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Right atrial pressure predicts worsening renal function in patients with acute right ventricular myocardial infarction
IJCA-25841; No of Pages 3 International Journal of Cardiology xxx (2017) xxx–xxx
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International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Short communication
Right atrial pressure predicts worsening renal function in patients with acute right ventricular myocardial infarction☆,☆☆ Juan Betuel Ivey-Miranda a,⁎, Edith Liliana Posada-Martínez b, Eduardo Almeida-Gutiérrez c, Gabriela Borrayo-Sánchez d, Eduardo Flores-Umanzor e a Department of Acute Cardiovascular Care, Cardiology Hospital, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, 330 Cuauhtémoc Avenue, Cuauhtémoc, Mexico City, Mexico b Department of Acute Cardiovascular Care, Instituto Nacional de Cardiología Ignacio Chavez, 1st Juan Badiano, Tlalpan, Mexico City, Mexico c Department of Education and Research, Cardiology Hospital, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, 330 Cuauhtémoc Avenue, Cuauhtémoc, Mexico City, Mexico d Department of Medical Direction and Research, Cardiology Hospital, Cardiology Hospital, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, 330 Cuauhtémoc Avenue, Cuauhtémoc, Mexico City, Mexico e Institute Clinic Cardiovascular, Hospital Clinic, 170 Villarroel, Barcelona, Spain
a r t i c l e
i n f o
Article history: Received 28 June 2017 Received in revised form 6 December 2017 Accepted 21 December 2017 Available online xxxx Keywords: Right atrial pressure Worsening renal function Right ventricular myocardial infarction
a b s t r a c t Background: Right ventricular myocardial infarction (RVMI) is associated with serious complications in the short-term. Worsening renal function (WRF) is a frequent and dangerous complication. We investigated if right atrial pressure (RAP) predicts WRF in these patients. Methods: We prospectively studied patients with RVMI. RAP was obtained invasively at admission to coronary care unit. Blood samples were extracted from patients at baseline and every 24 h for creatinine measurements for seven days. We defined WRF as an increase of 25% or 0.5 mg/dl in serum creatinine during the first seven days compared to baseline creatinine. Results: We included forty-five patients (age 68 ± 10 years, male 71%). WRF occurred in 51%. The best cut-off value of RAP for WRF prediction was 11 mm Hg. RAP ≥11 mm Hg was associated with WRF at univariate analysis (OR 5.5, 95% CI 1.27–24.3, p = 0.023) and multivariate analysis (OR 6.1, 95% CI 1.07–35.4, p = 0.042). RAP ≥11 mm Hg improved reclassification and discrimination after usual prediction with the Mehran score (net reclassification improvement 64.8%, p = 0.030; integrated discrimination improvement 7.5%, p = 0.037). Conclusion: In patients with RVMI, RAP ≥11 mm Hg predicted WRF and improved discrimination. © 2017 Elsevier B.V. All rights reserved.
1. Introduction In patients with inferior myocardial infarction, right ventricular myocardial infarction (RVMI) is associated with a higher number of complications [1,2]. In patients with chronic heart failure, worsening renal function (WRF) occurs as a complication due to low cardiac output, and elevated right atrial pressure (RAP) and is associated with high mortality [3,4]. In patients with RVMI, WRF is associated with acute heart failure and is called type 1 cardiorenal syndrome [5,6]. However, in RVMI patients, it is uncertain if RAP is associated with WRF. In patients with acute myocardial infarction, the Mehran score is the usual way to predict WRF or contrast-induced nephropathy [7]. ☆ All authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation. ☆☆ This study was carried out at the Cardiology Hospital, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social. ⁎ Corresponding author. E-mail addresses: [email protected] (J.B. Ivey-Miranda), [email protected] (E. Almeida-Gutiérrez), [email protected] (G. Borrayo-Sánchez), fl[email protected] (E. Flores-Umanzor).
