Relation of the severity of contrast induced nephropathy to SYNTAX score and long term prognosis in patients treated with primary percutaneous coronary intervention

doi:10.1016/j.ijcard.2013.04.166

International Journal of Cardiology

Volume 168, Issue 4, 9 October 2013, Pages 3480-3485

https://doi.org/10.1016/j.ijcard.2013.04.166 Get rights and content

Abstract

Background

SYNTAX score (SXscore) has been developed to assess the severity and complexity of coronary artery disease. The aim of this study was to evaluate whether baseline SXscore was associated with contrast induced nephropathy (CIN) after primary percutaneous coronary intervention (p-PCI) in patients with ST-elevation myocardial infarction (STEMI). Secondarily we aimed to investigate the relation of the severity of CIN to long term prognosis.

Methods

We retrospectively enrolled 1893 patients with STEMI treated by p-PCI. We prospectively followed up the patients for a mean duration of 45 months. The patients were grouped according to the development of no nephropathy (grade 0, n: 1634), mild nephropathy (grade 1, n: 153) or severe nephropathy (grade 2, n: 106).

Results

SXscore was significantly higher (19.4 ± 5.9 vs 15.6 ± 4.8, p < 0.001) in patients with CIN (grades 1 and 2) compared to those without CIN. SXscore was higher in patients with grade 2 CIN compared to those with grade 1 CIN (18.5 ± 5.7 vs 20.7 ± 5.9, p < 0.001). In the multivariate analysis, SXscore was identified as an independent predictor of CIN (for one unit increment, OR: 1.06, 95% CI: 1.01–1.14, p = 0.006). At long-term follow-up, death (p < 0.001), stroke (p = 0.006), reinfarction (p = 0.024) and permanent HD requirement (p < 0.001) were most frequent in grade 2 nephropathy group. HD was associated with very high in-hospital (60%) and long-term (83.3%) mortality rates.

Conclusions

SXscore is an independent predictor of development and severity of CIN after p-PCI. CIN is associated with poor prognosis during both early and late postinfarction period.

Introduction

Contrast-induced nephropathy (CIN) is a significant cause of acute renal failure in patients with acute ST segment elevation myocardial infarction, treated by primary percutaneous coronary intervention (p-PCI). CIN is related to increased mortality rates [1], [2]. The most commonly accepted definition of CIN is > 25% or > 0.5 mg/dl increase of baseline creatinine values during postprocedural first 48/72 h [3], [4]. A >50% or >1 mg/dl increase in creatinine levels [5], [6] or >2 times or >2 mg/dl increase in the baseline creatinine level or requirement of hemodialysis following the procedure are alternative definitions [7]. Harjai et al., graded CIN according to the level of creatinine elevation (grade 0: < 25% increase, grade 1: > 25% but < 0.5 mg/dl increase, grade 2: > 25% and > 0.5 mg/dl increase) and reported significant relation of the severity of CIN to clinical outcomes [8]. SYNTAX score (SXscore) is a useful scoring system that has been developed to assess the severity and complexity of coronary artery disease (CAD) in order to determine the appropriate revascularization strategy [9], [10]. It has been recently demonstrated that SXscore was associated with post-procedural no-reflow [11], renal functions [12], mortality and revascularization [13] in patients who underwent p-PCI.

We investigated whether SXscore was related to development and severity of CIN. Furthermore we evaluated the relation of the presence and severity of CIN to long-term cardiovascular events (death, stroke, revascularization, reinfarction, and heart failure) and hemodialysis requirement.

Section snippets

Study population

We retrospectively reviewed 2501 patients with acute STEMIs who were admitted to the Kartal Kosuyolu Heart Education and Research Hospital and underwent p-PCI between January 2006 and August 2009. We prospectively followed up the patients for a mean duration of 45 months. The inclusion criteria were as follows: (a) presentation within the first 12 h of the onset of chest pain, (b) ST elevation of at least 1 mm in two or more contiguous leads (2 mm for leads V1–V3), or new-onset left bundle branch

Patient characteristics

CIN developed in 259 (13.7%) of the 1893 (368 females, mean age 57.6) study patients, 106 of which had grade 2 nephropathy (5.6% of total population). The incidences of comorbidities such as advanced age, diabetes, hypertension and peripheral artery disease, presentation with cardiogenic shock, periprocedural hypotension, prolonged reperfusion time and intraaortic balloon pump use were significantly higher in patients who developed grade 2 nephropathy. Blood glucose, CRP, uric acid and

Discussion

The main findings of this study can be summarized as follows: Baseline SXscore predicts development and severity of CIN independent of the contrast volume used. The incidences of heart failure, stroke, major bleeding, hemodynamic instability and death were higher in patients with CIN during early in-hospital period. Likewise, death, stroke, reinfarction and rehospitalization due to worsening heart failure were more frequent in patients with CIN at long term follow-up. The differences were even

Conclusions

SXscore is an independent predictor for development and severity of CIN in STEMI patients treated with p-PCI. CIN, particularly grade 2 nephropathy is associated with very high rates of adverse cardiovascular events both during in-hospital period and at long term follow-up. Long term HD requirement is very frequent in patients with grade 2 nephropathy and high SXscore. The prognosis in patients who required HD is very poor.

