Contrast-Associated AKI and Use of Cardiovascular Medications after Acute Coronary Syndrome

Abstract

Background and objectives AKI after coronary angiography is associated with poor long-term outcomes. The relationship between contrast-associated AKI and subsequent use of prognosis-modifying cardiovascular medications is unknown.Design, setting, participants, & measurements A cohort study of 5911 participants 66 years of age or older with acute coronary syndrome who received a coronary angiogram in Alberta, Canada was performed between November 1, 2002, and November 30, 2008. AKI was identified according to Kidney Disease Improving Global Outcomes AKI criteria.Results In multivariable logistic regression models, compared with participants without AKI, those with stages 1 and 2-3 AKI had lower odds of subsequent use of angiotensin-converting enzyme inhibitors/angiotensin receptor blocker within 120 days of hospital discharge (adjusted odds ratio, 0.65; 95% confidence interval, 0.53 to 0.80 and odds ratio, 0.34; 95% confidence interval, 0.23 to 0.48, respectively). Subsequent statin and b-blockers use within 120 days of hospital discharge was significantly lower among those with stages 2-3 AKI (adjusted odds ratio, 0.44; 95% confidence interval, 0.31 to 0.64 and odds ratio, 0.46; 95% confidence interval, 0.31 to 0.66, respectively). These associations were consistently seen in patients with diabetes mellitus, heart failure, low baseline eGFR, and albuminuria; 952 participants died during subsequent follow-up after hospital discharge (mean=3.1 years). The use of each class of cardiovascular medication was associated with lower mortality, including among those who had experienced AKI.Conclusions Strategies to optimize the use of cardiac medications in people with AKI after coronary angiography might improve care.

Epidemiology and Mechanisms of Uremia-Related Cardiovascular Disease

“…135 It is less clear whether this apparently favorable risk-to-benefit ratio applies to dialysis patients or would persist if revascularization were more liberally used in CKD patients. On the other hand, even among patients undergoing coronary revascularization, postprocedural use of potentially cardioprotective medications is lower in CKD patients than in those with normal kidney function, 136 suggesting that closer attention to medical regimens may improve outcomes.…”

From the nephrologist's point of view: diversity of causes and clinical features of acute kidney injury

“…Patients with pre-existing cardiac dysfunctions often show a risk profile including hypertension, diabetes mellitus and/or arteriosclerosis and medications that also influence the susceptibility for renal dysfunction and are especially vulnerable to contrast-induced AKI [ 13 ]. AKI following percutaneous coronary angiography occurs in about 10% of patients and has been associated with adverse short- and long-term effects on cardiovascular morbidity, mortality and progression to end-stage renal disease [ 14 ]. In a recent observational study including almost 6000 Canadian patients, Leung et al were able to show that statins, beta-blockers and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers were less likely prescribed in patients who experienced mild or severe AKI especially if they were of older age despite the well-established beneficial effects on cardiovascular outcome.…”

“…The use of these medications was associated with lower long-term mortality even in patients after AKI. Therefore, the decision to prescribe cardiovascular medications seems to be consistently modified by kidney function and age even in patients at high risk for life-threatening cardiovascular events [ 14 – 16 ].…”

Clinical Decision Support to Reduce Contrast-Induced Kidney Injury During Cardiac Catheterization: Design of a Randomized Stepped-Wedge Trial

“…Follow-up laboratory testing for kidney function and electrolytes is required to identify patients with CI-AKI and ensure that they receive appropriate timely follow-up. 23,[29][30][31][32][33] Through processes coordinated before discharge from each cardiac catheterization laboratory, patients at increased risk of CI-AKI, who are discharged the same day as their procedures, are provided with an information package for themselves and their primary care providers including instructions for oral hydration, follow-up, and a laboratory requisition for serum creatinine testing 48 to 72 hours postprocedure. Information for primary care physicians is designed to bridge transition to community care and includes a link to the online provincial clinical pathway for testing, management, and referral for kidney disease (http://www.ckdpathway.ca/).…”