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Previous Volume 351:1285-1295 September 23, 2004 Number 13 Next

	Full Text PDF PDA Full Text PowerPoint Slide Set Editorial by Hostetter, T. H. Letters Add to Personal Archive Add to Citation Manager Notify a Friend E-mail When Cited E-mail When Letters Appear PubMed Citation

ABSTRACT

Background 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.

Methods 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.

Results 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.

Conclusions Even mild renal disease, as assessed by the estimated GFR, should be considered a major risk factor for cardiovascular complications after a myocardial infarction.

Source Information

From the Cardiovascular Division, Brigham and Women's Hospital, Boston (N.S.A., S.D.S., M.A.P.); the Department of Cardiology, Western Infirmary, Glasgow, Scotland (J.J.V.M.); Duke University Medical Center, Durham, N.C. (E.J.V., J.D.L., R.M.C.); the Department of Cardiology, Rigshospitalet, Copenhagen (L.K.); the Montreal Heart Institute, Montreal (J.-L.R.); the Department of Cardiology, Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand (H.D.W.); the Department of Cardiology, Stockholm South Hospital, Stockholm (R.N.); the Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence, Italy (A.M.); the Department of Cardiology, Central Hospital in Rogaland, Stavanger, Norway (K.D.); and Novartis Pharmaceuticals, East Hanover, N.J. (S.Z.).

Address reprint requests to Dr. Pfeffer at the Cardiovascular Division, Brigham and Women's Hospital, 75 Francis St., Boston, MA 02115, or at mpfeffer{at}rics.bwh.harvard.edu.

Full Text of this Article

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N Engl J Med 2005; 352:199-200, Jan 13, 2005. Correspondence

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