慢性肾脏病合并 ST 段抬高型心肌梗死患者的治疗策略和临床结局的时间趋势：不来梅 STEMI 注册研究结果。
Temporal trends in treatment strategies and clinical outcomes among patients with advanced chronic kidney disease and ST-elevation myocardial infarctions: results from the Bremen STEMI registry.
机构信息
From the Bremen Institute for Heart and Circulation Research, am Klinikum Links der Weser, Senator-Weßling-Str. 1, 28277, Bremen, Germany.
Medical Clinic III, Department of Nephrology and Cardiology, Klinikum Bremen Mitte, Bremen, Germany.
出版信息
BMC Cardiovasc Disord. 2022 Apr 1;22(1):142. doi: 10.1186/s12872-022-02573-1.
BACKGROUND
Although the detrimental effects of advanced chronic kidney disease (CKD) on prognosis in coronary artery disease is known, there are few data on the efficacy and safety of modern interventional therapies and medications in patients with advanced CKD, because this special patient cohort is often excluded or underrepresented in randomized trials.
METHODS
In the present study all patients admitted with ST-elevation myocardial infarctions (STEMI) from the region of Bremen/Germany treated between 2006 and 2019 were analyzed. Advanced CKD was defined as glomerular filtration rate < 45 ml/min.
RESULTS
Of 9605 STEMI-patients, 1018 (10.6%) had advanced CKD with a serum creatinine of 2.22 ± 4.2 mg/dl at admission and with lower rates of primary percutaneous coronary intervention (pPCI) (84.1 vs. 94.1%, p < 0.01) and higher all-cause-mortality (44.4 vs. 3.6%, p < 0.01). Over time, advanced CKD-patients were more likely to be treated with pPCI (2015-2019: 90.3% vs. 2006-2010:75.8%, p < 0.01) and with ticagrelor/prasugrel (59.6% vs. 1.7%, p < 0.01) and drug eluting stents (90.7% vs. 1.3%, p < 0.01). During the study period a decline in adverse ischemic events (OR 0.3, 95% CI 0.1-0.7) and an increase in bleedings (OR 2.2, 95% CI 1.3-3.8) within 1 year after the index event could be observed in patients with advanced CKD while 1-year-mortality (OR 1.0, 95% CI 0.7-1.4) and rates of acute kidney injury (OR 1.2, 95% CI 0.8-1.7) did not change in a multivariate model. Both, ticagrelor/prasugrel (OR 0.48, 95% CI 0.2-0.98) and DES (OR 0.38, 95% CI 0.2-0.8) were associated with a decrease in ischemic events at 1 year.
CONCLUSIONS
During the observed time period STEMI-patients with advanced CKD were more likely to be treated with primary PCI, ticagrelor or prasugrel and DE-stents. These changes probably have contributed to the decline in ischemic events and the increase in bleedings within 1 year after STEMI while overall mortality at 1-year remained unchanged for this high-risk patient group.
背景
虽然晚期慢性肾脏病（CKD）对冠状动脉疾病预后的不利影响是已知的，但关于晚期 CKD 患者现代介入治疗和药物的疗效和安全性的数据很少，因为这一特殊患者群体在随机试验中经常被排除或代表性不足。
方法
本研究分析了 2006 年至 2019 年期间德国不来梅地区因 ST 段抬高型心肌梗死（STEMI）入院的所有患者。晚期 CKD 的定义为肾小球滤过率<45ml/min。
结果
在 9605 例 STEMI 患者中，1018 例（10.6%）患有晚期 CKD，入院时血清肌酐为 2.22±4.2mg/dl，行直接经皮冠状动脉介入治疗（pPCI）的比例较低（84.1%比 94.1%，p<0.01），全因死亡率较高（44.4%比 3.6%，p<0.01）。随着时间的推移，晚期 CKD 患者更有可能接受 pPCI（2015-2019 年：90.3%比 2006-2010 年：75.8%，p<0.01）和替格瑞洛/普拉格雷（59.6%比 1.7%，p<0.01）和药物洗脱支架（90.7%比 1.3%，p<0.01）。在研究期间，可观察到晚期 CKD 患者 1 年内不良缺血事件（OR 0.3，95%CI 0.1-0.7）减少和出血（OR 2.2，95%CI 1.3-3.8）增加，而 1 年死亡率（OR 1.0，95%CI 0.7-1.4）和急性肾损伤（OR 1.2，95%CI 0.8-1.7）在多变量模型中没有变化。替格瑞洛/普拉格雷（OR 0.48，95%CI 0.2-0.98）和 DES（OR 0.38，95%CI 0.2-0.8）均与 1 年内缺血事件减少相关。
结论
在观察期间，晚期 CKD 的 STEMI 患者更有可能接受 pPCI、替格瑞洛或普拉格雷和 DE 支架治疗。这些变化可能有助于 STEMI 后 1 年内缺血事件减少和出血增加，而对于这一高危患者群体，1 年的总体死亡率保持不变。
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