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1 October 2002 | Volume 137 Issue 7 | Pages 555-562
Background: Patients with end-stage renal disease are known to have decreased survival after myocardial infarction, but the association of less severe renal dysfunction with survival after myocardial infarction is unknown.
Objectives: To determine how patients with renal insufficiency are treated during hospitalization for myocardial infarction and to determine the association of renal insufficiency with survival after myocardial infarction.
Design: Cohort study.
Setting: All nongovernment hospitals in the United States.
Patients: 130 099 elderly patients with myocardial infarction hospitalized between April 1994 and July 1995.
Measurements: Patients were categorized according to initial serum creatinine level: no renal insufficiency (creatinine level < 1.5 mg/dL [<132 µmol/L]; n = 82 455), mild renal insufficiency (creatinine level, 1.5 to 2.4 mg/dL [132 to 212 µmol/L]; n = 36 756), or moderate renal insufficiency (creatinine level, 2.5 to 3.9 mg/dL [221 to 345 µmol/L]; n = 10 888). Vital status up to 1 year after discharge was obtained from Social Security records.
Results: Compared with patients with no renal insufficiency, patients with moderate renal insufficiency were less likely to receive aspirin, ß-blockers, thrombolytic therapy, angiography, and angioplasty during hospitalization. One-year mortality was 24% in patients with no renal insufficiency, 46% in patients with mild renal insufficiency, and 66% in patients with moderate renal insufficiency (P < 0.001). After adjustment for patient and treatment characteristics, mild (hazard ratio, 1.68 [95% CI, 1.63 to 1.73]) and moderate (hazard ratio, 2.35 [CI, 2.26 to 2.45]) renal insufficiency were associated with substantially elevated risk for death during the first month of follow-up. This increased mortality risk continued until 6 months after myocardial infarction.
Conclusions: Renal insufficiency was an independent risk factor for death in elderly patients after myocardial infarction. Targeted interventions may be needed to improve treatment for this high-risk population.
Editors' Notes
Context
Contribution
Implications
–The Editors
Author and Article Information
From San Francisco Veterans Affairs Medical Center and University of California, San Francisco, San Francisco, California; Palo Alto Veterans Affairs Medical Center and Stanford University, Palo Alto, California; and Toyo-Eiwa University, Kanagawa, Japan.
Acknowledgments: The authors thank Dr. Eric Vittinghoff for his contributions to this manuscript.
Grant Support: By the Centers for Medicare & Medicaid Services (formerly the Health Care Financing Administration) (500-96-P535) and the National Institute on Aging. Dr. Shlipak and Dr. Heidenreich are Research Career Development Awardees from the Health Research and Development Division of the Veterans Administration. Dr. Shlipak is also supported by the National Heart, Lung, and Blood Institute (RO3 HL68099-01).
Requests for Single Reprints: Michael G. Shlipak, MD, MPH, General Internal Medicine Section, Veterans Affairs Medical Center (111A1), 4150 Clement Street, San Francisco, CA 94121; e-mail, shlip{at}itsa.ucsf.edu.
Current Author Addresses: Dr. Shlipak: General Internal Medicine Section, Veterans Affairs Medical Center (111A1), 4150 Clement Street, San Francisco, CA 94121.
Dr. Heidenreich: Veterans Affairs Palo Alto Health Care System, 3801 Miranda Avenue, Palo Alto, CA 94304.
Dr. Noguchi: Toyo-Eiwa University, 32 Miho-cho, Midoritau, Yokohama, Kanagawa, Japan 226-0015.
Dr. Chertow: Division of Nephrology, University of California, San Francisco, 3333 California Street, Suite 430, San Francisco, CA 94118.
Dr. Browner: California Pacific Medical Center, 2340 Clay Street, Room 114, San Francisco, CA 94115.
Dr. McClellan: Council of Economics Advisor, The White House, Eisenhower Executive Building, Room 320, Washington, DC 20502.
Author Contributions: Conception and design: M.G. Shlipak, W.S. Browner, M.B. McClellan.
Analysis and interpretation of the data: M.G. Shlipak, P.A. Heidenreich, H. Noguchi, G.M. Chertow, W.S. Browner.
Drafting of the article: M.G. Shlipak, W.S. Browner.
