304

Infuence of Renal Dysfunction on Clinical Outcomes in Patients

With Congestive Heart Failure Complicating
Acute Myocardial Infarction
Chang Seong Kim,
1
MD, Min Jee Kim,
1
MD, Yong Un Kang,
1
MD, Joon Seok Choi,
1
MD,
Eun Hui Bae,
1
MD, Seong Kwon Ma,
1
MD, Young-Keun Ahn,
1,2
MD, Myung Ho Jeong,
1,2
MD,
Young Jo Kim,
3
MD, Myeong Chan Cho,
4
MD, Chong Jin Kim,
5
MD, and Soo Wan Kim,
1
MD,
for Korea Acute Myocardial Infarction Registry Investigators
Summary
The clinical course and medical treatment of patients with congestive heart failure (CHF) complicating acute myo-
cardial infarction (AMI) are not well established, especially in patients with concomitant renal dysfunction. We per-
formed a retrospective analysis of the prospective Korean Acute Myocardial Infarction Registry to assess the medical
treatments and clinical outcomes of patients with CHF (Killip classes II or III) complicated by AMI, in the presence or
absence of renal dysfunction. Of 13,498 patients with AMI, 2769 (20.5%) had CHF on admission. Compared to CHF
patients with preserved renal function, in-hospital mortality and major adverse cardiac events were increased both at 1
month and at 1 year after discharge in patients with renal dysfunction (1154; 41.7%). Postdischarge use of aspirin, beta-
blockers, calcium channel blockers, angiotensin-converting enzyme inhibitors, or angiotensin II receptor blockers and
statins signifcantly reduced the 1-year mortality rate for CHF patients with renal dysfunction; such reduction was not
observed for those without renal dysfunction, except in the case of aspirin. Patients with CHF complicating AMI, which
is accompanied by renal dysfunction, are at higher risk for adverse cardiovascular outcomes than patients without renal
dysfunction. However, they receive fewer medications proven to reduce mortality rates. (Int Heart J 2013; 54: 304-310)
Key words: Major adverse cardiac events
P
atients with acute myocardial infarctions (AMIs) fre-
quently show evidence of congestive heart failure
(CHF) and have a high risk of morbidity and mortality.
These patients have a 3- to 4-fold increased risk of in-hospital
mortality and have longer hospital stays than patients with
AMIs but no signs of heart failure.
1-3)
Furthermore, patients
with heart failure often develop worsening renal function, and
this is associated with poor prognoses.
4)
In addition, heart and
renal dysfunctions often occur simultaneously because they
share common causes and pathogenetic mechanisms, includ-
ing hypertension, diabetes mellitus, and atherosclerosis, as
well as the activation of the renin-angiotensin-aldosterone sys-
tem (RAAS), the sympathetic nervous system, and oxidative
stress.
5-7)
Given these fndings, renal dysfunction is one of the most
important comorbidities and may promote adverse clinical out-
comes in patients with CHF complicating AMI. However, the
clinical outcomes and medical management of these patients
are less well established, especially in patients with concomi-
tant renal dysfunction; most studies have predominantly re-
cruited populations with preserved renal function.
8)
The Korean Acute Myocardial Infarction Registry (KA-
MIR) is a Korean prospective multicenter data collection regis-
try refecting real-world treatment practices and outcomes in
Asian patients diagnosed with AMI. The purpose of this study
was to use this registry to compare differences between demo-
graphic and clinical characteristics, use of medical treatments,
and cardiovascular outcomes in patients with and without renal
dysfunction accompanying CHF after AMI.
Methods
Study design and patient population: The study population in-
cluded patients enrolled in the nationwide prospective KAMIR
from November 2005 to September 2008. This registry in-
volves 52 community and university hospitals with facilities
for primary percutaneous coronary intervention, thrombolytic
From the
1
Department of Internal Medicine, Chonnam National University Medical School,
2
Cardiovascular Research Institute of Chonnam National University,
Gwangju,
3
Department of Internal Medicine, Yeungnam University, Daegu,
4
Department of Internal Medicine, Chungbuk National University, Cheongju, and
5
Depart-
ment of Internal Medicine, Kyunghee University, Seoul, Korea.
