Reperfusion strategy and mortality in ST-elevation myocardial infarction among patients with and without impaired renal function.
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.
Chan
Mark Y
MY
National University Heart Centre, Singapore, Singapore. chanyymark@gmail.com
Becker
Richard C
RC
Sim
Ling-Ling
LL
Tan
Virlynn
V
Lee
Chi-Hang
CH
Low
Adrian F H
AF
Teo
Swee-Guan
SG
Ng
Kheng-Siang
KS
Tan
Huay-Cheem
HC
Yeo
Tiong-Cheng
TC
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
D000933:Antifibrinolytic Agents