The aim of this study was to evaluate if RAP predicts WRF in RVMI patients and improves prediction of the Mehran score. 2. Methods 2.1. Population We analyzed patients with ST-elevation RVMI. We prospectively included all consecutive cases from 2015 to 2017 at a third level cardiology hospital. Patients fulfilled the third universal definition of MI, plus ST-segment elevation of at least 0.1 mV in V4R lead [8]. 2.2. Right atrial pressure measurement Upon admission to the coronary care unit, patients were placed on a central venous catheter (CVC), and RAP was measured as described previously [9]. We measured RAP three times and collected the average blood pressure in mm Hg. The investigators who measured RAP did not know the value of serum creatinine at baseline or at the end of the follow-up. 2.3. Data collection We collected demographic and clinical data by reviewing medical records. We collected blood samples for creatinine measurements from patients eight times—upon arriving at
https://doi.org/10.1016/j.ijcard.2017.12.087 0167-5273/© 2017 Elsevier B.V. All rights reserved.
Please cite this article as: J.B. Ivey-Miranda, et al., Right atrial pressure predicts worsening renal function in patients with acute right ventricular myocardial infarction, Int J Cardiol (2017), https://doi.org/10.1016/j.ijcard.2017.12.087
2
J.B. Ivey-Miranda et al. / International Journal of Cardiology xxx (2017) xxx–xxx
the emergency department, and then once a day for seven days and was available for all analyzed patients. We defined WRF as an increase ≥25% and/or ≥0.5 mg/dl in serum creatinine during follow-up at seven days vs. baseline [7]. Investigators who were unaware of RAP determined WRF and other cardiovascular events. Patients with ischemia-to-reperfusion time ≤ 12 h were taken to percutaneous coronary intervention (PCI) if the door-to-balloon time was expected to be ≤90 min; otherwise thrombolysis was administered and patients were taken to PCI either as pharmacoinvasive or rescue strategy. Failed reperfusion was defined as coronariography showing TIMI flow ≤1, or if the patient was not taken to coronariography and there were no electrocardiographic signs of reperfusion. The Hospital Ethical Committee revised and approved protocol, and all patients gave written informed consent.
2.4. Statistical analyses
WRF. Dyes did not show association with WRF; the reason could be that most patients received the same amount of dyes. In Kaplan–Meier analysis, patients with RAP ≥11 mm Hg had lower WRF-free survival rate (Fig. 1). At multivariate analysis only the Mehran score and RAP ≥11 mm Hg were independent predictors of WRF (Table 1). Finally, RAP ≥11 mm Hg increased reclassification and discrimination indices via the Mehran score (NRI 64.8% p = 0.030, IDI 7.5% p = 0.037).
4. Discussion
We used median and interquartile range for quantitative variables, and absolute frequencies and percentages for qualitative variables. We compared groups with Mann–Whitney's U test and chi square test or Fisher's exact test. We used simple logistic regression to evaluate association of RAP and clinical variables to predict WRF. We fit a multivariable logistic regression model with stepwise backward-selection; entry criteria was association at univariate analysis with a p value b0.20; the exit criteria was a p value N0.05. Kaplan–Meier survival estimates and log rank test were used to compare WRF-free survival rate in patients with and without RAP ≥11 mm Hg. Finally, we evaluated improvement in classification probabilities due to RAP with category-free net reclassification improvement (NRI) and integrated discrimination improvement (IDI) [10,11]. We used Stata 12 (StataCorp LP, College Station, TX) for statistical analysis.