This research was supported by the National Research Foundation of Korea (NRF) grant (MRC for Gene Regulation, 2011-0030132) funded by the Korea government
(MSIP).
Address for correspondence: Soo Wan Kim, MD, Department of Internal Medicine, Chonnam National University Medical School, 42 Jebongro, Gwangju 501-757,
Korea.
Received for publication February 1, 2013.
Revised and accepted April 4, 2013.
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therapy, and on-site cardiac surgery. Data were collected by an
experienced study coordinator on the basis of a standardized
case report form and protocol. The study protocol was ap-
proved by the ethics committee at each participating institu-
tion, and all patients provided informed consent for their par-
ticipation in the registry. Among the 13,498 consecutive
patients whose discharge diagnosis (based on clinical symp-
toms, cardiac enzyme levels, and 12-lead electrocardiogram
results) was AMI, patients were included in the present analy-
sis if they were admitted with Killip class II or III, an estimated
glomerular fltration rate (eGFR) was available, and they had
completed at least 1 year of follow-up. Killip class IV patients
were excluded due to cardiogenic shock. The Killip classifca-
tion has been designed to provide a clinical estimate of the se-
verity of myocardial derangement in the treatment of AMI and
validated in acute heart failure after AMI.
9,10)
A fnal population
of 2769 AMI patients with CHF was analyzed in this study.
Patients were grouped based on the presence or absence of re-
nal dysfunction.
Assessment of renal function: Serum creatinine levels were
analyzed by the Jaffe method, which has been calibrated to
isotope dilution mass spectrometry. The level of creatinine was
measured prior to angiography, and renal function was as-
sessed based on the eGFR. Renal dysfunction was defned as
an eGFR of < 60 mL/(minute1.73 m
2
), calculated using the
Chronic Kidney Disease Epidemiology Collaboration (CKD-
EPI) equation as follows: mL/(minute1.73 m
2
) = 141 mini-
mum (creatinine/, 1)

maximum (creatinine/, 1)
-1.209

0.993
age
1.018 (if female) 1.159 (if black), where is 0.7
for women and 0.9 for men and is -0.329 for women and
-0.411 for men.
11)
Study endpoints: All of the patients underwent regular follow-
up examinations at 1 month and 1 year after discharge from
the hospital. The primary endpoints were major adverse cardi-
ac events (MACEs), including a composite of all cause-of-
death, myocardial infarctions, target lesion revascularization,
and coronary artery bypass grafts during the 1-year clinical
follow-up period. Target lesion revascularization was defned
as restenosis or reocclusion within the stent or adjacent 5-mm
border.
Statistical analysis: Continuous variables have been presented
as the mean SD, and categorical variables as the number of
cases and percentages. Comparative analyses were performed
using Students t-test for continuous variables and Pearsons
chi-square test or Fishers exact test for categorical variables.
Continuous variables with skewed distributions have been pre-
sented in terms of median values (with 25
th
and 75
th
percen-
tiles) and have been compared using the Mann-Whitney test.
Event-free survival was estimated by the Kaplan-Meier meth-
od, and the signifcance levels were assessed by the log-rank
test. Variables found to be signifcant in univariate analysis and
other variables that have been reported to be associated with
the prognosis of patients with AMI were entered into multivar-
iate logistic regression models and Cox proportional hazard
models. Logistic regression was performed to identify the in-
dependent predictors of mortality at 1-month and 1-year fol-
low-up. Cox proportional hazards analyses were used to iden-
tify the effect of in-hospital and discharge medications on
1-year mortality in patients with CHF complicating AMI, ac-
cording to the presence or absence of renal dysfunction. The
following variables required adjustment: age, gender, tachycar-
dia (heart rate > 100 beats/minute) on admission, history of
hypertension, presence of dyslipidemia, presence of diabetes
mellitus, previous coronary artery disease, Killip class on ad-
mission, multivessel disease, smoking status, ST-segment-ele-
vation acute myocardial infarction, high-sensitivity C-reactive
protein (hs-CRP) level > 2 mg/L, and medications. All statisti-
cal tests were two-tailed, and a P < 0.05 was considered signif-
icant. Analyses were performed using the Statistical Package
for Social Sciences software, version 17.0 (SPSS, Chicago, IL,
USA).
