Relation between Renal Dysfunction and Cardiovascular Outcomes after Myocardial Infarction

TLDR

Coexisting conditions, especially renal failure, markedly worsen outcomes after acute myocardial infarction, but the impact of milder renal impairment remains unclear. To evaluate how varying degrees of renal dysfunction affect mortality and cardiovascular outcomes in patients with acute myocardial infarction. The VALIANT trial randomized 14,527 AMI patients to captopril, valsartan, or both, estimated GFR using the MDRD equation, grouped patients into four GFR categories, and applied a 70‑variable model to compare mortality and cardiovascular events across these groups. Lower estimated GFR was associated with higher prevalence of risk factors, lower use of guideline‑directed therapies, and a progressively increased risk of death or major cardiovascular events, with each 10‑ml decline below 81 ml/min/1.73 m² conferring a 10 % higher hazard independent of treatment.

Abstract

The presence of coexisting conditions has a substantial effect on the outcome of acute myocardial infarction. Renal failure is associated with one of the highest risks, but the influence of milder degrees of renal impairment is less well defined.As part of the Valsartan in Acute Myocardial Infarction Trial (VALIANT), we identified 14,527 patients with acute myocardial infarction complicated by clinical or radiologic signs of heart failure, left ventricular dysfunction, or both, and a documented serum creatinine measurement. Patients were randomly assigned to receive captopril, valsartan, or both. The glomerular filtration rate (GFR) was estimated by means of the four-component Modification of Diet in Renal Disease equation, and the patients were grouped according to their estimated GFR. We used a 70-candidate variable model to adjust and compare overall mortality and composite cardiovascular events among four GFR groups.The distribution of estimated GFR was wide and normally shaped, with a mean (+/-SD) value of 70+/-21 ml per minute per 1.73 m2 of body-surface area. The prevalence of coexisting risk factors, prior cardiovascular disease, and a Killip class of more than I was greatest among patients with a reduced estimated GFR (less than 45.0 ml per minute per 1.73 m2), and the use of aspirin, beta-blockers, statins, or coronary-revascularization procedures was lowest in this group. The risk of death or the composite end point of death from cardiovascular causes, reinfarction, congestive heart failure, stroke, or resuscitation after cardiac arrest increased with declining estimated GFRs. Although the rate of renal events increased with declining estimated GFRs, the adverse outcomes were predominantly cardiovascular. Below 81.0 ml per minute per 1.73 m2, each reduction of the estimated GFR by 10 units was associated with a hazard ratio for death and nonfatal cardiovascular outcomes of 1.10 (95 percent confidence interval, 1.08 to 1.12), which was independent of the treatment assignment.Even mild renal disease, as assessed by the estimated GFR, should be considered a major risk factor for cardiovascular complications after a myocardial infarction.