MedicalResearch.com Interview with:
Renato D. Lopes MD, MHS, PhD
Duke University Medical Center
Duke Clinical Research Institute
Durham, NC 27705
John P. Vavalle, MD, MHS
Assistant Professor of Medicine
Division of Cardiology
UNC Center for Heart & Vascular Care
Medical Research: What is the background for this study? What are the main findings?
Dr. Lopes: Patients with varying degrees of underlying renal failure who presented for primary percutaneous coronary intervention (PCI) for the treatment of ST-segment elevation myocardial infarction (STEMI) were studied as part of the APEX-AMI trial.
Baseline renal dysfunction portends a worse prognosis in patients undergoing PCI. However, the association between clinical outcomes and angiographic results with baseline renal function in this population of STEMI patients is not clearly defined. We report the results of a trial population with a full spectrum of underlying renal function (normal to dialysis dependent) and developed a prediction model for the development of acute kidney injury following primary percutaneous coronary intervention.
In summary, patients with worse underlying renal function had worse angiographic outcomes, higher mortality, and were less likely to be treated with evidence-based medications. The rate of acute kidney injury (AKI) after PCI appears to increase with worsening underlying renal function, except for those with Class IV chronic kidney disease where the rate of AKI was lowest. Our novel prediction model for the development of AKI found that the strongest predictors of AKI were age and presenting in Killip Class III or IV.
Medical Research: What should clinicians and patients take away from your report?
Dr. Vavalle: Underlying renal disease in patients presenting for primary PCI for the treatment of STEMI is associated not only with worse clinical outcomes, but also worse angiographic outcomes such as lower post-PCI coronary TIMI flow. An important finding of this study is that patients with worse underlying renal disease were much less likely to be treated with evidence-based medications. Clinicians need to be aware of this treatment paradox, as these are the patients most likely to benefit from evidence-based medications.
Medical Research: What recommendations do you have for future research as a result of this study?
Dr. Lopes: This study is unique because it represents one of the very few that includes STEMI patients treated with primary PCI with the full spectrum of underlying renal disease, including patients on dialysis. Historically, patients on dialysis have been excluded from trials like this. We need many more studies that include patients on dialysis to better understand how our treatments for heart disease work in this population. For many of the medications and therapies we use today, we must extrapolate from studies that did not include patients on dialysis and some of our assumptions may be wrong. Secondly, this treatment paradox of patients with worse renal function and worse outcomes being the least likely to receive evidence based care must be further studied. Is the lack of treatment with proven medications the cause of the worse outcomes, or a result of inability to safely use these medications in those who are most ill? Lastly, the AKI prediction model we have developed needs to be validated in other patient cohorts before we can confidently recommend its routine use in clinical practice.
Renal failure in patients with ST-segment elevation acute myocardial infarction treated with primary percutaneous coronary intervention: Predictors, clinical and angiographic features, and outcomes
Vavalle, John P. et al.
Published Online:December 11, 2015
American Heart Journal , Volume 0 , Issue 0 ,
Renato D. Lopes MD, MHS, PhD (2016). STEMI Patients With Kidney Disease Have Worse Clinical and Angiographic PCI Outcomes