Combined Value of Contrast-Induced Nephropathy and the CHA2DS2-VASc Score for Predicting Mortality in Patients with Acute Coronary Syndrome Who Were Undergoing Percutaneous Coronary Intervention

Year 2018, Volume: 21 Issue: 3, 211 - 216, 02.12.2018

Eyüp Avcı , Didar Elif Akgün Onursal Buğra Ahmet Dolapoğlu Aykan Çelik Tuncay Kırış

Abstract

Introduction:
Both contrast-induced nephropathy
(CIN) and CHA2DS2-VASc score have predictive value for mortality in patients
with acute coronary syndrome (ACS) who underwent percutaneous coronary
intervention (PCI), whereas the prognostic significance CHA2DS2-VASc of risk
score combined with CIN remains unclear. This study was designed to explore the
combined value of CIN and CHA2DS2-VASc score for predicting long-term
mortality in these patients.

Patients
and Methods: This
retrospective study included 1058 consecutive patients with ACS who were
treated with PCI. CIN was defined as a serum creatinine increase ≥ 0.5 mg/dL or
≥ 25% within 48-72 hours after contrast exposure. The patients were divided
into two groups, as survivors or nonsurvivors.

Results:
The
CHA2DS2-VASc score and CIN were independently predictive for all-cause
mortality (HR: 1.444, 95% CI: 1.327-1.572, p< 0.001; HR: 1.850, 95% CI:
1.298-2.637, p= 0.001, respectively). Also, multivessel diseases, Killip ≥ 2,
beta blockers, and ACE/ARB use at follow-up were independently risk factors for
all-cause mortality. Adding CIN on top of the CHA2DS2-VASc score yielded
superior risk-predictive capacity beyond CHA2DS2-VASc score alone
[AUC: 0.735 (0.701-0.769)], which is shown by improved AUC [AUC: 0.754
(0.720-0.787, difference p= 0.0149)] as well as net reclassification
improvement (NRI 28.5%, p< 0.001) and integrated discrimination improvement
(IDI 0.021, p< 0.001).

Conclusion:
Our
study demonstrated that combining the predictive value
of CIN and the CHA2DS2-VASc score yielded a more accurate
predictive value for long-term mortality in ACS patients who underwent PCI as
compared to the CHA2DS2-VASc score alone.

Keywords

Acute coronary syndrome, mortality, risk score, renal function

Perkütan Koroner Girişim Uygulanan Akut Koroner Sendromlu Hastalarda Kontrastla İlişkili Nefropati ve CHA2DS2-VASC Skoru Kombinasyonunun Mortalite için Öngördürücü Değeri

Abstract

Giriş: Kontrast madde nefropatisi (KMN)’nin ve CHA2DS2-VASc skorunun, perkütan
koroner girişim (PKG) uygulanan akut koroner sendromlu (AKS) hastalarda
mortalite için prediktif değeri vardır; oysaki KMN ile kombine edilmiş olan
CHA2DS2-VASc risk skorunun prognostik önemi belirsizliğini korumaktadır. Bu çalışma,
bu hastalarda uzun süreli mortaliteyi öngörmek için KMN ve CHA2DS2-VASc
skorunun kombine değerini araştırmak üzere tasarlanmıştır.

Hastalar ve
Yöntem: Bu retrospektif çalışmada PKG ile tedavi edilen
AKS’li 1058 hasta çalışmaya dahil edildi. KMN, kontrast maruziyetinden 48-72
saat sonra serum kreatinin ≥ 0.5 mg/dL veya ≥ %25 artışı olarak tanımlandı.
Hastalar sağ kalanlar ve ölenler olmak üzere iki gruba ayrıldı.

Bulgular: CHA2DS2-VASc skoru ve
KMN tüm nedenlere bağlı mortalitenin bağımsız 
öngördürücüleriydi (HR: 1.444, %95 CI: 1.327-1.572, p< 0.001; HR:
1.850, %95 CI: 1.298-2.637, p= 0.001, sırasıyla). Ayrıca çok damar hastalıkları,
killip ≥ 2, beta-bloker ve anjiyotensin dönüştürücü enzim/anjiyotensin reseptör
blokerleri (ACE/ARB) kullanımı izlemde tüm nedenlere bağlı mortalite için bağımsız
risk faktörleri idi. CHA2DS2-VASc skorunun üstüne KMN eklenmesi, tek başına
CHA2DS2-VASc skorunun (AUC: 0.735 (0.701-0.769)) ötesinde üstün risk tahmini
kapasitesi sağladı, bu da AUC: 0.754 (0.720-0.787, 0.0149)], net yeniden sınıflandırma
iyileştirme (NRI %28.5, p< 0.001) ve entegre ayrımcılık iyileştirmesi (IDI
0.021, p< 0.001) ile gösterildi.

