Michael G. Shlipak, MD, MPH; Paul A. Heidenreich, MD, MS; Haruko Noguchi, PhD; Glenn M. Chertow, MD, MPH; Warren S. Browner, MD, MPH; Mark B. McClellan, MD, PhD
Acknowledgments: The authors thank Dr. Eric Vittinghoff for his contributions to this manuscript.
Grant Support: By the Centers for Medicare & Medicaid Services (formerly the Health Care Financing Administration) (500-96-P535) and the National Institute on Aging. Dr. Shlipak and Dr. Heidenreich are Research Career Development Awardees from the Health Research and Development Division of the Veterans Administration. Dr. Shlipak is also supported by the National Heart, Lung, and Blood Institute (RO3 HL68099-01).
Requests for Single Reprints: Michael G. Shlipak, MD, MPH, General Internal Medicine Section, Veterans Affairs Medical Center (111A1), 4150 Clement Street, San Francisco, CA 94121; e-mail, firstname.lastname@example.org.
Current Author Addresses: Dr. Shlipak: General Internal Medicine Section, Veterans Affairs Medical Center (111A1), 4150 Clement Street, San Francisco, CA 94121.
Dr. Heidenreich: Veterans Affairs Palo Alto Health Care System, 3801 Miranda Avenue, Palo Alto, CA 94304.
Dr. Noguchi: Toyo-Eiwa University, 32 Miho-cho, Midoritau, Yokohama, Kanagawa, Japan 226-0015.
Dr. Chertow: Division of Nephrology, University of California, San Francisco, 3333 California Street, Suite 430, San Francisco, CA 94118.
Dr. Browner: California Pacific Medical Center, 2340 Clay Street, Room 114, San Francisco, CA 94115.
Dr. McClellan: Council of Economics Advisor, The White House, Eisenhower Executive Building, Room 320, Washington, DC 20502.
Author Contributions: Conception and design: M.G. Shlipak, W.S. Browner, M.B. McClellan.
Analysis and interpretation of the data: M.G. Shlipak, P.A. Heidenreich, H. Noguchi, G.M. Chertow, W.S. Browner.
Drafting of the article: M.G. Shlipak, W.S. Browner.
Critical revision of the article for important intellectual content: M.G. Shlipak, P.A. Heidenreich, G.M. Chertow, W.S. Browner.
Final approval of the article: M.G. Shlipak, P.A. Heidenreich, G.M. Chertow, W.S. Browner, M.B. McClellan.
Provision of study materials or patients: M.B. McClellan.
Statistical expertise: M.G. Shlipak, H. Noguchi, W.S. Browner, M.B. McClellan.
Obtaining of funding: M.B. McClellan.
Collection and assembly of data: H. Noguchi.
Patients with end-stage renal disease are known to have decreased survival after myocardial infarction, but the association of less severe renal dysfunction with survival after myocardial infarction is unknown.
To determine how patients with renal insufficiency are treated during hospitalization for myocardial infarction and to determine the association of renal insufficiency with survival after myocardial infarction.
All nongovernment hospitals in the United States.
130 099 elderly patients with myocardial infarction hospitalized between April 1994 and July 1995.
Patients were categorized according to initial serum creatinine level: no renal insufficiency (creatinine level < 1.5 mg/dL [<132 µmol/L]; n = 82 455), mild renal insufficiency (creatinine level, 1.5 to 2.4 mg/dL [132 to 212 µmol/L]; n = 36 756), or moderate renal insufficiency (creatinine level, 2.5 to 3.9 mg/dL [221 to 345 µmol/L]; n = 10 888). Vital status up to 1 year after discharge was obtained from Social Security records.
Compared with patients with no renal insufficiency, patients with moderate renal insufficiency were less likely to receive aspirin, β-blockers, thrombolytic therapy, angiography, and angioplasty during hospitalization. One-year mortality was 24% in patients with no renal insufficiency, 46% in patients with mild renal insufficiency, and 66% in patients with moderate renal insufficiency (P < 0.001). After adjustment for patient and treatment characteristics, mild (hazard ratio, 1.68 [95% CI, 1.63 to 1.73]) and moderate (hazard ratio, 2.35 [CI, 2.26 to 2.45]) renal insufficiency were associated with substantially elevated risk for death during the first month of follow-up. This increased mortality risk continued until 6 months after myocardial infarction.
Renal insufficiency was an independent risk factor for death in elderly patients after myocardial infarction. Targeted interventions may be needed to improve treatment for this high-risk population.
Renal insufficiency increases the risk for cardiovascular disease, but whether it affects survival after myocardial infarction is unknown.
This large cohort study of Medicare beneficiaries hospitalized between April 1994 and July 1995 revealed the following: 1-year post–myocardial infarction mortality for no, mild, and moderate renal insufficiency was 24%, 46%, and 66%, respectively. Moderate renal insufficiency was more common in black and male patients and in patients with diabetes or previous stroke. Patients with moderate renal insufficiency received aspirin, β-blockers, thrombolytic therapy, angiography, and angioplasty less often than patients with mild or no renal insufficiency.
Patients with moderate renal insufficiency have increased mortality after myocardial infarction. They also get fewer effective treatments for myocardial infarction, which may explain the higher death rate.
Table 1. Characteristics of Elderly Patients with Myocardial Infarction, Based on Serum Creatinine Level at Presentation
Table 2. Treatments for Myocardial Infarction in Elderly Patients, Based on Initial Serum Creatinine Level
Unadjusted 1-year survival for 130 099 elderly patients after myocardial infarction, by initial serum creatinine levels.P
Table 3. Association of Renal Insufficiency with Survival after Myocardial Infarction in Elderly Patients
Unadjusted 1-year survival for 130 099 elderly patients after myocardial infarction, by tertiles of creatinine clearance estimated by using the Cockroft–Gault equation.P
Table 4. Association of Medical Therapies with 1-Month Mortality after Myocardial Infarction in Elderly Patients, Based on Baseline Renal Function
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Shlipak MG, Heidenreich PA, Noguchi H, Chertow GM, Browner WS, McClellan MB. Association of Renal Insufficiency with Treatment and Outcomes after Myocardial Infarction in Elderly Patients. Ann Intern Med. 2002;137:555-562. doi: 10.7326/0003-4819-137-7-200210010-00006
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Published: Ann Intern Med. 2002;137(7):555-562.
Acute Coronary Syndromes, Cardiology, Coronary Heart Disease, Emergency Medicine, Nephrology.
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