Results
Baseline characteristics: Between November 2005 and Sep-
tember 2008, a total of 13,498 patients presenting with AMI
were enrolled. Of these, 2769 (20.5%) patients (mean age
standard deviation, 67.7 12.2 years; 62.2% men) had CHF
on admission and were included in the present study. In the
present study population, 1154 (41.7%) patients had renal dys-
function. Baseline clinical characteristics of patients are shown
in Table I. Patients with renal dysfunction were older and more
likely to be female and had a higher prevalence of diabetes,
hypertension, dyslipidemia, history of previous coronary artery
disease, multivessel disease, and elevated hs-CRP levels. These
patients also presented with higher heart rates and a higher Kil-
lip class (Killip class II, 49.9%; Killip class III, 50.1%) and
had lower left ventricular ejection fractions (LVEF) than pa-
tients without renal dysfunction. Although there were no sig-
nifcant differences in the admission rates to cardiac care units
(CCU), patients with renal dysfunction had longer CCU stays
than those without renal dysfunction (6.1 7.8 versus 4.3
7.8, P < 0.001, respectively).
Medications: Patients with renal dysfunction were less likely
to receive aspirin, beta-blockers, statins, and angiotensin-con-
verting enzyme (ACE) inhibitors but were more likely to re-
ceive diuretics, calcium channel blockers (CCBs), and angi-
otensin II receptor blockers (ARBs) than those without renal
dysfunction during hospitalization. Similarly, discharge medi-
cations such as aspirin, nitrates beta-blockers, statins, and ACE
inhibitors were less likely to be prescribed; diuretics, CCBs,
and ARBs were more frequently prescribed at the time of dis-
charge to patients with renal dysfunction (Table II).
Clinical events and outcomes: Clinical events during the
1-year follow-up period are listed in Table III. Patients present-
ing with renal dysfunction experienced more adverse clinical
events. In-hospital mortality was 3 times higher for patients
with renal dysfunction than for those without renal dysfunction
(15.2% versus 4.7%, P < 0.001). Moreover, 1-month and
1-year composite MACEs for patients with renal dysfunction
were significantly higher (24.8% versus 9.4%, P < 0.001;
38.3% versus 18.1%, P < 0.001, respectively) than for those
without renal dysfunction. Kaplan-Meier survival curves,
based on the presence or absence of renal dysfunction, are pre-
sented in Figure 1 and show a significantly higher mortality
rate for patients with renal dysfunction (log-rank P < 0.001)
than for those without renal dysfunction.
Multivariate analysis: We performed multivariate logistic re-
gression analysis to identify the independent predictors of
1-month and 1-year mortality in patients with CHF complicat-
ing AMI. Multivariate analysis showed that age, male gender,
306
Int Heart J
September 2013 KIM, ET AL
diabetes mellitus, heart rate > 100 (beats/minute), hs-CRP > 2
(mg/L), ST-segment-elevation acute myocardial infarction, and
renal dysfunction were signifcantly associated with 1-month
mortality in patients with CHF complicating AMI. Also, age,
male gender, heart rate > 100 (beats/minute), hs-CRP > 2 (mg/
L), and renal dysfunction were predictors of 1-year mortality
in this population (Table IV).
Cox proportional hazards analysis was performed to
identify the effect of in-hospital and discharge medications on
1-year mortality rates in patients with CHF complicating AMI,
according to the presence or absence of renal dysfunction.