Sonuç: Çalışmamızda, KMN ve CHA2DS2-VASc skoru kombinasyonunun prediktif değerinin, tek başına CHA2DS2-VASc skoruna kıyasla PKG yapılan hastalarda, uzun dönem mortalite için daha doğru bir öngörü değeri sağladığını gösterdik.

Keywords

Akut koroner sendrom, mortalite, risk skoru, renal fonksiyon

References

• 1. Amsterdam EA, Wenger NK, Brindis RG, Casey DE Jr, Ganiats TG, Holmes DR Jr, et al. 2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary .A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014;64:139-228.
• 2. Nakatani D, Sakata Y, Suna S, Usami M, Matsumoto S, Shimizu M, et al. Incidence, predictors, and subsequent mortality risk of recurrent myocardial infarction in patients following discharge for acute myocardial infarction. Circ J 2013;77:439-46.
• 3. Antman EM, Cohen M, Bernink PJ, McCabe CH, Horacek T, Papuchis G, et al. The TIMI risk score for unstable angina/non-ST elevation MI: A method for prognostication and therapeutic decision making. JAMA 2000;284:835-42.
• 4. Boersma E, Pieper KS, Steyerberg EW, Wilcox RG, Chang WC, Lee KL, et al. Predictors of outcome in patients with acute coronary syndromes without persistent ST-segment elevation. Results from an international trial of 9461 patients. The PURSUIT Investigators. Circulation 2000;101:2557-67.
• 5. Granger CB, Goldberg RJ, Dabbous O, Pieper KS, Eagle KA, Cannon CP, et al. Predictors of hospital mortality in the Global Registry of Acute Coronary Events. Arch Intern Med 2003;163:2345-53.
• 6. Camm AJ, Kirchhof P, Lip GY, Schotten U, Savelieva I, Ernst S, et al. Rutten FH Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). Eur Heart J 2010;31:2369-429.
• 7. Chua SK, Lo HM, Chiu CZ, Shyu KG. Use of CHADS2 and CHA2DS2-VASc scores to predict subsequent myocardial infarction, stroke, and death in patients with acute coronary syndrome: data from taiwan acute coronary syndrome full spectrum registry. PLoS One 2014;24:9:e 111167.
• 8. Poçi D, Hartford M, Karlsson T, Herlitz J, Edvardsson N, Caidahl K. Role of the CHADS2 score in acute coronary syndromes: risk of subsequent death or stroke in patients with and without atrial fibrillation. Chest 2012;141:1431-40.
• 9. Barra S, Almeida I, Caetano F, Providência R, Paiva L, Dinis P, et al. Stroke prediction with an adjusted R-CHA2DS2VASc score in a cohort of patients with a myocardial infarction. Thromb Res 2013;132:293-9.
• 10. McCullough PA, Stacul F, Becker CR, Adam A, Lameire N, Tumlin JA, et al. CIN Consensus Working Panel. Contrast-Induced Nephropathy (CIN) Consensus Working Panel: executive summary. Rev Cardiovasc Med 2006;7:177-97.
• 11. Lazaros G, Tsiachris D, Tousoulis D, Patialiakas A, Dimitriadis K, Roussos D, et al. In-hospital worsening renal function is an independent predictor of oneyear mortality in patients with acute myocardial infarction. Int J Cardiol 2012;155:97-101.
• 12. Steg PG, James SK, Atar D, Badano LP, Blömstrom-Lundqvist C, Borger MA, et al. ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology (ESC). Eur Heart J 2012;33:2569- 619.
• 13. Sacco RL, Kasner SE, Broderick JP, Caplan LR, Connors JJ, Culebras A et al. An updated definition of stroke for the 21st century: a statement for healthcare professionals from the American Heart Association/America Stroke Association. Stroke 2013;44:2064-89.
• 14. Lip GY, Nieuwlaat R, Pisters R, Lane DA, Crijns HJ. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation. Chest 2010;137:263-72.
• 15. DeLong ER, DeLong DM, Clarke-Pearson DL. Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach. Biometrics 1988;44:837-45.
• 16. Pencina MJ, D’Agostino RB Sr, Steyerberg EW. Extensions of net reclassification improvement calculations to measure usefulness of new biomarkers. Stat Med 2011;30:11-21.
• 17. January CT, Wann LS, Alpert JS, Calkins H, Cigarroa JE, Cleveland JC Jr, et al. 2014 AHA/ACC/HRS Guideline for the management of patients with atrial fibrillation: Executive Summary A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2014;64:2246-80.
• 18. John Camm A. Managing anticoagulation for atrial fibrillation: current issues and future strategies. J Intern Med 2013;273:31-41.