3. Results From 2015 to 2016, 106 patients fulfilled the RV infarction criteria; forty-five patients received a CVC and no complications were noted. Reliable RAP and complete follow-up were obtained on all subjects. Characteristics of patients are summarized in Table 1. We found that 51% of patients developed WRF during follow-up. The rate of in-hospital complications was high—64% of patients presented with shock and 49% received a temporal pacemaker; 87% of patients were taken to coronariography. The proportion of failed reperfusion was high (44%), perhaps because the ischemia-to-reperfusion time was quite long (median 9 h). At univariate analysis the Mehran score showed the strongest association with WRF. As expected, a higher RAP was associated with
In this study, WRF was a very frequent complication and was associated with higher baseline creatinine, TAPSE, S′ wave, RAP, ischemia-toreperfusion time, temporal pacemaker, shock, Mehran and ACEF score. Mehran et al. published a paper in which they developed and validated a score to predict contrast-induced nephropathy. This was defined as an increase ≥25% and/or ≥0.5 mg/dl in serum creatinine at 48 h after PCI vs. baseline [7]. We decided to include this score because stratification of patients at admission to the coronary care unit includes calculation of the Mehran score. The ACEF score and the score published by Marenzi were also studied, but only the Mehran score remained as an independent predictor [12,13]. It is reasonable to think that RAP adds prognostic information to develop WRF in patients with RVMI because RAP is a marker of right ventricular dysfunction. Right ventricular dysfunction impairs kidney performance through low cardiac output and thus lower renal perfusion, and high RAP that means high renal venous pressure that impairs filtration of the kidney [14–16]. The association of raised RAP with higher risk of WRF was reported by Gambardella et al., in patients with cardiac surgery [17]. Shacham et al. showed similar results in patients with ST-segment elevation myocardial infarction [18]. Chen et al. showed that each 1 cm H2O higher RAP was associated with a 2% higher risk of WRF in critically ill adult patients [19]. All these studies are consistent in that the higher the RAP, the higher the risk of WRF. This study adds new and relevant prognostic information about WRF since higher RAP was independently associated with WRF even after
Table 1 Univariate and multivariate predictors for worsening renal function.
Age (years) Male Diabetes mellitus Hypertension Previous coronary artery disease Systolic blood pressure (mm Hg) Baseline creatinine (mg/dl) Hemoglobin TAPSE (mm) S′ wave (cm/seg) RAP ≥11 mm Hg Ischemia to reperfusion time ≥ 12 h Ischemia to reperfusion time (hours) Thrombolysis PCI Dyes (ml) Failed reperfusion Three-vessel disease Intra-aortic balloon pump Temporal pacemaker Shock or use of inotropes Mehran score ACEF score Marenzi score
No WRF (n = 22)
WRF (n = 23)
pa
69 (56–70) 17 (77%) 12 (54%) 17 (77%) 4 (18%) 130 (100–148) 0.94 (0.87–1.1) 14.6 (13.8–15.1) 19 (16–21) 11.8 (10.3–12.9) 12 (55%) 4 (18%) 7 (2−11) 7 (32%) 20 (91%) 150 (105–210) 8 (36%) 7 (32%) 1 (5%) 7 (32%) 9 (41%) 5 (4–10) 1.18 (1.05–1.55) 1 (0–1)
70 (60–74) 15 (65%) 14 (61%) 17 (74%) 4 (17%) 100 (90–135) 1.83 (1.27–2.15) 13.7 (13.2–14.8) 14 (9–18) 9.7 (6.5–12.1) 20 (87%) 12 (52%) 13 (7–24) 7 (30%) 19 (83%) 150 (120–190) 12 (52%) 4 (17%) 0 15 (65%) 20 (87%) 12 (10–17) 1.58 (1.32–2.30) 1 (1–1)
0.198 0.372 0.668 0.793 0.945 0.136 b0.001 0.106 0.003 0.028 0.023 0.029 0.015 0.920 0.665 0.560 0.291 0.190 0.489 0.038 0.002 b0.001 0.005 0.079
Univariate OR (95% CI)
Multivariateb OR (95% CI)
48 (4.9–473) 0.79 (0.67–0.93) 0.75 (0.58–0.96) 5.5 (1.27–24.3) 4.5 (1.16–17.3) 1.03 (0.98–1.08)
4.01 (1.16–13.9) 9.62 (2.18–42.3) 1.29 (1.10–1.51) 6.49 (1.59–26.5)
6.1 (1.07–35.4)
1.30 (1.10–1.53)
Data are n (%) and median (quartile 1–quartile 3). a Comparison of patients without WRF vs. patients with WRF. b Multivariate model after stepwise backward-selection (variables with p value ≥ 0.05 were removed); the full model included: age, systolic blood pressure, TAPSE, S′ wave, raised RAP, ischemia-to-reperfusion time, three-vessel disease, shock at admission, Mehran and ACEF score. Only variables with a p value b 0.05 after stepwise backward-selection were retained.
