Ismail Muhammad Dzafir, Jalalonmuhali Maisarah, Azhari Zaid, Mariapun Jeevitha, Lee Zhen-Vin, Zainal Abidin Imran, Wan Ahmad Wan Azman, Zuhdi Ahmad Syadi Mahmood
Division of Cardiology, Department of Medicine, University Malaya Medical Centre, 59100, Kuala Lumpur, Malaysia.
Division of Nephrology, Department of Medicine, University Malaya Medical Centre, 59100, Kuala Lumpur, Malaysia.
BMC Cardiovasc Disord. 2018 Sep 24;18(1):184. doi: 10.1186/s12872-018-0919-9.
Patients with renal impairment often left out from most major clinical trials assessing the optimal treatment for ST-elevation myocardial infarction (STEMI). Large body of evidence from various cardiovascular registries reflecting more 'real-world' experience might contribute to the knowledge on how best to treat this special cohort. We aim to analyze the outcomes of Malaysian STEMI patients with renal impairment treated with coronary angioplasty.
Utilizing the Malaysian National Cardiovascular Disease Database-Percutaneous Coronary Intervention (NCVD-PCI) registry data from 2007 to 2014, STEMI patients treated with percutaneous coronary intervention (PCI) were stratified into presence (GFR < 60 mls/min/1.73m) or absence (GFR ≥ 60 mls/min/1.73m) of chronic kidney disease (CKD). Patient's demographics, extent of coronary artery disease, procedural data, discharge medications, short (in-hospital) and long (1 year) term outcomes were critically assessed.
A total of 6563 patients were included in the final analysis. STEMI CKD cohort was predominantly male (80%) with mean age of 61.02 ± 9.95 years. They had higher cardiovascular risk factors namely diabetes mellitus (54.6%), hypertension (79.2%) and dyslipidemia (68.8%) in contrast to those without CKD. There were notably higher percentage of CKD patients presented with Killip class 3 and 4; 24.9 vs 8.7%. Thrombolytic therapy remained the most commonly instituted treatment regardless the status of kidney function. Furthermore, our STEMI CKD cohort also was more likely to receive less of evidence-based treatment upon discharge. In terms of outcomes, patients with CKD were more likely to develop in-hospital death (OR: 4.55, 95% CI 3.11-6.65), MACE (OR: 3.42, 95% CI 2.39-4.90) and vascular complications (OR: 1.88, 95% CI 0.95-3.7) compared to the non-CKD patients. The risk of death at 1-year post PCI in STEMI CKD patients was also reported to be high (HR: 3.79, 95% CI 2.84-5.07).
STEMI and CKD is a deadly combination, proven in our cohort, adding on to the current evidence in the literature. We noted that our STEMI CKD patients tend to be younger than the Caucasian with extremely high prevalence of diabetes mellitus. The poor outcome mainly driven by immediate or short term adverse events peri-procedural, therefore suggesting that more efficient treatment in this special group is imperative.
在评估ST段抬高型心肌梗死（STEMI）最佳治疗方案的大多数主要临床试验中，肾功能不全患者常常被排除在外。来自各种心血管注册研究的大量证据反映了更多“现实世界”的经验，这可能有助于了解如何最好地治疗这一特殊人群。我们旨在分析接受冠状动脉成形术治疗的马来西亚STEMI合并肾功能不全患者的预后。
利用2007年至2014年马来西亚国家心血管疾病数据库-经皮冠状动脉介入治疗（NCVD-PCI）注册数据，将接受经皮冠状动脉介入治疗（PCI）的STEMI患者根据是否存在慢性肾脏病（CKD）（估算肾小球滤过率＜60ml/min/1.73m²）分为两组。对患者的人口统计学特征、冠状动脉疾病范围、手术数据、出院用药、短期（住院期间）和长期（1年）结局进行了严格评估。
共有6563例患者纳入最终分析。STEMI合并CKD组以男性为主（80%），平均年龄61.02±9.95岁。与无CKD患者相比，他们有更多的心血管危险因素，即糖尿病（54.6%）、高血压（79.2%）和血脂异常（68.8%）。合并CKD的患者中出现Killip 3级和 Killip 4级的比例明显更高，分别为24.9%和8.7%。无论肾功能状况如何，溶栓治疗仍然是最常用的治疗方法。此外，我们的STEMI合并CKD组患者出院时接受循证治疗的可能性也更低。在结局方面，与非CKD患者相比，合并CKD的患者更易发生住院死亡（比值比：4.55，95%置信区间3.11-6.65）、主要不良心血管事件（比值比：3.42，95%置信区间2.39-4.90）和血管并发症（比值比：1.88，95%置信区间0.95-3.7）。据报道，STEMI合并CKD患者PCI术后1年的死亡风险也很高（风险比：3.79，95%置信区间2.84-5.07）。
STEMI合并CKD是一种致命组合，在我们的队列中得到证实，进一步补充了目前文献中的证据。我们注意到，我们的STEMI合并CKD患者往往比白种人年轻，糖尿病患病率极高。不良结局主要由围手术期即刻或短期不良事件驱动，因此表明对这一特殊群体进行更有效的治疗势在必行。
