Nabais Sérgio, Rocha Sérgia, João Costa, Marques Jorge, Torres Márcia, Magalhães Sónia, Pereira Miguel Alvares, Correia Adelino
Serviço de Cardiologia, Hospital de S. Marcos, Braga, Portugal.
Rev Port Cardiol. 2008 Mar;27(3):303-12; discussion 315-7.
End-stage renal disease is associated with high cardiovascular mortality. The prognostic importance of milder degrees of renal impairment in patients who have had an acute coronary syndrome (ACS) is less well defined. The purpose of this study was to evaluate the impact of baseline renal dysfunction assessed by estimated glomerular filtration rate (GFR) on mortality in patients admitted with an ACS.
We studied all patients with an ACS consecutively admitted to an Intensive Cardiac Care Unit over 18 months. The GFR was estimated by means of the four-component Modification of Diet in Renal Disease study equation. Patients were grouped according to their estimated GFR (less than 45.0; 45.0 to 59.9; 60.0 to 74.9; and at least 75.0 ml/min/1.73 m2). Primary outcome was death from any cause.
The mean age of the 589 study patients was 64.1 years, 73.7% were male, and 49.2% had an ACS with ST-segment elevation. Arterial hypertension, diabetes mellitus, prior myocardial infarction, and Killip class > I were incrementally more common across increasing renal dysfunction strata (p < 0.01). The use of reperfusion therapy, beta-blockers, and coronary angioplasty was lower in groups with reduced estimated GFR (p < 0.001). Overall six-month mortality was 13.6%. Using the group with an estimated GFR of at least 75.0 ml/min/1.73 m2 as the reference group yielded odds ratios for six-month mortality that increased with the degree of renal impairment. After adjusting for baseline characteristics, impaired renal funtion remained associated with increased mortality. The multivariable-adjusted odds ratio for six-month mortality in patients with mild renal impairment (GFR 60.0 to 74.9 ml/min/1.73 m2) was 2.71 (95% confidence interval [CI] 1.09 to 6.69), compared with 7.53 (95% CI, 3.21 to 17.71) and 8.10 (95% CI, 3.18 to 20.60) in patients with moderate and more severe renal dysfunction, respectively.
Baseline renal dysfunction, as assessed by estimated GFR, is a potent and easily identifiable determinant of outcome after an ACS. Even mild levels of renal impairment are independently associated with increased mortality after an ACS.
终末期肾病与心血管疾病高死亡率相关。急性冠状动脉综合征(ACS)患者中较轻程度肾功能损害的预后重要性尚未明确界定。本研究的目的是评估通过估算肾小球滤过率(GFR)评估的基线肾功能不全对ACS住院患者死亡率的影响。
我们对18个月内连续入住重症心脏监护病房的所有ACS患者进行了研究。GFR通过肾病饮食改良研究方程的四成分法估算。患者根据估算的GFR分组(低于45.0;45.0至59.9;60.0至74.9;以及至少75.0 ml/min/1.73 m²)。主要结局是任何原因导致的死亡。
589例研究患者的平均年龄为64.1岁,73.7%为男性,49.2%患有ST段抬高型ACS。随着肾功能不全程度的增加,动脉高血压、糖尿病、既往心肌梗死和Killip分级> I越来越常见(p < 0.01)。估算GFR降低的组中,再灌注治疗、β受体阻滞剂和冠状动脉血管成形术的使用较低(p < 0.001)。总体六个月死亡率为13.6%。以估算GFR至少为75.0 ml/min/1.73 m²的组作为参照组,六个月死亡率的比值比随肾功能损害程度增加。在对基线特征进行调整后,肾功能受损仍与死亡率增加相关。轻度肾功能损害(GFR 60.0至74.9 ml/min/1.73 m²)患者六个月死亡率的多变量调整比值比为2.71(95%置信区间[CI] 1.09至6.69),而中度和重度肾功能不全患者分别为7.53(95% CI,3.21至17.71)和8.10(95% CI,3.18至20.60)。
通过估算GFR评估的基线肾功能不全是ACS后结局的一个有力且易于识别的决定因素。即使是轻度肾功能损害也与ACS后死亡率增加独立相关。