Please cite this article as: J.B. Ivey-Miranda, et al., Right atrial pressure predicts worsening renal function in patients with acute right ventricular myocardial infarction, Int J Cardiol (2017), https://doi.org/10.1016/j.ijcard.2017.12.087
J.B. Ivey-Miranda et al. / International Journal of Cardiology xxx (2017) xxx–xxx
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References
Fig. 1. Worsening renal function-free survival rate by normal or high right atrial pressure. Legend: patients with raised RAP (≥11 mm Hg) had a lower WRF-free survival rate (33 ± 8%) at seven days compared with those with lower RAP (b11 mm Hg). Most of outcomes happened during the first four days. RAP = right atrial pressure; WRF = worsening renal function.
adjusting for Mehran score. NRI may be interpreted as: in 64.8% patients, using RAP will improve the reclassification. Finally, we think that the absolute cut-off value of 11 mm Hg for RAP should not be used alone because this is a small study, and this number might be biased for the small sample size. We think that the clinician should interpret this result as follows: higher RAP values imply a higher probability for WRF even after adjusting for the Mehran score. For example, a patient with a Mehran score of 5 points (low risk group) will have six times the risk for WRF if RAP is high than if the same patient had a normal RAP value.
4.1. Limitations This is a single-center study with a small sample size, and thus the results should be interpreted cautiously. The variability of RAP was not evaluated in this study, however it is a standardized procedure. We did not evaluate if changes in RAP with diuretic therapy or volume infusion was associated with a higher or lower WRF risk; however RAP was measured at stable conditions (neither before nor after diuretic therapy or volume infusion). We acknowledge the lack of other hemodynamic parameters that could have been useful. In addition, WRF diagnosis was done by serum creatinine changes, and there might be patients with kidney injury who might not be seen via changes in serum creatinine.
5. Conclusion In patients with RVMI, higher RAP was associated with WRF. In addition, RAP ≥ 11 mm Hg improved discrimination after usual prediction with the Mehran score.
Grants None.
Conflicts of interests The authors report no relationships that could be construed as a conflict of interest.
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Please cite this article as: J.B. Ivey-Miranda, et al., Right atrial pressure predicts worsening renal function in patients with acute right ventricular myocardial infarction, Int J Cardiol (2017), https://doi.org/10.1016/j.ijcard.2017.12.087
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Short communication
Right atrial pressure predicts worsening renal function in patients with acute right ventricular myocardial infarction☆,☆☆ Juan Betuel Ivey-Miranda a,⁎, Edith Liliana Posada-Martínez b, Eduardo Almeida-Gutiérrez c, Gabriela Borrayo-Sánchez d, Eduardo Flores-Umanzor e a Department of Acute Cardiovascular Care, Cardiology Hospital, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, 330 Cuauhtémoc Avenue, Cuauhtémoc, Mexico City, Mexico b Department of Acute Cardiovascular Care, Instituto Nacional de Cardiología Ignacio Chavez, 1st Juan Badiano, Tlalpan, Mexico City, Mexico c Department of Education and Research, Cardiology Hospital, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, 330 Cuauhtémoc Avenue, Cuauhtémoc, Mexico City, Mexico d Department of Medical Direction and Research, Cardiology Hospital, Cardiology Hospital, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, 330 Cuauhtémoc Avenue, Cuauhtémoc, Mexico City, Mexico e Institute Clinic Cardiovascular, Hospital Clinic, 170 Villarroel, Barcelona, Spain
a r t i c l e
i n f o
Article history: Received 28 June 2017 Received in revised form 6 December 2017 Accepted 21 December 2017 Available online xxxx Keywords: Right atrial pressure Worsening renal function Right ventricular myocardial infarction
a b s t r a c t Background: Right ventricular myocardial infarction (RVMI) is associated with serious complications in the short-term. Worsening renal function (WRF) is a frequent and dangerous complication. We investigated if right atrial pressure (RAP) predicts WRF in these patients. Methods: We prospectively studied patients with RVMI. RAP was obtained invasively at admission to coronary care unit. Blood samples were extracted from patients at baseline and every 24 h for creatinine measurements for seven days. We defined WRF as an increase of 25% or 0.5 mg/dl in serum creatinine during the first seven days compared to baseline creatinine. Results: We included forty-five patients (age 68 ± 10 years, male 71%). WRF occurred in 51%. The best cut-off value of RAP for WRF prediction was 11 mm Hg. RAP ≥11 mm Hg was associated with WRF at univariate analysis (OR 5.5, 95% CI 1.27–24.3, p = 0.023) and multivariate analysis (OR 6.1, 95% CI 1.07–35.4, p = 0.042). RAP ≥11 mm Hg improved reclassification and discrimination after usual prediction with the Mehran score (net reclassification improvement 64.8%, p = 0.030; integrated discrimination improvement 7.5%, p = 0.037). Conclusion: In patients with RVMI, RAP ≥11 mm Hg predicted WRF and improved discrimination. © 2017 Elsevier B.V. All rights reserved.
