title: Reperfusion strategy and mortality in ST-elevation myocardial infarction among patients with and without impaired renal function.
abstract: BACKGROUND
  Several randomised controlled trials have demonstrated better outcomes with primary percutaneous coronary intervention (PCI) over fibrinolytic therapy in the treatment of patients with ST-segment elevation myocardial infarction (STEMI) and normal renal function. Whether this benefit extends to patients with impaired renal function is uncertain.
  
  
  METHODS
  We studied 1672 patients with STEMI within 12 hours of symptom onset who were admitted to 2 major public hospitals in Singapore from 2000 to 2002. All patients received either upfront fibrinolytic or PCI as determined by the attending cardiologist. Serum creatinine was measured on admission and the glomerular filtration rate (GFR) was determined using the Modification of Diet in Renal Disease equation. The impact of reperfusion strategy on 30-ay mortality was then determined for patients with GFR > or =60 mL min-(1) 1.73 m-(2) and GFR <60 mL min-(1) 1.73 m-(2).
  
  
  RESULTS
  The mean age was 56 +/- 12 years (85% male) and mean GFR was 81 +/- 30 mL min-(1) 1.73 m-(2). Unadjusted 30-day mortality rates for fibrinolytic-treated vs primary PCI-treated patients were 29.4% vs 17.9%, P <0.05, in the impaired renal function group and 5.4% vs 3.1%, P <0.05, in the normal renal function group. After adjusting for covariates, primary PCI was associated with a significantly lower mortality in the normal renal function group [odds ratio (OR), 0.41; 95% confidence interval (CI), 0.19-0.89] but not in the impaired renal function group [OR, 0.70; 95% CI, 0.31-1.60].
  
  
  CONCLUSIONS
  Primary PCI was associated with improved 30-day survival among patients with normal renal function but not among those with impaired renal function. Randomised trials are needed to study the relative efficacy of both reperfusion strategies in patients with impaired renal function.
authors.affiliation: National University Heart Centre, Singapore, Singapore. chanyymark@gmail.com
authors.forename: Mark Y
authors.initials: MY
authors.lastname: Chan
authors.forename: Richard C
authors.initials: RC
authors.lastname: Becker
authors.forename: Ling-Ling
authors.initials: LL
authors.lastname: Sim
authors.forename: Virlynn
authors.initials: V
authors.lastname: Tan
authors.forename: Chi-Hang
authors.initials: CH
authors.lastname: Lee
authors.forename: Adrian F H
authors.initials: AF
authors.lastname: Low
authors.forename: Swee-Guan
authors.initials: SG
authors.lastname: Teo
authors.forename: Kheng-Siang
authors.initials: KS
authors.lastname: Ng
authors.forename: Huay-Cheem
authors.initials: HC
authors.lastname: Tan
authors.forename: Tiong-Cheng
authors.initials: TC
authors.lastname: Yeo
mesh_terms: D000328:Adult; D015906:Angioplasty, Balloon, Coronary; D000933:Antifibrinolytic Agents / Q000627:therapeutic use; D004562:Electrocardiography; D005260:Female; D005919:Glomerular Filtration Rate; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000150:complications* / Q000188:drug therapy / Q000601:surgery*; D012042:Registries; D051436:Renal Insufficiency, Chronic / Q000150:complications*; D012189:Retrospective Studies; D016019:Survival Analysis
chemical_list: D000933:Antifibrinolytic Agents