Impact of Chronic Kidney Disease on In-Hospital and 3-Year Clinical
Total Page：16
File Type：pdf, Size：1020Kb
Advance Publication Circulation Journal ORIGINAL ARTICLE doi: 10.1253/circj.CJ-20-1115 Impact of Chronic Kidney Disease on In-Hospital and 3-Year Clinical Outcomes in Patients With Acute Myocardial Infarction Treated by Contemporary Percutaneous Coronary Intervention and Optimal Medical Therapy ― Insights From the J-MINUET Study ― Yousuke Hashimoto, MD; Yukio Ozaki, MD, PhD; Shino Kan, MD; Koichi Nakao, MD, PhD; Kazuo Kimura, MD, PhD; Junya Ako, MD, PhD; Teruo Noguchi, MD, PhD; Satoru Suwa, MD, PhD; Kazuteru Fujimoto, MD, PhD; Kazuoki Dai, MD; Takashi Morita, MD, PhD; Wataru Shimizu, MD, PhD; Yoshihiko Saito, MD, PhD; Atsushi Hirohata, MD, PhD; Yasuhiro Morita, MD, PhD; Teruo Inoue, MD, PhD; Atsunori Okamura, MD, PhD; Toshiaki Mano, MD; Minoru Wake, MD; Kengo Tanabe, MD, PhD; Yoshisato Shibata, MD, PhD; Mafumi Owa, MD, PhD; Kenichi Tsujita, MD, PhD; Hiroshi Funayama, MD, PhD; Nobuaki Kokubu, MD, PhD; Ken Kozuma, MD, PhD; Shiro Uemura, MD, PhD; Tetsuya Tobaru, MD, PhD; Keijiro Saku, MD, PhD; Shigeru Oshima, MD, PhD; Satoshi Yasuda, MD, PhD; Tevfik F Ismail, MD, PhD; Takashi Muramatsu, MD, PhD; Hideo Izawa, MD, PhD; Hiroshi Takahashi, PhD; Kunihiro Nishimura, MD, PhD; Yoshihiko Miyamoto, MD, PhD; Hisao Ogawa, MD, PhD; Masaharu Ishihara, MD, PhD on behalf of J-MINUET Investigators Background: The impact of chronic kidney disease (CKD) on long-term outcomes following acute myocardial infarction (AMI) in the era of modern primary PCI with optimal medical therapy is still in debate. Methods and Results: A total of 3,281 patients with AMI were enrolled in the J-MINUET registry, with primary PCI of 93.1% in STEMI. CKD stage on admission was classified into: no CKD (eGFR ≥60 mL/min/1.73 m2); moderate CKD (60>eGFR≥30 mL/ min/1.73 m2); and severe CKD (eGFR <30 mL/min/1.73 m2). While the primary endpoint was all-cause mortality, the secondary endpoint was major adverse cardiac events (MACE), defined as a composite of all-cause death, cardiac failure, myocardial infarction (MI) and stroke. Of the 3,281 patients, 1,878 had no CKD, 1,073 had moderate CKD and 330 had severe CKD. Pre-person-days age- and sex-adjusted in-hospital mortality significantly increased from 0.014% in no CKD through 0.042% in moderate CKD to 0.084% in severe CKD (P<0.0001). Three-year mortality and MACE significantly deteriorated from 5.09% and 15.8% in no CKD through 16.3% and 38.2% in moderate CKD to 36.7% and 57.9% in severe CKD, respectively (P<0.0001). C-index significantly increased from the basic model of 0.815 (0.788–0.841) to 0.831 (0.806–0.857), as well as 0.731 (0.708–0.755) to 0.740 (0.717– 0.764) when adding CKD stage to the basic model in predicting 3-year mortality (P=0.013; net reclassification improvement [NRI] 0.486, P<0.0001) and MACE (P=0.046; NRI 0.331, P<0.0001) respectively. Conclusions: CKD remains a useful predictor of in-hospital and 3-year mortality as well as MACE after AMI in the modern PCI and optimal medical therapy era. Key Words: Acute myocardial infarction; Chronic kidney disease; Major adverse cardiac events; Percutaneous coronary intervention Received October 28, 2020; revised manuscript received March 4, 2021; accepted March 17, 2021; J-STAGE Advance Publication released online June 3, 2021 Time for primary review: 34 days Department of Cardiology, Fujita Health University Hospital and FHU Okazaki Medical Center, Aichi (Y.H., Y.O., S.K., T.F.I., T. Muramatsu, H.I.); Saiseikai Kumamoto Hospital Cardiovascular Center, Kumamoto (K. Nakao); Cardiovascular Center, Yokohama City University Medical Center, Yokohama (K. Kimura); Department of Integrated Medicine, Kitasato University, Sagamihara (J.A.); Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita (T.N., S.Y., H.O.); Department of Cardiology, Juntendo University Shizuoka Hospital, Shizuoka (S.S.); Department of Cardiology, National Hospital Organization Kumamoto Medical Center, Kumamoto (K.F.); Department of Cardiology, Hiroshima City Hospital, Hiroshima (K.D.); Department of Cardiology, Osaka General Medical Center, Osaka (T. Morita); Department of Cardiovascular Medicine, Nippon Medical School, Tokyo (W.S.); Department of Cardiovascular Medicine, Nara Medical University, Kashihara (Y. Saito); Department of Cardiovascular Medicine, The Sakakibara Heart Institute of Okayama, Okayama (A.H.); Department (Footnote continued the next page.) Advance Publication 2 HASHIMOTO Y et al. hronic kidney disease (CKD) is known to be asso- ciated with adverse outcomes in patients presenting Editorial p ???? C with acute myocardial infarction (AMI).1–5 Serum creatinine is an important component of the GRACE one of the following: symptoms of ischemia: ECG changes score and similar scoring systems for the risk