1. Introduction In patients with inferior myocardial infarction, right ventricular myocardial infarction (RVMI) is associated with a higher number of complications [1,2]. In patients with chronic heart failure, worsening renal function (WRF) occurs as a complication due to low cardiac output, and elevated right atrial pressure (RAP) and is associated with high mortality [3,4]. In patients with RVMI, WRF is associated with acute heart failure and is called type 1 cardiorenal syndrome [5,6]. However, in RVMI patients, it is uncertain if RAP is associated with WRF. In patients with acute myocardial infarction, the Mehran score is the usual way to predict WRF or contrast-induced nephropathy [7]. ☆ All authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation. ☆☆ This study was carried out at the Cardiology Hospital, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social. ⁎ Corresponding author. E-mail addresses: [email protected] (J.B. Ivey-Miranda), [email protected] (E. Almeida-Gutiérrez), [email protected] (G. Borrayo-Sánchez), fl[email protected] (E. Flores-Umanzor).
The aim of this study was to evaluate if RAP predicts WRF in RVMI patients and improves prediction of the Mehran score. 2. Methods 2.1. Population We analyzed patients with ST-elevation RVMI. We prospectively included all consecutive cases from 2015 to 2017 at a third level cardiology hospital. Patients fulfilled the third universal definition of MI, plus ST-segment elevation of at least 0.1 mV in V4R lead [8]. 2.2. Right atrial pressure measurement Upon admission to the coronary care unit, patients were placed on a central venous catheter (CVC), and RAP was measured as described previously [9]. We measured RAP three times and collected the average blood pressure in mm Hg. The investigators who measured RAP did not know the value of serum creatinine at baseline or at the end of the follow-up. 2.3. Data collection We collected demographic and clinical data by reviewing medical records. We collected blood samples for creatinine measurements from patients eight times—upon arriving at
https://doi.org/10.1016/j.ijcard.2017.12.087 0167-5273/© 2017 Elsevier B.V. All rights reserved.
Please cite this article as: J.B. Ivey-Miranda, et al., Right atrial pressure predicts worsening renal function in patients with acute right ventricular myocardial infarction, Int J Cardiol (2017), https://doi.org/10.1016/j.ijcard.2017.12.087
2
J.B. Ivey-Miranda et al. / International Journal of Cardiology xxx (2017) xxx–xxx
the emergency department, and then once a day for seven days and was available for all analyzed patients. We defined WRF as an increase ≥25% and/or ≥0.5 mg/dl in serum creatinine during follow-up at seven days vs. baseline [7]. Investigators who were unaware of RAP determined WRF and other cardiovascular events. Patients with ischemia-to-reperfusion time ≤ 12 h were taken to percutaneous coronary intervention (PCI) if the door-to-balloon time was expected to be ≤90 min; otherwise thrombolysis was administered and patients were taken to PCI either as pharmacoinvasive or rescue strategy. Failed reperfusion was defined as coronariography showing TIMI flow ≤1, or if the patient was not taken to coronariography and there were no electrocardiographic signs of reperfusion. The Hospital Ethical Committee revised and approved protocol, and all patients gave written informed consent.
2.4. Statistical analyses
WRF. Dyes did not show association with WRF; the reason could be that most patients received the same amount of dyes. In Kaplan–Meier analysis, patients with RAP ≥11 mm Hg had lower WRF-free survival rate (Fig. 1). At multivariate analysis only the Mehran score and RAP ≥11 mm Hg were independent predictors of WRF (Table 1). Finally, RAP ≥11 mm Hg increased reclassification and discrimination indices via the Mehran score (NRI 64.8% p = 0.030, IDI 7.5% p = 0.037).