These rates were adjusted for potential confounding factors
(Figure 2). The in-hospital use of aspirin and ACE inhibitors or
ARBs was associated with signifcantly reduced 1-year mortal-
Table I. Baseline Clinical Characteristics
Congestive heart failure
P No renal dysfunction
(n = 1,615)
Renal dysfunction
(n = 1,154)
Age (years) 64 12 73 10 < 0.001
Male (%) 1128 (69.9) 579 (51.8) < 0.001
HR (beats/minute) 81 26 87 26 < 0.001
Systolic blood pressure (mmHg) 128 27 128 34 0.916
Diastolic blood pressure (mmHg) 78 16 76 19 0.017
History of smoking (%) 912 (56.8) 442 (38.8) < 0.001
Diabetes mellitus (%) 442 (27.4) 537 (46.6) < 0.001
Previous hypertension (%) 684 (42.5) 768 (66.6) < 0.001
Previous dyslipidemia (%) 120 (7.5) 131 (11.4) < 0.001
Previous CAD (%) 239 (14.8) 306 (26.6) < 0.001
Multi-vessel disease (%) 847 (58.7) 676 (77.0) < 0.001
Killip class
II (%) 1099 (68.2) 576 (49.9) < 0.001
III (%) 516 (32.0) 578 (50.1) < 0.001
hs-CRP (mg/L) 1.12 (0.23,5.24) 2.69 (0.59,11.69) < 0.001
LVEF (%) 48 13 44 14 < 0.001
STEMI (%) 1041 (64.5) 538 (46.7) < 0.001
Non-STEMI (%) 573 (35.5) 613 (53.3) < 0.001
Admission rate of CCU (%) 1339 (82.9) 968 (83.9) 0.158
Lengths of CCU stay (days) 4.3 7.8 6.1 7.8 < 0.001
Kidney function
Serum creatinine (mg/dL) 0.9 0.2 2.3 3.3 < 0.001
Estimated GFR (mL/minute/1.73m
2
) 82 16 38 16 < 0.001
Data are presented as mean SD values or number of patients (percentage). Variables that were not normally distribut-
ed have been described in terms of the median (25
th
and 75
th
percentiles). HR indicates heart rate; CAD, coronary artery
disease; hs-CRP, high-sensitivity C-reactive protein; LVEF, left ventricular ejection fraction; STEMI, ST-segment-ele-
vation acute myocardial infarction; CCU, cardiac care unit; and GFR, glomerular fltration rate.
Table II. In-hospital and Discharge Medications
Congestive heart failure
P No renal dysfunction
(n = 1,615)
Renal dysfunction
(n = 1,154)
In hospital medication (%)
Diuretics 730 (45.6) 772 (67.2) < 0.001
Nitrate 1147 (71.6) 797 (69.4) 0.203
Aspirin 1578 (98.6) 1120 (97.5) 0.046
Beta-blockers 1152 (72.0) 741 (64.5) < 0.001
CCB 207 (12.9) 244 (21.2) < 0.001
Statins 1138 (71.1) 738 (64.2) < 0.001
ACE inhibitors 1120 (70.0) 723 (62.9) < 0.001
ARB 259 (16.2) 246 (21.4) 0.001
Discharge medications (%)
Diuretics 480 (29.7) 493 (42.7) < 0.001
Nitrate 702 (43.5) 442 (38.3) 0.007
Aspirin 1463 (90.6) 863 (74.8) < 0.001
Beta-blockers 1019 (63.1) 601 (52.1) < 0.001
CCB 140 (8.7) 157 (13.6) < 0.001
Statins 1095 (67.8) 612 (53.0) < 0.001
ACE inhibitors 934 (57.8) 507 (43.9) < 0.001
ARB 297 (17.3) 235 (20.4) 0.042
CCB indicates calcium channel blocker; ACE, angiotensin-converting enzyme; and ARB, angiotensin II receptor
blocker.
