Lourenço Carolina, Teixeira Rogério, António Natália, Monteiro Sílvia, Baptista Rui, Jorge Elisabete, Gonçalves Francisco, Monteiro Pedro, Gonçalves Lino, Freitas Mário, Providência Luís A
Serviço de Cardiologia e Clínica Universitária de Cardiologia - Faculdade de Medicina e Hospitais da Universidade de Coimbra, E.P.E., Coimbra, Portugal.
Rev Port Cardiol. 2010 Sep;29(9):1331-52.
Renal failure patients have a dismal prognosis in the setting of acute coronary syndromes (ACS). Several studies have shown that this population is undertreated, benefiting less frequently from cardiovascular agents and interventions. The aim of our study was to evaluate patients hospitalized for ACS who also presented renal dysfunction, identifying baseline clinical characteristics, treatment options and prognosis. We also assessed whether renal failure was an independent predictor of mortality and cardiovascular events.
We performed an observational, longitudinal, prospective and continuous study, including 1039 consecutive patients hospitalized in a single center for ACS. Two groups were compared according to estimated glomerular filtration rate (eGFR): eGFR > or = 60 ml/min (group A) and eGFR < 60 ml/min (group B). The mean follow-up was twelve months after discharge. Multivariate analysis was used to identify predictors of mortality and major adverse cardiovascular events (MACE) in this population.
Group B patients were older and more frequently female, and presented a higher prevalence of cardiovascular risk factors and previous cardiovascular disease, and more severe coronary artery disease. Group B also had more cases of non-ST-elevation acute myocardial infarction, as well as higher blood glucose, higher heart rate on admission, and lower left ventricular ejection fraction. Patients in group B were less frequently treated with the main cardiovascular drugs or by an invasive strategy; this group also presented higher in-hospital mortality (9.1 vs. 2.5%, p < 0.001). During clinical follow-up, survival and MACE-free rates were significantly lower in group B patients (86.6 vs. 93.6%, p < 0.001, and 76.2 vs. 86.2%, p < 0.001, respectively). Multivariate analysis showed that eGFR of < 30 ml/min was an independent predictor of in-hospital mortality (OR 6.92; C statistic = 0.87) and that eGFR of < 60 ml/min was an independent predictor of MACE during follow-up (OR 2.19; C statistic = 0.71).
We found that moderate to severe renal dysfunction is common in ACS patients, and this variable was an independent predictor of mortality and MACE. However, we also found that these patients are undertreated, which may contribute to their poor prognosis. Early identification of these high-risk patients is important so that the procedures recommended in the international guidelines can be more consistently implemented.
在急性冠脉综合征（ACS）背景下，肾衰竭患者预后不佳。多项研究表明，这一人群治疗不足，较少从心血管药物和干预措施中获益。我们研究的目的是评估因ACS住院且伴有肾功能不全的患者，确定其基线临床特征、治疗选择和预后情况。我们还评估了肾衰竭是否为死亡率和心血管事件的独立预测因素。
我们进行了一项观察性、纵向、前瞻性和连续性研究，纳入了在单一中心因ACS住院的1039例连续患者。根据估计肾小球滤过率（eGFR）将患者分为两组：eGFR≥60 ml/分钟（A组）和eGFR＜60 ml/分钟（B组）。出院后平均随访12个月。采用多变量分析确定该人群中死亡率和主要不良心血管事件（MACE）的预测因素。
B组患者年龄更大，女性比例更高，心血管危险因素和既往心血管疾病患病率更高，冠状动脉疾病更严重。B组非ST段抬高型急性心肌梗死病例更多，血糖更高，入院时心率更快，左心室射血分数更低。B组患者接受主要心血管药物治疗或采用侵入性治疗策略的频率更低；该组患者院内死亡率也更高（9.1%对2.5%，p＜0.001）。在临床随访期间，B组患者的生存率和无MACE率显著更低（分别为86.6%对93.6%，p＜0.001；76.2%对86.2%，p＜0.001）。多变量分析显示，eGFR＜30 ml/分钟是院内死亡率的独立预测因素（比值比6.92；C统计量=0.87），eGFR＜60 ml/分钟是随访期间MACE的独立预测因素（比值比2.19；C统计量=0.71）。
我们发现中度至重度肾功能不全在ACS患者中很常见，且这一变量是死亡率和MACE的独立预测因素。然而，我们也发现这些患者治疗不足，这可能导致其预后不良。早期识别这些高危患者很重要，以便更一致地实施国际指南中推荐的治疗方案。