4. Discussion
We used median and interquartile range for quantitative variables, and absolute frequencies and percentages for qualitative variables. We compared groups with Mann–Whitney's U test and chi square test or Fisher's exact test. We used simple logistic regression to evaluate association of RAP and clinical variables to predict WRF. We fit a multivariable logistic regression model with stepwise backward-selection; entry criteria was association at univariate analysis with a p value b0.20; the exit criteria was a p value N0.05. Kaplan–Meier survival estimates and log rank test were used to compare WRF-free survival rate in patients with and without RAP ≥11 mm Hg. Finally, we evaluated improvement in classification probabilities due to RAP with category-free net reclassification improvement (NRI) and integrated discrimination improvement (IDI) [10,11]. We used Stata 12 (StataCorp LP, College Station, TX) for statistical analysis.
3. Results From 2015 to 2016, 106 patients fulfilled the RV infarction criteria; forty-five patients received a CVC and no complications were noted. Reliable RAP and complete follow-up were obtained on all subjects. Characteristics of patients are summarized in Table 1. We found that 51% of patients developed WRF during follow-up. The rate of in-hospital complications was high—64% of patients presented with shock and 49% received a temporal pacemaker; 87% of patients were taken to coronariography. The proportion of failed reperfusion was high (44%), perhaps because the ischemia-to-reperfusion time was quite long (median 9 h). At univariate analysis the Mehran score showed the strongest association with WRF. As expected, a higher RAP was associated with
In this study, WRF was a very frequent complication and was associated with higher baseline creatinine, TAPSE, S′ wave, RAP, ischemia-toreperfusion time, temporal pacemaker, shock, Mehran and ACEF score. Mehran et al. published a paper in which they developed and validated a score to predict contrast-induced nephropathy. This was defined as an increase ≥25% and/or ≥0.5 mg/dl in serum creatinine at 48 h after PCI vs. baseline [7]. We decided to include this score because stratification of patients at admission to the coronary care unit includes calculation of the Mehran score. The ACEF score and the score published by Marenzi were also studied, but only the Mehran score remained as an independent predictor [12,13]. It is reasonable to think that RAP adds prognostic information to develop WRF in patients with RVMI because RAP is a marker of right ventricular dysfunction. Right ventricular dysfunction impairs kidney performance through low cardiac output and thus lower renal perfusion, and high RAP that means high renal venous pressure that impairs filtration of the kidney [14–16]. The association of raised RAP with higher risk of WRF was reported by Gambardella et al., in patients with cardiac surgery [17]. Shacham et al. showed similar results in patients with ST-segment elevation myocardial infarction [18]. Chen et al. showed that each 1 cm H2O higher RAP was associated with a 2% higher risk of WRF in critically ill adult patients [19]. All these studies are consistent in that the higher the RAP, the higher the risk of WRF. This study adds new and relevant prognostic information about WRF since higher RAP was independently associated with WRF even after
Table 1 Univariate and multivariate predictors for worsening renal function.
