).
abstract: OBJECTIVE
  We investigated the relative benefit of reperfusion strategies in renal dysfunction and ST-segment elevation/left bundle branch block (STE/LBBB).
  
  
  BACKGROUND
  Few data are available informing the treatment of STE myocardial infarction in the presence of renal dysfunction.
  
  
  METHODS
  Patients (N = 12,532) from the GRACE (Global Registry of Acute Coronary Events) presenting with STE/LBBB were stratified by renal function and receipt of fibrinolysis, primary percutaneous coronary intervention (PCI), or neither.
  
  
  RESULTS
  As renal function declined, hospital mortality increased and reperfusion decreased (both p < 0.001). Compared with no reperfusion, primary PCI was associated with lower hospital mortality in patients with normal renal function (1.9% vs. 3.7%, p = 0.001, adjusted) but no reduction in those with renal dysfunction (14% vs. 15% for glomerular filtration rate [GFR] 30 to 59 ml/min/1.73 m(2); 29% vs. 32% for GFR <30 ml/min/1.73 m(2)). Fibrinolysis was not associated with lower hospital mortality for normal (3.1% vs. 3.7%, p = NS) or low renal function (32% vs. 32%, p = NS) and with higher mortality with moderate renal dysfunction (adjusted odds ratio: 1.35, 95% confidence interval: 1.01 to 1.80). Primary PCI was associated with increased hospital bleeding and fibrinolysis with increased stroke in all patients. Among hospital survivors, primary PCI, but not fibrinolysis, was associated with lower mortality for moderate dysfunction. Both reperfusion strategies were associated with higher mortality for severe dysfunction.
  
  
  CONCLUSIONS
  In STE/LBBB and renal dysfunction, mortality rates are high and reperfusion rates are lower. In moderate renal dysfunction, primary PCI is associated with mortality reduction at 6 months. Outcomes remain poor with severe renal dysfunction, despite receipt of reperfusion therapy.
authors.affiliation: Coronary Care Unit, Concord Hospital, Sydney, Australia.
authors.forename: Caroline
authors.initials: C
authors.lastname: Medi
authors.forename: Gilles
authors.initials: G
authors.lastname: Montalescot
authors.forename: Andrzej
authors.initials: A
authors.lastname: Budaj
authors.forename: Keith A A
authors.initials: KA
authors.lastname: Fox
authors.forename: José
authors.initials: J
authors.lastname: López-Sendón
authors.forename: Gordon
authors.initials: G
authors.lastname: FitzGerald
authors.forename: David B
authors.initials: DB
authors.lastname: Brieger
mesh_terms: D054058:Acute Coronary Syndrome / Q000188:drug therapy / Q000401:mortality / Q000628:therapy*; D000368:Aged; D000369:Aged, 80 and over; D015906:Angioplasty, Balloon, Coronary; D002037:Bundle-Branch Block; D016001:Confidence Intervals; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D005919:Glomerular Filtration Rate; D017052:Hospital Mortality; D006801:Humans; D015994:Incidence; D007676:Kidney Failure, Chronic / Q000503:physiopathology*; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000188:drug therapy / Q000401:mortality / Q000628:therapy*; D015425:Myocardial Reperfusion; D016017:Odds Ratio; D011446:Prospective Studies; D012042:Registries; D040242:Risk Reduction Behavior; D016896:Treatment Outcome
chemical_list: D005343:Fibrinolytic Agents