title: Long-term impact of chronic kidney disease in patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention: the HORIZONS-AMI (Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction) trial.
abstract: OBJECTIVE
  This study sought to investigate the impact of chronic kidney disease (CKD) in patients undergoing percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) with different antithrombotic strategies.
  
  
  BACKGROUND
  CKD is associated with increased risk of adverse ischemic and hemorrhagic events after primary PCI for STEMI.
  
  
  METHODS
  HORIZONS-AMI (Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction) trial was a multicenter, international, randomized trial comparing bivalirudin monotherapy or heparin plus a glycoprotein IIb/IIIa inhibitor (GPI) during primary PCI in STEMI. CKD, defined as creatinine clearance <60 ml/min, was present at baseline in 554 of 3,397 patients (16.3%). Patients were followed for 3 years. Net adverse cardiac event (NACE) was defined as the composite of death, reinfarction, ischemia-driven target vessel revascularization (TVR), stroke or non-coronary artery bypass grafting (CABG)-related major bleeding.
  
  
  RESULTS
  Patients with CKD compared with patients without had higher rates of NACE (41.4% vs. 23.8%, p < 0.0001), death (18.7% vs. 4.4%, p < 0.0001), and major bleeding (19.3% vs. 6.7%, p < 0.0001). Multivariable analysis identified baseline creatinine as an independent predictor of death at 3 years (hazard ratio: 1.51, 95% confidence interval: 1.21 to 1.87, p < 0.001). Patients with CKD randomized to bivalirudin monotherapy versus heparin plus GPI had no significant difference in major bleeding (19.0% vs. 19.6%, p = 0.72) or death (19.0% vs. 18.4%, p = 0.88) at 3 years. In patients with CKD, there was no difference in the rates of TVR in bare-metal stents (BMS) versus drug-eluting stents (DES) at 3 years (14.1% vs. 15.1%, p = 0.8).
  
  
  CONCLUSIONS
  STEMI patients with CKD have significantly higher rates of death and major bleeding compared with those without CKD. In patients with CKD, there appears to be no benefit of bivalirudin compared with heparin + GPI, or DES versus BMS during primary PCI in improving clinical outcomes.
authors.affiliation: Columbia University Medical Center and the Cardiovascular Research Foundation, New York, New York, USA.
authors.forename: Adam J
authors.initials: AJ
authors.lastname: Saltzman
authors.forename: Gregg W
authors.initials: GW
authors.lastname: Stone
authors.forename: Bimmer E
authors.initials: BE
authors.lastname: Claessen
authors.forename: Amar
authors.initials: A
authors.lastname: Narula
authors.forename: Selene
authors.initials: S
authors.lastname: Leon-Reyes
authors.forename: Giora
authors.initials: G
authors.lastname: Weisz
authors.forename: Bruce
authors.initials: B
authors.lastname: Brodie
authors.forename: Bernhard
authors.initials: B
authors.lastname: Witzenbichler
authors.forename: Giulio
authors.initials: G
authors.lastname: Guagliumi
authors.forename: Ran
authors.initials: R
authors.lastname: Kornowski
authors.forename: Dariusz
authors.initials: D
authors.lastname: Dudek
authors.forename: D Christopher
authors.initials: DC
authors.lastname: Metzger
authors.forename: Alexandra J
authors.initials: AJ
authors.lastname: Lansky
authors.forename: Eugenia
authors.initials: E
authors.lastname: Nikolsky
authors.forename: George D
authors.initials: GD
authors.lastname: Dangas
authors.forename: Roxana
authors.initials: R
authors.lastname: Mehran
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D015906:Angioplasty, Balloon, Coronary / Q000009:adverse effects / Q000295:instrumentation* / Q000401:mortality; D000925:Anticoagulants / Q000627:therapeutic use; D016009:Chi-Square Distribution; D002908:Chronic Disease; D054855:Drug-Eluting Stents; D005060:Europe; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D006470:Hemorrhage; D006493:Heparin / Q000627:therapeutic use; D006629:Hirudins; D006801:Humans; D007557:Israel; D053208:Kaplan-Meier Estimate; D007674:Kidney Diseases / Q000150:complications* / Q000401:mortality; D008297:Male; D008670:Metals; D008875:Middle Aged; D009203:Myocardial Infarction / Q000150:complications / Q000401:mortality / Q000628:therapy*; D010446:Peptide Fragments / Q000627:therapeutic use; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use; D019039:Platelet Glycoprotein GPIIb-IIIa Complex / Q000037:antagonists & inhibitors; D016016:Proportional Hazards Models; D011446:Prospective Studies; D011474:Prosthesis Design; D011994:Recombinant Proteins / Q000627:therapeutic use; D012008:Recurrence; D018570:Risk Assessment; D012307:Risk Factors; D015607:Stents; D020521:Stroke / Q000209:etiology; D013927:Thrombosis / Q000209:etiology; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States
chemical_list: D000925:Anticoagulants; D005343:Fibrinolytic Agents; D006629:Hirudins; D008670:Metals; D010446:Peptide Fragments; D010975:Platelet Aggregation Inhibitors; D019039:Platelet Glycoprotein GPIIb-IIIa Complex; D011994:Recombinant Proteins; D006493:Heparin; C074619:bivalirudin