Age (years) Male Diabetes mellitus Hypertension Previous coronary artery disease Systolic blood pressure (mm Hg) Baseline creatinine (mg/dl) Hemoglobin TAPSE (mm) S′ wave (cm/seg) RAP ≥11 mm Hg Ischemia to reperfusion time ≥ 12 h Ischemia to reperfusion time (hours) Thrombolysis PCI Dyes (ml) Failed reperfusion Three-vessel disease Intra-aortic balloon pump Temporal pacemaker Shock or use of inotropes Mehran score ACEF score Marenzi score
No WRF (n = 22)
WRF (n = 23)
pa
69 (56–70) 17 (77%) 12 (54%) 17 (77%) 4 (18%) 130 (100–148) 0.94 (0.87–1.1) 14.6 (13.8–15.1) 19 (16–21) 11.8 (10.3–12.9) 12 (55%) 4 (18%) 7 (2−11) 7 (32%) 20 (91%) 150 (105–210) 8 (36%) 7 (32%) 1 (5%) 7 (32%) 9 (41%) 5 (4–10) 1.18 (1.05–1.55) 1 (0–1)
70 (60–74) 15 (65%) 14 (61%) 17 (74%) 4 (17%) 100 (90–135) 1.83 (1.27–2.15) 13.7 (13.2–14.8) 14 (9–18) 9.7 (6.5–12.1) 20 (87%) 12 (52%) 13 (7–24) 7 (30%) 19 (83%) 150 (120–190) 12 (52%) 4 (17%) 0 15 (65%) 20 (87%) 12 (10–17) 1.58 (1.32–2.30) 1 (1–1)
0.198 0.372 0.668 0.793 0.945 0.136 b0.001 0.106 0.003 0.028 0.023 0.029 0.015 0.920 0.665 0.560 0.291 0.190 0.489 0.038 0.002 b0.001 0.005 0.079
Univariate OR (95% CI)
Multivariateb OR (95% CI)
48 (4.9–473) 0.79 (0.67–0.93) 0.75 (0.58–0.96) 5.5 (1.27–24.3) 4.5 (1.16–17.3) 1.03 (0.98–1.08)
4.01 (1.16–13.9) 9.62 (2.18–42.3) 1.29 (1.10–1.51) 6.49 (1.59–26.5)
6.1 (1.07–35.4)
1.30 (1.10–1.53)
Data are n (%) and median (quartile 1–quartile 3). a Comparison of patients without WRF vs. patients with WRF. b Multivariate model after stepwise backward-selection (variables with p value ≥ 0.05 were removed); the full model included: age, systolic blood pressure, TAPSE, S′ wave, raised RAP, ischemia-to-reperfusion time, three-vessel disease, shock at admission, Mehran and ACEF score. Only variables with a p value b 0.05 after stepwise backward-selection were retained.
Please cite this article as: J.B. Ivey-Miranda, et al., Right atrial pressure predicts worsening renal function in patients with acute right ventricular myocardial infarction, Int J Cardiol (2017), https://doi.org/10.1016/j.ijcard.2017.12.087
J.B. Ivey-Miranda et al. / International Journal of Cardiology xxx (2017) xxx–xxx
3
References
Fig. 1. Worsening renal function-free survival rate by normal or high right atrial pressure. Legend: patients with raised RAP (≥11 mm Hg) had a lower WRF-free survival rate (33 ± 8%) at seven days compared with those with lower RAP (b11 mm Hg). Most of outcomes happened during the first four days. RAP = right atrial pressure; WRF = worsening renal function.
adjusting for Mehran score. NRI may be interpreted as: in 64.8% patients, using RAP will improve the reclassification. Finally, we think that the absolute cut-off value of 11 mm Hg for RAP should not be used alone because this is a small study, and this number might be biased for the small sample size. We think that the clinician should interpret this result as follows: higher RAP values imply a higher probability for WRF even after adjusting for the Mehran score. For example, a patient with a Mehran score of 5 points (low risk group) will have six times the risk for WRF if RAP is high than if the same patient had a normal RAP value.
4.1. Limitations This is a single-center study with a small sample size, and thus the results should be interpreted cautiously. The variability of RAP was not evaluated in this study, however it is a standardized procedure. We did not evaluate if changes in RAP with diuretic therapy or volume infusion was associated with a higher or lower WRF risk; however RAP was measured at stable conditions (neither before nor after diuretic therapy or volume infusion). We acknowledge the lack of other hemodynamic parameters that could have been useful. In addition, WRF diagnosis was done by serum creatinine changes, and there might be patients with kidney injury who might not be seen via changes in serum creatinine.
5. Conclusion In patients with RVMI, higher RAP was associated with WRF. In addition, RAP ≥ 11 mm Hg improved discrimination after usual prediction with the Mehran score.
Grants None.
Conflicts of interests The authors report no relationships that could be construed as a conflict of interest.
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Please cite this article as: J.B. Ivey-Miranda, et al., Right atrial pressure predicts worsening renal function in patients with acute right ventricular myocardial infarction, Int J Cardiol (2017), https://doi.org/10.1016/j.ijcard.2017.12.087