心肌梗死后肾功能不全与心血管结局之间的关系。

Relation between renal dysfunction and cardiovascular outcomes after myocardial infarction.

作者信息

Anavekar Nagesh S, McMurray John J V, Velazquez Eric J, Solomon Scott D, Kober Lars, Rouleau Jean-Lucien, White Harvey D, Nordlander Rolf, Maggioni Aldo, Dickstein Kenneth, Zelenkofske Steven, Leimberger Jeffrey D, Califf Robert M, Pfeffer Marc A

机构信息

Cardiovascular Division, Brigham and Women's Hospital, Boston, MA 02115, USA.

出版信息

N Engl J Med. 2004 Sep 23;351(13):1285-95. doi: 10.1056/NEJMoa041365.

DOI:10.1056/NEJMoa041365

PMID:15385655

Abstract

BACKGROUND

The presence of coexisting conditions has a substantial effect on the outcome of acute myocardial infarction. Renal failure is associated with one of the highest risks, but the influence of milder degrees of renal impairment is less well defined.

METHODS

As part of the Valsartan in Acute Myocardial Infarction Trial (VALIANT), we identified 14,527 patients with acute myocardial infarction complicated by clinical or radiologic signs of heart failure, left ventricular dysfunction, or both, and a documented serum creatinine measurement. Patients were randomly assigned to receive captopril, valsartan, or both. The glomerular filtration rate (GFR) was estimated by means of the four-component Modification of Diet in Renal Disease equation, and the patients were grouped according to their estimated GFR. We used a 70-candidate variable model to adjust and compare overall mortality and composite cardiovascular events among four GFR groups.

RESULTS

The distribution of estimated GFR was wide and normally shaped, with a mean (+/-SD) value of 70+/-21 ml per minute per 1.73 m2 of body-surface area. The prevalence of coexisting risk factors, prior cardiovascular disease, and a Killip class of more than I was greatest among patients with a reduced estimated GFR (less than 45.0 ml per minute per 1.73 m2), and the use of aspirin, beta-blockers, statins, or coronary-revascularization procedures was lowest in this group. The risk of death or the composite end point of death from cardiovascular causes, reinfarction, congestive heart failure, stroke, or resuscitation after cardiac arrest increased with declining estimated GFRs. Although the rate of renal events increased with declining estimated GFRs, the adverse outcomes were predominantly cardiovascular. Below 81.0 ml per minute per 1.73 m2, each reduction of the estimated GFR by 10 units was associated with a hazard ratio for death and nonfatal cardiovascular outcomes of 1.10 (95 percent confidence interval, 1.08 to 1.12), which was independent of the treatment assignment.

CONCLUSIONS

Even mild renal disease, as assessed by the estimated GFR, should be considered a major risk factor for cardiovascular complications after a myocardial infarction.

摘要

背景

并存疾病的存在对急性心肌梗死的预后有重大影响。肾衰竭是风险最高的情况之一，但轻度肾功能损害的影响尚不太明确。

方法

作为缬沙坦治疗急性心肌梗死试验（VALIANT）的一部分，我们纳入了14527例急性心肌梗死患者，这些患者伴有心力衰竭、左心室功能障碍或两者的临床或放射学体征，且有血清肌酐测量记录。患者被随机分配接受卡托普利、缬沙坦或两者。通过四变量的肾脏病饮食改良方程估算肾小球滤过率（GFR），并根据估算的GFR对患者进行分组。我们使用一个包含70个变量的模型来调整和比较四个GFR组的总死亡率和复合心血管事件。

结果

估算的GFR分布广泛且呈正态分布，平均（±标准差）值为每分钟70±21 ml/1.73 m²体表面积。估算的GFR降低（每分钟低于45.0 ml/1.73 m²）的患者中，并存危险因素、既往心血管疾病以及Killip分级超过I级的患病率最高，而该组中阿司匹林、β受体阻滞剂、他汀类药物或冠状动脉血运重建术的使用率最低。死亡风险或心血管原因死亡、再梗死、充血性心力衰竭、中风或心脏骤停后复苏的复合终点风险随着估算的GFR降低而增加。尽管肾脏事件的发生率随着估算的GFR降低而增加，但不良结局主要是心血管方面的。在每分钟低于81.0 ml/1.73 m²时，估算的GFR每降低10个单位，死亡和非致命心血管结局的风险比为1.10（95%置信区间，1.08至1.12），这与治疗分配无关。