Short-term outcomes of acute myocardial infarction in patients with acute kidney injury: a report from the national cardiovascular data registry

Abstract

Background: Acute kidney injury (AKI) is a risk factor for long-term adverse outcomes, including acute myocardial infarction and death. However, the relationship between severity of AKI and in-hospital outcomes in the setting of acute myocardial infarction has not been well documented.

Methods and results: The study population (n = 59,970) was drawn from the Acute Coronary Treatment and Intervention Outcomes Network (ACTION) Registry-Get With the Guidelines (GWTG), a nationwide sample of myocardial infarction patients admitted to 383 hospitals in the United States between July 2008 and September 2009. AKI was defined using absolute changes in serum creatinine (SCr; peak SCr minus admission SCr) and categorized as no AKI (SCr change, <0.3 mg/dL), mild AKI (SCr change, 0.3-<0.5 mg/dL), moderate AKI (SCr change, 0.5-<1.0 mg/dL), and severe AKI (SCr change, ≥1.0 mg/dL). Overall, 16.1% had AKI, including 6.5% with mild AKI, 5.6% with moderate AKI, and 4.0% with severe AKI. In-hospital mortality rates for those with mild, moderate, and severe AKI were 6.6%, 14.2%, and 31.8% compared with 2.1% in those without AKI. The odds ratios for in-hospital death were 2.4 (95% confidence interval, 2.0-2.7), 4.5 (95% confidence interval, 3.9-5.1), and 12.6 (95% confidence interval, 11.1-14.3) for mild, moderate, and severe AKI compared with those without AKI. Although patients with AKI were less likely to undergo early invasive care or to receive antiplatelet therapies, rates of major bleeding ranged from 8.4% (no AKI) to 32.7% (severe AKI).

Conclusion: AKI is common and associated with mortality and bleeding, underscoring the importance of efforts to identify risk factors and to prevent AKI in acute myocardial infarction care.

Conflict of interest statement

Conflict of Interest Disclosures: Dr. Roe: Research funding: Eli Lilly, Novartis, Merck-Schering Plough, Bristol-Myers Squibb, American College of Cardiology, American Heart Association. Consulting or honoraria: Glaxo Smith Kline, KAI Pharmaceuticals, Novartis, Eli Lilly, Bristol-Myers Squibb, Sanofi-Aventis, Astra Zeneca. Dr. Wiviott: Research funding: Daiichi Sankyo, Eli Lilly, and Schering-Plough. Consulting: AstraZeneca, Bristol-Myers Squibb, and Sanofi-Aventis, Arena. Honoraria: Bristol-Myers Squibb, Daiichi Sankyo, Eli Lilly, Schering-Plough, Merck, the Medicine’s Company, Bayer. ACTION-GTWG Registry is administered by the American College of Cardiology Foundation (ACCF) and is sponsored by Bristol-Myers Squibb/Sanofi Pharmaceuticals Partnership, Genentech, and Schering-Plough Corporation

Figures

Figure 1

Prevalence of AKI by category (mild, moderate, severe) by baseline CKD admission status.

Figure 2

Mortality rates and multivariable-adjusted* Odds ratios for mortality by AKI category (mild, moderate, severe) among A) the overall sample and those without shock; B) those with and without CKD at presentation; C) those who did and did not undergo a CABG during their hospitalization. All unadjusted and adjusted p-value (trend) < 0.001. *Covariates in the multivariable-adjusted model include: age, prior peripheral arterial disease, systolic blood pressure (SBP) on presentation, heart rate on presentation, heart failure (HF) or shock on admission (HF only, shock only or HF with shock, vs. none), electrocardiographic findings (STEMI, ST-segment depression or transient ST-segment elevation vs. no ST-segment changes), initial troponin ratio, and initial serum creatinine. ST-segment changes included ST depression or transient ST elevations and no ST-segment changes included T-wave inversions and no electrocardiogram changes.

Figure 2

Mortality rates and multivariable-adjusted* Odds ratios for mortality by AKI category (mild, moderate, severe) among A) the overall sample and those without shock; B) those with and without CKD at presentation; C) those who did and did not undergo a CABG during their hospitalization. All unadjusted and adjusted p-value (trend) < 0.001. *Covariates in the multivariable-adjusted model include: age, prior peripheral arterial disease, systolic blood pressure (SBP) on presentation, heart rate on presentation, heart failure (HF) or shock on admission (HF only, shock only or HF with shock, vs. none), electrocardiographic findings (STEMI, ST-segment depression or transient ST-segment elevation vs. no ST-segment changes), initial troponin ratio, and initial serum creatinine. ST-segment changes included ST depression or transient ST elevations and no ST-segment changes included T-wave inversions and no electrocardiogram changes.

Figure 2

Mortality rates and multivariable-adjusted* Odds ratios for mortality by AKI category (mild, moderate, severe) among A) the overall sample and those without shock; B) those with and without CKD at presentation; C) those who did and did not undergo a CABG during their hospitalization. All unadjusted and adjusted p-value (trend) < 0.001. *Covariates in the multivariable-adjusted model include: age, prior peripheral arterial disease, systolic blood pressure (SBP) on presentation, heart rate on presentation, heart failure (HF) or shock on admission (HF only, shock only or HF with shock, vs. none), electrocardiographic findings (STEMI, ST-segment depression or transient ST-segment elevation vs. no ST-segment changes), initial troponin ratio, and initial serum creatinine. ST-segment changes included ST depression or transient ST elevations and no ST-segment changes included T-wave inversions and no electrocardiogram changes.

Figure 3

Mortality rates by ACTION mortality risk category (x-axis; 1=low risk; 4=high risk) and AKI category (y-axis).

Figure 3

Mortality rates by ACTION mortality risk category (x-axis; 1=low risk; 4=high risk) and AKI category (y-axis).