Abstract
Aims
To establish the relationship between renal insufficiency, bleeding and prescription of cardiovascular medication.
Methods and results
This was a prospective, multi-center, cohort study of consecutive patients undergoing PCI during three NHLBI Dynamic Registry recruitment waves. Major and minor bleeding, access site bleeding and rates of prescription of cardiovascular medication at discharge were determined based on estimated glomerular filtration rate (eGFR).
Renal insufficiency was an independent predictor of major adverse cardiovascular events (MACE). Bleeding events and access site bleeding requiring transfusion were significantly associated with degrees of renal insufficiency (p < 0.001). There was an incremental decline in prescription of cardiovascular medication at discharge proportionate to the degree of renal impairment (aspirin, thienopyridine, statin, coumadin (overall p < 0.001), beta blocker (overall p = 0.003), ACE inhibitor (overall p = 0.02). Bleeders were less likely to be discharged on a thienopyridine (95.4% versus 89.9% for bleeding, p < 0.001 and 95.3% versus 87.9% for access site bleeding, p = 0.005), but not aspirin (96.3% versus 96.2%, p = 0.97 and 96.3% versus 93.6%, p = 0.29 respectively). Failure to prescribe anti-platelet therapy at discharge was strongly associated with increased MACE at one year.
Conclusions
Renal insufficiency is associated with bleeding in patients undergoing PCI. Patients with renal insufficiency are less likely to receive recommended discharge pharmacotherapy.
Highlights
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Patients undergoing PCI frequently have derangements in renal function, which is an independent risk factor for MACE.
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Renal impairment increases the risk of bleeding complications the squeal of which is a failure to discharge patients on guideline pharmacotherapy.
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This is associated with higher rates of death, re-infarction and repeat revascularization upon follow-up.
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Introduction
Nineteen million patients in the U.S suffer from CKD (GFR < 90 ml/min) and cardiovascular disease is the major cause of mortality in this population . As the general population ages the burden of patients who present with co-existent cardiovascular disease and CKD will grow . It is estimated that each 10 ml/min decline in creatinine clearance has an impact on death rates that is comparable to a ten-year increase in age . Furthermore, renal insufficiency predicts adverse cardiovascular events in an incremental fashion after PCI . Factors that contribute to worse outcome may include the nephrotoxicity of contrast dye, presence of more severe CAD, concomitant PAD, microvascular disease, intrinsic platelet dysfunction, higher peri-procedural complication rates and higher risk of bleeding .
Patients who undergo PCI and suffer bleeding complications are less likely to be discharged on dual anti-platelet therapy. Failure to reintroduce dual anti-platelet therapy following bleeding strongly predicts future cardiovascular events . As a result, patients with CKD are less likely to be revascularized and to receive appropriate antiplatelet therapy as renal function declines .
Many cardiovascular medications carry precautions with regard to use in patients with renal impairment and thus dose adjustment is required. Furthermore, patients with renal impairment are frequently prescribed multiple medications. In this study we aimed to demonstrate that patients undergoing PCI with even mild degrees of renal impairment experienced increased bleeding. We also hypothesized that renally impaired patients would be less likely to receive evidence based cardiovascular pharmacotherapy at the time of discharge and not only antiplatelet therapy and that this would influence outcome.
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