Acknowledgments

The authors of this manuscript have certified that they comply with the principles of ethical publishing in the International Journal of Cardiology.

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The Target Vessel SYNTAX Score: A Novel Pre-Procedural Predictor for Contrast-Induced Acute Kidney Injury After Rotational Atherectomy
2023, Cardiovascular Revascularization Medicine
Rotational atherectomy (RA) is a complex procedure often associated with high contrast load. Known risk scores do not predict contrast-induced acute kidney injury (CI-AKI) before RA. We aim to investigate pre-procedural predictors of CI-AKI after RA, and the role of the target vessel SYNTAX score (tvSS).
Among 295 patients who underwent RA between 01.2010 and 02.2019 at a single center, 49 developed CI-AKI. Those who were on chronic hemodialysis or with no available 48-h' kidney function tests were excluded. Predictors of CI-AKI were assessed in the whole cohort and those with no basal renal impairment.
The rate of CI-AKI was 16.6 %. The tvSS was 18 [14–23] vs. 12 [9–18] in patients with vs. without CI-AKI (p < 0.001). The tvSS cut-off value of 15 provided 75 % sensitivity and 60 % specificity for predicting CI-AKI. Consequently, a tvSS ≥15 emerged as an independent pre-procedural predictor for CI-AKI (adjusted OR: 4.94, 95 % CI: 2.38–10.20, p < 0.001), along with left ventricular ejection fraction (LVEF) ≤35 % (p = 0.016) and glomerular filtration rate (GFR) <45 ml/min (p = 0.004). TvSS was the only independent pre-procedural predictor for CI-AKI in patients with GFR ≥60 ml/min (p < 0.001). The contrast volume/GFR ratio and peri-procedural myocardial infarction (MI) were independent procedural predictors for CI-AKI in the whole cohort and in patients with basal GFR ≥60 ml/min.
CI-AKI after RA is frequent. The tvSS is an efficient pre-procedural predictor for CI-AKI after RA, along with LVEF ≤35 % and GFR <45 ml/min. Contrast volume/GFR ratio and peri-procedural MI emerged as procedural predictors for CI-AKI.
Relationship between sleep-disordered breathing and renal dysfunction in acute coronary syndrome
2018, Journal of Cardiology
Citation Excerpt :
Renal dysfunction at discharge was defined as an eGFR of less than 45 mL/min/1.73 m2 [16–18]. Contrast-induced nephropathy was defined as a greater than 25% increase in the sCr level or a greater than 0.5 mg/dL sCr level within 3 days after the intravascular administration of contrast medium [19]. Left ventricular ejection fraction was measured on admission by echocardiography.
Sleep-disordered breathing (SDB) is associated with cardiovascular complications. However, the effect of SDB on renal function in patients with acute coronary syndrome (ACS) treated by percutaneous coronary intervention (PCI) remains unclear.
We enrolled 154 consecutive ACS patients without heart failure. A sleep study was performed immediately after PCI.
The mean apnea-hypopnea index (AHI) was 16.4 ± 13.1, and 33 patients (21%) had severe SDB, defined as AHI ≥ 25. Estimated glomerular filtration rate (eGFR) values on admission (60 ± 12 mL/min/1.73 m² vs. 67 ± 17 mL/min/1.73 m², p = 0.046) and at discharge (54 ± 15 mL/min/1.73 m² vs. 63 ± 15 mL/min/1.73 m², p = 0.002) were lower in patients with severe SDB than in those patients without severe SDB. Multiple linear regression analysis showed that AHIs were significantly correlated with absolute changes in eGFR values from admission to discharge (β = 0.201, p = 0.004). Median 24-h urinary noradrenaline excretion measured on the same day of the sleep study was higher [297 (interquartile range {IQR}: 232–472) vs. 174 (IQR: 107–318) μg/day, p = 0.021] in patients with severe SDB. On multivariate logistic regression analysis, the presence of severe SDB was a significant predictor (adjusted odds ratio 3.76, 95% confidence interval 1.06–13.9, p = 0.047) for eGFR of less than 45 mL/min/1.73 m² at discharge. This association was independent of age, eGFR on admission, and a presentation of ST-segment elevation myocardial infarction.
In patients with ACS who undergo PCI, severe SDB is associated with impaired renal function on admission and its deterioration during hospitalization. Further studies will be needed to conclude that SDB would be a therapeutic target in ACS.
Long-Term Adverse Effects of Low-Osmolar Compared With Iso-Osmolar Contrast Media After Coronary Angiography