• 19. Avezum A, Makdisse M, Spencer F, Gore JM, Fox KA, Montalescot G, et al. GRACE Investigators. Impact of age on management and outcome of acute coronary syndrome: observations from the Global Registry of Acute Coronary Events (GRACE). Am Heart J. 2005;149:67-73.
• 20. Gustafsson F, Kober L, Torp-Pedersen C, Hildebrandt P, Ottesen MM, Sonne B, et al. Long-term prognosis after acute myocardial infarction in patients with a history of arterial hypertension. TRACE study group. Eur Heart J 1998;19:588-94.
• 21. Sarwar N, Gao P, Seshasai SR, Gobin R, Kaptoge S, Di Angelantonio E, et al. Diabetes mellitus, fasting blood glucose concentration, and risk of vascular disease: a collaborative meta-analysis of 102 prospective studies. Lancet 2010;375:2215-22.
• 22. Malmberg K, Yusuf S, Gerstein HC, Brown J, Zhao F, Hunt D, et al. Impact of diabetes on long-term prognosis in patients with unstable angina and non-Q-wave myocardial infarction: results of the OASIS (Organization to Assess Strategies for Ischemic Syndromes) Registry. Circulation 2000;102:1014-9.
• 23. Herman B, Greiser E, Pohlabeln H. A sex difference in short-term survival after initial acute myocardial infarction. The MONICA-Bremen Acute Myocardial Infarction Register, 1985-1990. Eur Heart J 1997;18:963-70.
• 24. Hochman JS, Tamis JE, Thompson TD, Weaver WD, White HD, Van de Werf F, et al. Sex, clinical presentation, and outcome in patients with acute coronary syndromes. Global Use of Strategies to Open Occluded Coronary Arteries in Acute Coronary Syndromes IIb Investigators. N Engl J Med 1999;341:226-32.
• 25. Kim KH, Kim W, Hwang SH, Kang WY, Cho SC, Kim W, et al. Other Korean Working Group in Myocardial Infarction Registry Investigators. The CHA2DS2VASc score can be used to stratify the prognosis of acute myocardial infarction patients irrespective of presence of atrial fibrillation. J Cardiol 2015;65:121-7.
• 26. Ferrer-Hita JJ, Dominguez-Rodriguez A, Garcia-Gonzalez MJ, Abreu-Gonzalez P. Renal dysfunction is an independent predictor of in-hospital mortality in patients with ST-segment elevation myocardial infarction treated with primary angioplasty. Int J Cardiol. 2007 31;118:243-5.
• 27. Koreny M, Karth GD, Geppert A, Neunteufl T, Priglinger U, Heinz G, et al. Prognosis of patients who develop acute renal failure during the first 24 hours of cardiogenic shock after myocardial infarction. Am J Med 2002;112:115-9.
• 28. Marenzi G, Assanelli E, Campodonico J, Lauri G, Marana I, De Metrio M, et al. Contrast volume during primary percutaneous coronary intervention and subsequent contrast-induced nephropathy and mortality. Ann Intern Med 2009;150:170-7.
• 29. Murata N, Kaneko H, Yajima J, Oikawa Y, Oshima T, Tanaka S, et al. The prognostic impact of worsening renal function in Japanese patients undergoing percutaneous coronary intervention with acute coronary syndrome. J Cardiol 2015;66:326-32.
• 30. Hsieh MJ, Chen YC, Chen CC, Wang CL, Wu LS, Wang CC. Renal dysfunction on admission, worsening renal function, and severity of acute kidney injury predict 2-year mortality in patients with acute myocardial infarction. Circ J 2013;77:217-23.
• 31. Caccamo G, Bonura F, Bonura F, Vitale G, Novo G, Evola S, et al. Insulin resistance and acute coronary syndrome. Atherosclerosis 2010;211:672-5.
• 32. Taki K, Takayama F, Tsuruta Y, Niwa T. Oxidative stress, advanced glycation end product, and coronary artery calcification in hemodialysis patients. Kidney Int 2006;70:218-24.
• 33. Zoccali C. The endothelium as a target in renal diseases. J Nephrol 2007;20:39-44.
• 34. Hanna EB, Chen AY, Roe MT, Saucedo JF. Characteristics and in-hospital outcomes of patients presenting with non-ST-segment elevation myocardial infarction found to have significant coronary artery disease on coronary angiography and managed medically: stratification according to renal function. Am Heart J 2012;164:52-7.
• 35. Liu Y, Gao L, Xue Q, Yan M, Chen P, Wang Y, et al. Impact of renal dysfunction on long-term outcomes of elderly patients with acute coronary syndrome: a longitudinal, prospective observational study. BMC Nephrol 2014;9;15:78.