Reference: Fox y colaboradores. Short-term Outcomes of Acute Myocardial Infarction in Patients with Acute Kidney Injury: A Report from the National Cardiovascular Data Registry. Circulation 2012 (in press).
The presence of chronic renal failure is common in patients referred for angioplasty. Its presence is associated with increased mortality and bleeding. However, the prevalence is unknown as is the impact of acute renal failure (ARF) in the context of acute myocardial infarction (AMI). In a recent analysis of the U.S. national registry and ACTION Registry ®-GWTG (N = 59 970, July 2008 to September 2009), ARF rate (change of creatinine > 0.3 mg / dl) was 16%. In this study, incidence of ARF was related to emergency surgery or the need for catheterization and the presence of multiple coronary risk factors. A higher mortality in patients with ARF (2.1% versus 15%, p <0.001), increase of mortality depended on the ARF severity (6.6% mild, moderate 14.2% and 31.8% severe). In addition, excess risk of death persisted even when patients in cardiogenic shock, emergency surgery or pre-existing renal insufficiency were excluded. Notably, ARF patients received fewer antithrombotic drugs and less revascularization than patients without ARF. Despite this, they had a higher risk of bleeding (22% versus 8.4%, p <0.01).
Discussion: Presence of ARF is common during AMI and its impact depends on the presence of coronary risk factors and stability of their clinical presentation. In this study, bleeding risk and death increased with the severity of ARF. In order to optimize medical and invasive treatment in this group of high risk patients, we must find a balance between bleeding and ischemic risk. Regardless of the presence of ARF, there are some maneuvers that can be implemented to improve the outcome in the context of percutaneous AMI: 1) Reducing door-to-ball time, 2) adopt a transradial approach which reduces bleeding risk in the vascular access site, 3) using bivalirudin as anticoagulant monotherapy which reduces bleeding risk, 4) use of new generation anti-thrombotic (prasugrel and ticagrelor). In particular, ticagrelor has proved more effective in reducing ischemic risk and is as safe as clopidogrel in acute coronary syndrome and chronic renal insufficiency patients. 5) Use low-dose aspirin (100-200 mg) when using ticagrelor or prasugrel. 6) Avoid treating vessel injuries or nonculprit lesions which reduces the number of stents implanted, a factor directly related to risk of thrombosis. 7) Pharmacological use of next-generation stents is probably beneficial due to their low thrombosis rate and high antiproliferative effect.
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