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Jo et al. showed the CIN incidence was 7.9% in the IOCM (iodixanol) group and 17.0% in the LOCM (ioxaglate) group18; Aspelin et al. also found a CIN incidence of 3% and 26% in IOCM (iodixanol) and LOCM (iohexol) groups, respectively.19 Patients with CKD in particular have repeatedly been shown at substantially greater risk for CIN in the short and long term with both LOCM and IOCM20–23; CIN incidence in the short term has previously been linked to greater long-term adverse renal outcomes and mortality.7,24,25 We recognized several limitations in this study.
The relative incidence of long-term adverse effects between low-osmolar contrast media (LOCM) and iso-osmolar contrast media (IOCM) after coronary angiography is still unclear. We analyzed cardiology patients undergoing coronary angiography from January 2006 to July 2013 using either LOCM (iohexol, iopromide) or IOCM (iodixanol) at a single institution. For each contrast medium, primary (all-cause mortality, n = 6,992) and secondary outcomes (long-term renal injury and cardiovascular events beyond 90 days, n = 2,792) were recorded. Inverse probability weighing (IPW) was applied to minimize the selection bias between groups. Unadjusted all-cause mortality was significantly lower for LOCM versus IOCM (hazard ratio [HR] 0.28, 95% CI 0.23 to 0.34). After multivariate Cox regression or IPW, all-cause mortality became comparable and lost statistical significance. Chronic kidney disease subgroup had higher mortality risk when receiving LOCM compared with IOCM (regression adjusted HR 1.80, 95% CI 0.95 to 3.42; IPW-adjusted HR 1.57, 95% CI 0.99 to 2.48). In conclusion, after coronary angiography, patients receiving LOCM had comparable overall long-term mortality compared with IOCM after adjustment. LOCM tended to induce higher long-term mortality than IOCM in chronic kidney disease cohorts.
Risk Stratification for Percutaneous Coronary Intervention
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Aggressive hydraTion in patients with ST-Elevation Myocardial infarction undergoing Primary percutaneous coronary intervention to prevenT contrast-induced nephropathy (ATTEMPT): Study design and protocol for the randomized, controlled trial, the ATTEMPT, RESCIND 1 (First study for REduction of contraSt-induCed nephropathy followINg carDiac catheterization) trial
2016, American Heart Journal
Adequate hydration is recommended for acute ST-elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI) to prevent contrast-induced nephropathy (CIN). However, the optimal hydration regimen has not been well established in these high-risk patients. The objective of this study is to evaluate the efficacy of a preprocedural loading dose plus postprocedural aggressive hydration with normal saline guided by the left ventricular end-diastolic pressure (LVEDP) compared with general hydration for CIN prevention. The ATTEMPT study is a multicenter, open-label, investigator-driven, randomized controlled trial in China. Approximately 560 patients with STEMI undergoing primary PCI will be randomized (1:1) to receive either periprocedural general hydration (control group) or aggressive hydration (treatment group). Patients in the control group receive periprocedural general hydration with ≤500 mL normal saline (within 6 hours) at a normal rate (0.5 or 1 mL/kg · h). Patients in the treatment group receive a preprocedural loading dose (125/250 mL) of normal saline within 30 minutes and intravenous hydration at a normal rate until LVEDP is available, followed by postprocedural aggressive hydration guided by LVEDP for 4 hours and then continuous intravascular hydration at the normal rate until 24 hours after PCI. The primary end point is CIN, defined as a >25% or 0.5-mg/dL increase in serum creatinine from baseline during the first 48 to 72 hours after procedure. The ATTEMPT study has the potential to identify optimal hydration regimens for STEMI patients undergoing PCI.
Utility of the Logistic Clinical Syntax Score in the Prediction of Contrast-Induced Nephropathy After Primary Percutaneous Coronary Intervention
2016, Canadian Journal of Cardiology
Citation Excerpt :
Recently, studies have evaluated whether SS and CIN are associated in patients with STEMI and non-STEMI (NSTEMI). Oduncu et al.4 identified SS as an independent predictor of CIN that was also associated with increased adverse outcomes and hemodialysis in patients who underwent pPCI. Similarly, Elbasan et al.5 reported a relationship between SS and CIN in patients with STEMI.
