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Reperfusion in Patients With Renal Dysfunction After Presentation With ST-Segment Elevation or Left Bundle Branch Block

GRACE (Global Registry of Acute Coronary Events)

Caroline Medi, MBBS, FRACP^_*, Gilles Montalescot, MD, PhD, Andrzej Budaj, MD, PhD, Keith A.A. Fox, MB, ChB, FRCP, José López-Sendón, MD, FACC^||, Gordon FitzGerald, PhD^¶, David B. Brieger, MBBS, PhD, FRACP, FACC^_*,_* on behalf of the GRACE Investigators

^_* Coronary Care Unit, Concord Hospital, Sydney, Australia
Department of Cardiology, Centre Hospitalier Universitaire Pitié-Salpêtrière, Paris, France
Postgraduate Medical School, Department of Cardiology, Grochowski Hospital, Warsaw, Poland
Cardiovascular Research, Division of Medical & Radiological Sciences, The University of Edinburgh, Edinburgh, Scotland
^|| Department of Cardiology, Hospital Universitario Gregorio Marañón, Madrid, Spain
^¶ Center for Outcomes Research, University of Massachusetts Medical School, Worcester, Massachusetts

^_* Reprint requests and correspondence: Dr. David B. Brieger, Concord Repatriation General Hospital, Coronary Care Unit, Level 3, Multi Building, Hospital Road, Concord, NSW Australia 2139 (Email: davidb{at}email.cs.nsw.gov.au).

Objectives: We investigated the relative benefit of reperfusion strategies in renal dysfunction and ST-segment elevation/left bundle branch block (STE/LBBB).

Background: Few data are available informing the treatment of STE myocardial infarction in the presence of renal dysfunction.

Methods: Patients (N = 12,532) from the GRACE (Global Registry of Acute Coronary Events) presenting with STE/LBBB were stratified by renal function and receipt of fibrinolysis, primary percutaneous coronary intervention (PCI), or neither.

Results: As renal function declined, hospital mortality increased and reperfusion decreased (both p < 0.001). Compared with no reperfusion, primary PCI was associated with lower hospital mortality in patients with normal renal function (1.9% vs. 3.7%, p = 0.001, adjusted) but no reduction in those with renal dysfunction (14% vs. 15% for glomerular filtration rate [GFR] 30 to 59 ml/min/1.73 m²; 29% vs. 32% for GFR <30 ml/min/1.73 m²). Fibrinolysis was not associated with lower hospital mortality for normal (3.1% vs. 3.7%, p = NS) or low renal function (32% vs. 32%, p = NS) and with higher mortality with moderate renal dysfunction (adjusted odds ratio: 1.35, 95% confidence interval: 1.01 to 1.80). Primary PCI was associated with increased hospital bleeding and fibrinolysis with increased stroke in all patients. Among hospital survivors, primary PCI, but not fibrinolysis, was associated with lower mortality for moderate dysfunction. Both reperfusion strategies were associated with higher mortality for severe dysfunction.

Conclusions: In STE/LBBB and renal dysfunction, mortality rates are high and reperfusion rates are lower. In moderate renal dysfunction, primary PCI is associated with mortality reduction at 6 months. Outcomes remain poor with severe renal dysfunction, despite receipt of reperfusion therapy.

Key Words: fibrinolysis • percutaneous coronary intervention • renal dysfunction • left bundle branch block • ST-segment elevation

Abbreviations and Acronyms   ACS = acute coronary syndrome   GFR = glomerular filtration rate   LBBB = left bundle branch block   OR = odds ratio   PCI = percutaneous coronary intervention   STE = ST-segment elevation   STEMI = ST-segment elevation myocardial infarction

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