stratification indicative of new ischemia, development of pathological Q of patients presenting with acute coronary syndromes.6 waves in the ECG and imaging evidence of new loss of However, although these scoring systems have been derived viable myocardium or new regional wall motion abnor- from large robust multicenter international registry stud- malities. The type of cTn (cTnT or cTnI) measured ies, these were conducted over a decade ago.6 It is unclear depended on the attending physician, and the cut-off value whether advances in both the availability and deployment used at each institution was applied. Patients were evalu- of modern guideline-directed medical therapy, and espe- ated at baseline for demographic and clinical characteris- cially greater access to mechanical reperfusion therapy tics. STEMI was diagnosed in the presence of new ST using recent percutaneous coronary intervention (PCI) elevation at the J point in at least 2 contiguous leads ≥2 mm technology have altered outcomes in patients with CKD.7–9 (0.2 mV) in men or ≥1.5 mm (0.15 mV) in women in leads The status and importance of CKD as an independent risk V2–3 and/or ≥1 mm (0.1 mV) in other contiguous chest factor for short- and long-term mortality and major adverse leads or the limb leads.13,14 New or presumably new left cardiac events after AMI in the modern era of primary PCI bundle branch block was considered a STEMI equivalent. and recent advances in medical therapy therefore remains Urgent coronary angiography (CAG) was defined as angi- unresolved. ography performed within 48 h of hospital admission. We evaluated the prognostic significance of CKD on Optimal medical therapy (OMT) was defined as the use of in-hospital and 3-year cardiovascular outcomes in a large necessary medications for the control of cardiovascular contemporary registry cohort; the Japanese MINUET risk factors such as hypertension, diabetes, dyslipidemia study.10,11 In particular, we sought to determine the inde- and for the prevention of stent thrombosis (i.e., antiplatelet pendent impact of renal dysfunction on short- and long- therapy) based on guidelines.7–9,15 term adverse outcomes after AMI relative to potential Data on the treatment and in-hospital clinical events confounding-associated cardiovascular risk factors. were collected at the time of hospital discharge. Clinical 3-year follow up after the index MI was performed through Methods a review of medical records, telephone contact, and a mailed questionnaire.11 Study Design and Subjects This study was conducted in accordance with the Decla- The J-MINUET is a prospective observational multicenter ration of Helsinki. The protocol was approved by the eth- study (UMIN000010037). Consecutive patients hospital- ics committees of every participating institution. ized within 48 h of onset of AMI at 28 Japanese medical institutions were enrolled between July 2013 and May Study Endpoints 2014.10,11 Diagnosis of AMI was based on the ESC/ACC The primary endpoint was all-cause mortality for both in- Foundation (ACCF)/American Heart Association (AHA)/ hospital and at 3 years. The principal secondary endpoint World Heart Federation Task Force for the Universal was major adverse cardiac events (MACE), defined as a Definition of Myocardial Infarction.12 composite of all-cause death, myocardial infarction, cardiac Only type 1 AMI (spontaneous MI related to ischemia failure and stroke for both in-hospital and 3 years. Cardiac from a primary coronary event) and type 2 (MI secondary failure was defined as congestive heart failure and/or car- to ischemia because of either increased oxygen demand or diogenic shock that required treatment during the index decreased supply) were included in this registry. In brief, episode of hospitalization, or heart failure requiring re- AMI was diagnosed by the rise and/or fall of cardiac bio- hospitalization during follow up.11 Stroke was defined as markers (preferred: troponin) with at least 1 value above an acute episode of neurological dysfunction caused by the 99th percentile of the upper reference limit observed focal or global brain injury, regardless of whether the cause together with evidence of myocardial ischemia with at least was due to hemorrhage or infarction.11 Such definitions of of Cardiology, Ogaki Municipal Hospital, Ogaki (Y. Morita); Department of Cardiovascular Medicine, Dokkyo Medical University, Mibu (T.I.); Department of Cardiology, Sakurabashi Watanabe Hospital, Osaka (A.O.); Cardiovascular Center, Kansai Rosai Hospital, Amagasaki (T. Mano); Department of Cardiology, Okinawa Chubu Hospital, Uruma (M.W.); Division of Cardiology, Mitsui Memorial Hospital, Tokyo (K. Tanabe); Department of Cardiology, Miyazaki Medical Association Hospital, Miyazaki (Y. Shibata); Department of Cardiovascular Medicine, Suwa Red