对于合并慢性肾脏病的高危急性冠状动脉综合征患者，采用侵袭性管理策略与改善结局相关。
An invasive management strategy is associated with improved outcomes in high-risk acute coronary syndromes in patients with chronic kidney disease.
机构信息
Concord Hospital, Cardiology, Sydney, New South Wales, Australia.
出版信息
Intern Med J. 2011 Oct;41(10):743-50. doi: 10.1111/j.1445-5994.2010.02361.x. Epub 2010 Oct 8.
INTRODUCTION
Chronic kidney disease (CKD) is associated with poor outcomes after acute coronary syndromes, yet selection for invasive investigation and management is low.
METHODS
Patients presenting with ST segment elevation myocardial infarction (STEMI) or intermediate- to high-risk non-ST segment elevation acute coronary syndrome (NSTEACS) (n=2597) were stratified into groups based on kidney function, defined as normal (glomerular filtration rate (GFR)≥60mL/min/1.73m(2) ), moderate CKD (GFR 30-59mL/min/1.73m(2) ) and severe CKD (GFR <30mL/min/1.73m(2)). Based on these stratums of kidney function, incidence and outcome measures were obtained for: rates of angiography and revascularization; 6-month mortality; and the incidence and outcome of in-hospital acute kidney impairment (AKI).
RESULTS
Patients with CKD were less likely to be offered coronary angiography after STEMI/NSTEACS (P<0.001); however, after selection, revascularization rates were similar (percutaneous coronary intervention (P=0.8); surgery (P=0.4)). Six-month mortality rates increased with CKD (GFR≥60, 2.8%; GFR 30-59, 9.9%; GFR<30, 16.5%, P≤0.001), as well as the combined efficacy/safety end-point (GFR≥60, 9.4%; GFR 30-59, 20.2%; GFR<30, 27.1%, P≤0.001). Six-month mortality was lower in patients who had received prior angiography (GFR≥60, 1.5% vs 3.6%, P=0.001; GFR 30-59, 5.1% vs 12.7%, P<0.001; GFR<30, 7.3% vs 18.5%, P=0.094). Risk of AKI increased with CKD (GFR≥60, 0.7%; GFR 30-59, 3.4%; GFR<30, 6.8%, P≤0.001), and was associated with high 6-month mortality (35.6% vs 4.1%, P<0.001).
CONCLUSIONS
In patients with CKD after STEMI/NSTEACS, 6-month mortality and morbidity is high, selection for angiography is lower, yet angiography is associated with a reduced long-term mortality, and with comparable revascularization rates to those without CKD. In-hospital AKI is more common in CKD and predicts a high 6-month mortality.
简介
慢性肾脏病（CKD）与急性冠状动脉综合征（ACS）后不良结局相关，但侵袭性检查和治疗的选择率较低。
方法
将 2597 例 ST 段抬高型心肌梗死（STEMI）或中高危非 ST 段抬高型急性冠状动脉综合征（NSTEACS）患者按肾功能分为正常组（肾小球滤过率（GFR）≥60mL/min/1.73m²）、中度 CKD 组（GFR 30-59mL/min/1.73m²）和重度 CKD 组（GFR <30mL/min/1.73m²）。基于这些肾功能分层，获得以下指标的发生率和结局：血管造影和血运重建的发生率；6 个月死亡率；以及院内急性肾损伤（AKI）的发生率和结局。
结果
与 STEMI/NSTEACS 后相比，CKD 患者接受冠状动脉造影的可能性较小（P<0.001）；然而，在选择后，血运重建率相似（经皮冠状动脉介入治疗（P=0.8）；手术（P=0.4））。随着 CKD 的进展（GFR≥60，2.8%；GFR 30-59，9.9%；GFR<30，16.5%，P≤0.001），以及联合疗效/安全性终点（GFR≥60，9.4%；GFR 30-59，20.2%；GFR<30，27.1%，P≤0.001），6 个月死亡率也随之升高。与未接受过血管造影的患者相比，接受过血管造影的患者 6 个月死亡率较低（GFR≥60，1.5%比 3.6%，P=0.001；GFR 30-59，5.1%比 12.7%，P<0.001；GFR<30，7.3%比 18.5%，P=0.094）。随着 CKD 的进展，AKI 的风险增加（GFR≥60，0.7%；GFR 30-59，3.4%；GFR<30，6.8%，P≤0.001），且与高 6 个月死亡率相关（35.6%比 4.1%，P<0.001）。
结论
在 STEMI/NSTEACS 后的 CKD 患者中，6 个月死亡率和发病率较高，血管造影选择率较低，但血管造影与降低长期死亡率相关，且与无 CKD 患者的血运重建率相当。CKD 患者院内 AKI 更为常见，且预测 6 个月死亡率较高。
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