Critical revision of the article for important intellectual content: M.G. Shlipak, P.A. Heidenreich, G.M. Chertow, W.S. Browner.
Final approval of the article: M.G. Shlipak, P.A. Heidenreich, G.M. Chertow, W.S. Browner, M.B. McClellan.
Provision of study materials or patients: M.B. McClellan.
Statistical expertise: M.G. Shlipak, H. Noguchi, W.S. Browner, M.B. McClellan.
Obtaining of funding: M.B. McClellan.
Collection and assembly of data: H. Noguchi. ARTICLE
Association of Renal Insufficiency with Treatment and Outcomes after Myocardial Infarction in Elderly Patients
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M. Sachdev, J. L. Sun, A. A. Tsiatis, C. L. Nelson, D. B. Mark, and J. G. Jollis The prognostic importance of comorbidity for mortality in patients with stable coronary artery disease J. Am. Coll. Cardiol., February 18, 2004; 43(4): 576 - 582. [Abstract] [Full Text] [PDF]
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A. M. O'Hare, J. Feinglass, G. E. Reiber, R. A. Rodriguez, J. Daley, S. Khuri, W. G. Henderson, and K. L. Johansen Postoperative Mortality after Nontraumatic Lower Extremity Amputation in Patients with Renal Insufficiency J. Am. Soc. Nephrol., February 1, 2004; 15(2): 427 - 434. [Abstract] [Full Text] [PDF]
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M. Trovati and F. Cavalot Optimization of Hypolipidemic and Antiplatelet Treatment in the Diabetic Patient with Renal Disease J. Am. Soc. Nephrol., January 1, 2004; 15(90010): S12 - 20. [Abstract] [Full Text]
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G. Leoncini, F. Viazzi, D. Parodi, E. Ratto, S. Vettoretti, V. Vaccaro, M. Ravera, G. Deferrari, and R. Pontremoli Mild Renal Dysfunction and Cardiovascular Risk in Hypertensive Patients J. Am. Soc. Nephrol., January 1, 2004; 15(90010): S88 - 90. [Abstract] [Full Text]
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H. M. Sadeghi, G. W. Stone, C. L. Grines, R. Mehran, S. R. Dixon, A. J. Lansky, M. Fahy, D. A. Cox, E. Garcia, J. E. Tcheng, et al. Impact of Renal Insufficiency in Patients Undergoing Primary Angioplasty for Acute Myocardial Infarction Circulation, December 2, 2003; 108(22): 2769 - 2775. [Abstract] [Full Text] [PDF]
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J. H. Ix, M. G. Shlipak, H. H. Liu, N. B. Schiller, and M. A. Whooley Association between Renal Insufficiency and Inducible Ischemia in Patients with Coronary Artery Disease: The Heart and Soul Study J. Am. Soc. Nephrol., December 1, 2003; 14(12): 3233 - 3238. [Abstract] [Full Text] [PDF]
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C. M. Gibson, D. S. Pinto, S. A. Murphy, D. A. Morrow, H.-P. Hobbach, S. D. Wiviott, R. P. Giugliano, C. P. Cannon, E. M. Antman, E. Braunwald, et al. Association of creatinine and creatinine clearance on presentation in acute myocardial infarction with subsequent mortality J. Am. Coll. Cardiol., November 5, 2003; 42(9): 1535 - 1543. [Abstract] [Full Text] [PDF]
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W. J. French and R. S. Wright Renal insufficiency and worsened prognosis with STEMI: A call for action J. Am. Coll. Cardiol., November 5, 2003; 42(9): 1544 - 1546. [Full Text] [PDF]
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M. J. Sarnak, A. S. Levey, A. C. Schoolwerth, J. Coresh, B. Culleton, L. L. Hamm, P. A. McCullough, B. L. Kasiske, E. Kelepouris, M. J. Klag, et al. Kidney Disease as a Risk Factor for Development of Cardiovascular Disease: A Statement From the American Heart Association Councils on Kidney in Cardiovascular Disease, High Blood Pressure Research, Clinical Cardiology, and Epidemiology and Prevention Hypertension, November 1, 2003; 42(5): 1050 - 1065. [Full Text] [PDF]
