Renal function, concomitant medication use and outcomes following acute coronary syndromes.
Renal function, concomitant medication use and outcomes following acute coronary syndromes.
复制标题
急性冠状动脉综合征后的肾功能、伴随药物使用和结果。
DOI：
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发表时间：
2005
影响因子：
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通讯作者：
L. Newby
中科院分区：
文献类型：
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作者：
D. Reddan;L. Szczech;M. Bhapkar;D. Moliterno;R. Califf;E. Ohman;P. Berger;J. Hochman;F. Van de Werf;R. Harrington;L. Newby
背景
慢性肾脏病（CKD）在心血管疾病患者中非常普遍。我们使用两项大型急性冠状动脉综合征（ACS）试验的综合数据探讨CKD与结局的关系。我们还探讨了CKD与常见心血管药物处方模式的相关性，以及这些处方模式与临床结局的相关性。
方法
使用肌酐清除率（CrCl，ml/min）按CKD分期对患者进行分层，肌酐清除率（CrCl，ml/min）通过使用基线核心实验室肌酐测量值的改良MDRD方程估计。血清肌酐≥ 1.5 mg/dl是SYMPHONY试验的排除标准。比较不同CKD类别的基线特征和结局，并在调整先前确定的结局预测因子后，使用考克斯比例风险回归评估肾功能不全与临床结局的关系。在预测至死亡时间的最终考克斯比例风险模型中，检验了使用特定药物与计算的CrCl之间的相互作用。
结果
在分析的13707例患者中，6840例患者患有CKD I期（CrCl ≥ 90 ml/min），5909例患者患有II期（CrCl 60-89 ml/min），955例患者患有III期（CrCl 30-59 ml/min），3例患者患有IV期（CrCl <30 ml/min）。更晚期CKD（III）患者年龄较大，通常为女性，不吸烟，更可能患有合并症，包括糖尿病，高血压和充血性心力衰竭。CKD患者使用心血管药物的频率较低。CKD分期>或=II的患者未经校正的生存率较差。在校正分析中，对于CrCl ≤ 91的患者，CrCl每增加10 ml/min与死亡风险显著降低相关（风险比0.897，95%置信区间0.815-0.986）（P = 0.024）。使用血管紧张素转换酶（ACE）抑制剂和氯化铬之间的相互作用与结局显著相关; CKD患者中药物治疗的获益更大。
结论
CKD是ACS患者风险的独立预测因子，并且与较少使用已证实的药物治疗相关。CKD和ACS患者可能需要更积极地使用常规心血管治疗。
BACKGROUND
Chronic kidney disease (CKD) is highly prevalent in patients with cardiovascular disease. We explored the associations of CKD with outcomes using combined data from two large acute coronary syndrome (ACS) trials. We also explored the associations of CKD with prescription patterns for common cardiovascular medications and the association of these prescription patterns with clinical outcomes.
METHODS
Patients were stratified by CKD stage using creatinine clearance (CrCl, ml/min) estimated by the modified MDRD equation using baseline core laboratory creatinine measures. Serum creatinine > or =1.5 mg/dl was an exclusion criterion for the SYMPHONY trials. Baseline characteristics and outcomes across CKD categories were compared and Cox proportional hazards regression was used to assess the relationship of renal insufficiency with clinical outcomes after adjusting for previously identified outcome predictors. Interactions between the use of specific medications and calculated CrCl were tested in the final Cox proportional hazards model predicting time to mortality.
RESULTS
Of 13 707 patients analysed, 6840 had CKD stage I (CrCl > or =90 ml/min), 5909 stage II (CrCl 60-89 ml/min), 955 stage III (CrCl 30-59 ml/min) and three stage IV (CrCl <30 ml/min). Patients with more advanced CKD (III) were older, more often female, non-smokers and more likely to have co-morbid diseases including diabetes mellitus, hypertension and congestive heart failure. Cardiovascular medications were used less frequently in patients with CKD. Unadjusted survival was poorer in patients with CKD stages > or =II. In adjusted analyses, for those with CrCl < or =91, each 10 ml/min increase in CrCl was associated with a significantly decreased risk of mortality (hazards ratio 0.897, 95% confidence interval 0.815-0.986) (P = 0.024). The interaction between use of angiotensin-converting enzyme (ACE) inhibitors and CrCl was significantly associated with outcomes; the benefit of drug therapy was greater among patients with CKD.
CONCLUSIONS
CKD is an independent predictor of risk among ACS patients, and is associated with less frequent use of proven medical therapies. More aggressive use of conventional cardiovascular therapies in patients with CKD and ACS may be warranted.