The Logistic Clinical Syntax Score (log CSS) is a combined risk scoring system that includes clinical and anatomic parameters; it has been found to be effective for the prediction of mortality in patients with ST-elevation myocardial infarction (STEMI). The aim of the present study was to assess whether the log CSS was associated with the development of contrast-induced nephropathy (CIN) in patients who underwent primary percutaneous coronary intervention (pPCI).
A total of 930 patients with STEMI undergoing pPCI between January 2012 and August 2013 were included prospectively. The patients were grouped according to the development of CIN. Either an absolute serum creatinine level ≥ 0.5 mg/dL or a 25% increase in the serum creatinine level compared with the baseline level within 48 hours after the administration of contrast medium was defined as CIN.
The Synergy Between Percutaneous Coronary Interventions With Taxus and Cardiac Surgery score (SYNTAX [SS]) and log CSS were higher in patients with CIN than in those without. In the multivariate analysis, log CSS (odds ratio, 1.405, 95% confidence interval, 1.318-1.497; P < 0.001), hemoglobin, and contrast volume were found to be independent predictors of CIN. In the receiver operating characteristic analysis, a log CSS > 9.5 had a 74.5% sensitivity and a 90.5% specificity for predicting CIN, with an area under the curve (AUC) of 0.892, whereas an SS > 18.5 had a 64% sensitivity, a 58.1% specificity, and an AUC of 0.625 (0.892 vs 0.625; P < 0.001). A log CSS > 9.5 was associated with in-hospital and long-term mortality, reinfarction, revascularization, and in-hospital hemodialysis (P < 0.001 for each).
The log CSS may improve the accuracy of risk stratification for the development of CIN in patients undergoing pPCI.
Le Logistic Clinical Syntax Score (log CSS) est un système de score de risque combiné qui comprend des paramètres cliniques et anatomiques. Il s’est révélé efficace pour prédire la mortalité chez les patients souffrant d’infarctus du myocarde avec sus-décalage du segment ST (IM avec sus-décalage du segment ST). L’objectif de la présente étude était d’évaluer si le log CSS était associé au développement de la néphropathie induite par les produits de contraste (NIPC) chez les patients qui subissaient une intervention coronarienne percutanée primaire (ICPp).
Un total de 930 patients souffrant d’un IM avec sus-décalage du segment ST qui ont subi une ICPp entre janvier 2012 et août 2013 ont été inclus de manière prospective. Les patients ont été regroupés selon le développement de la NIPC. Soit une concentration absolue de créatinine sérique ≥ 0,5 mg/dl ou une augmentation de 25 % de la concentration de créatinine sérique comparativement à la concentration initiale dans les 48 heures après l’administration du produit de contraste a été définie comme une NIPC.
Le score SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery [SS]) et le log CSS étaient plus élevés chez les patients atteints d’une NIPC que chez ceux non atteints d’une NIPC. Dans l’analyse multivariée, le log CSS (ratio d’incidence approché, 1,405, intervalle de confiance à 95 %, 1,318-1,497; P < 0,001), l’hémoglobine et le volume du produit de contraste s’étaient révélés des prédicteurs indépendants de NIPC. Dans l’analyse caractéristique d’efficacité du récepteur, un log CSS > 9,5 avait une sensibilité de 74,5 % et une spécificité de 90,5 % de prédiction de la NIPC, avec une surface sous la courbe (SSC) de 0,892, alors qu’un SS > 18,5 avait une sensibilité de 64 %, une spécificité de 58,1 % et une SSC de 0,625 (0,892 vs 0,625; P < 0,001). Un log CSS > 9,5 était associé à la mortalité intrahospitalière et à long terme, à la récidive d’infarctus, à la revascularisation et à l’hémodialyse intra-hospitalière (P < 0,001 pour chacun).
Le log CSS peut améliorer la précision de la stratification du risque de développement de NIPC chez les patients subissant une ICPp.

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^☆: This work was performed at the Kartal Kosuyolu Heart Education and Research Hospital.

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Relation of the severity of contrast induced nephropathy to SYNTAX score and long term prognosis in patients treated with primary percutaneous coronary intervention☆

Abstract

Background

Methods

Results

Conclusions

Introduction

Section snippets

Study population

Patient characteristics

Discussion

Conclusions

Acknowledgments

Am J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

Am J Cardiol

Can J Cardiol

Am Heart J

J Am Coll Cardiol

J Am Coll Cardiol

Kidney Int

Kidney Int

Eur J Intern Med

Am J Med