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M. J. Sarnak, A. S. Levey, A. C. Schoolwerth, J. Coresh, B. Culleton, L. L. Hamm, P. A. McCullough, B. L. Kasiske, E. Kelepouris, M. J. Klag, et al. Kidney Disease as a Risk Factor for Development of Cardiovascular Disease: A Statement From the American Heart Association Councils on Kidney in Cardiovascular Disease, High Blood Pressure Research, Clinical Cardiology, and Epidemiology and Prevention Circulation, October 28, 2003; 108(17): 2154 - 2169. [Full Text] [PDF]
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R. Dikow and E. Ritz Cardiovascular complications in the diabetic patient with renal disease: an update in 2003 Nephrol. Dial. Transplant., October 1, 2003; 18(10): 1993 - 1998. [Full Text] [PDF]
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C. A. Herzog How to Manage the Renal Patient with Coronary Heart Disease: The Agony and the Ecstasy of Opinion-Based Medicine J. Am. Soc. Nephrol., October 1, 2003; 14(10): 2556 - 2572. [Full Text] [PDF]
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A. O. Ojo, P. J. Held, F. K. Port, R. A. Wolfe, A. B. Leichtman, E. W. Young, J. Arndorfer, L. Christensen, and R. M. Merion Chronic Renal Failure after Transplantation of a Nonrenal Organ N. Engl. J. Med., September 4, 2003; 349(10): 931 - 940. [Abstract] [Full Text] [PDF]
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J J Santopinto, K A A Fox, R J Goldberg, A Budaj, G Pinero, A Avezum, D Gulba, J Esteban, J M Gore, J Johnson, et al. Creatinine clearance and adverse hospital outcomes in patients with acute coronary syndromes: findings from the global registry of acute coronary events (GRACE) Heart, September 1, 2003; 89(9): 1003 - 1008. [Abstract] [Full Text] [PDF]
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K. C. Abbott, C. M. Yuan, A. J. Taylor, D. F. Cruess, and L. Y. C. Agodoa Early Renal Insufficiency and Hospitalized Heart Disease after Renal Transplantation in the Era of Modern Immunosuppression J. Am. Soc. Nephrol., September 1, 2003; 14(9): 2358 - 2365. [Abstract] [Full Text] [PDF]
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D. A. Morrow and E. Braunwald Future of Biomarkers in Acute Coronary Syndromes: Moving Toward a Multimarker Strategy Circulation, July 22, 2003; 108(3): 250 - 252. [Full Text] [PDF]
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A. K. Berger, S. Duval, and H. M. Krumholz Aspirin, beta-blocker, and angiotensin-converting enzyme inhibitor therapy in patients with end-stage renal disease and an acute myocardial infarction J. Am. Coll. Cardiol., July 16, 2003; 42(2): 201 - 208. [Abstract] [Full Text] [PDF]
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C. R. Conti Management of patients with acute myocardial infarction and end-stage renal disease J. Am. Coll. Cardiol., July 16, 2003; 42(2): 209 - 210. [Full Text] [PDF]
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J. S. Zebrack, J. L. Anderson, S. Beddhu, B. D. Horne, T. L. Bair, A. Cheung, J. B. Muhlestein, and Intermountain Heart Collaborative Study Group Do associations with C-Reactive protein and extent of coronary artery disease account for the increased cardiovascular risk of renal insufficiency? J. Am. Coll. Cardiol., July 2, 2003; 42(1): 57 - 63. [Abstract] [Full Text] [PDF]
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K. C. Abbott, L. Y. Agodoa, and P. G. O'Malley Hospitalized Psychoses after Renal Transplantation in the United States: Incidence, Risk Factors, and Prognosis J. Am. Soc. Nephrol., June 1, 2003; 14(6): 1628 - 1635. [Abstract] [Full Text] [PDF]
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P. A. James, A. J. Hartz, B. T. Levy, J. Z. Ayanian, M. B. Landrum, and P. Gaccione Specialty of Ambulatory Care Physicians and Mortality after Myocardial Infarction N. Engl. J. Med., March 27, 2003; 348(13): 1288 - 1289. [Full Text] [PDF]
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R. R. Townsend Cardiac Mortality in Chronic Kidney Disease: A Clearer Perspective Ann Intern Med, October 1, 2002; 137(7): 615 - 616. [Full Text] [PDF]
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