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ity, after adjusting for multiple risk factors, while diuretics in-
creased the risk of 1-year mortality, regardless of renal dys-
function. In-hospital use of statins was associated with more
signifcant reductions in 1-year mortality rates in patients with
renal dysfunction than in those without renal dysfunction
(Hazard ratio [HR], 0.63; 95% confdence interval [CI], 0.44
0.90; P = 0.012; and HR, 0.64; 95% CI, 0.391.07; P = 0.092,
respectively). Although postdischarge use of aspirin, beta-
blockers, CCBs, ACE inhibitors, or ARBs and statins, which
had been prescribed at discharge, appeared to favor the survival
of patients who had CHF complicating AMI and did not have
renal dysfunction, no statistically signifcant improvement was
observed in survival for any of the medications, except for as-
pirin. However, in patients with renal dysfunction, signifcant
benefcial effects were obtained for 1-year mortality for those
medications.
Discussion
This study demonstrated that the presence of renal dys-
function is associated with adverse clinical cardiovascular
prognoses in patients who develop CHF after AMI. Patients
with renal dysfunction were more likely to be older and female
and have a prior history of cardiovascular and other comorbid
diseases. We observed that renal dysfunction was associated
with reduced in-hospital or discharge prescriptions for aspirin,
beta-blockers, statins, and RAAS inhibitors (ie, ACE inhibitors
and ARBs); these medications are known to reduce cardiovas-
cular mortality.
12-15)
Among the total AMI population, CHF occurred in
20.5% of the individuals, which is consistent with previous
studies showing CHF in approximately 1525% of AMI pa-
tients.
16,17)
Since Killip and Kimball demonstrated that in-
creased hospital mortality is associated with a greater degree
of CHF severity (higher Killip class),
9)
the concurrence of heart
failure in patients with AMI has been consistently recognized
as a strong predictor of morbidity and mortality. As shown in
previous studies, reduced LVEFs, or signs of heart failure, after
AMI are associated with a relatively high incidence of in-hos-
pital mortality
18)
and complications and of long-term mortali-
ty.
1,3)
In addition, both heart failure and renal dysfunction are
well-known independent risk factors for cardiovascular and
all-cause mortality after myocardial infarction.
19,20)
Moreover,
adjusted all-cause mortality increases in patients with any renal
impairment from the heart failure population.
21)
Taken together, these results indicate that renal dysfunc-
tion might be regarded as one of the most important risk fac-
tors for cardiovascular outcomes in patients with AMI, espe-
cially in those with concomitant CHF. However, only a few
studies have addressed the clinical outcomes and medical treat-
ment of patients with concomitant renal dysfunction and CHF
after AMI; thus, clinical outcomes and medical treatment in
this population have not been well characterized. Palmer, et al
showed that a combination of increased N-terminal prohor-
mone of brain natriuretic peptide levels or depressed LVEFs
with lower eGFRs results in increased rates of long-term mor-
tality and heart failure after myocardial infarction.
22)
Similarly,
Table III. Clinical Outcomes During the In-hospital Period and Follow-up
Congestive heart failure
P No renal dysfunction
(n = 1,615)
Renal dysfunction
(n = 1,154)
In-hospital outcomes (n = 2769)
In-hospital death (%) 76 (4.7) 175 (15.2) < 0.001
1-month outcomes
Composite MACE (%) 135 (9.4) 248 (24.8) < 0.001
Death (%) 103 (7.2) 228 (22.8) < 0.001
MI (%) 8 (0.6) 10 (1.0) 0.234
Re-PCI (%) 18 (1.3) 6 (0.6) 0.114
CABG (%) 6 (0.4) 4 (0.4) 0.947
12-month outcomes
Composite MACE (%) 225 (18.1) 337 (38.3) < 0.001
Death (%) 135 (10.9) 288 (32.7) < 0.001
MI (%) 9 (0.7) 13 (1.5) 0.126
Re-PCI (%) 70 (5.6) 30 (3.4) 0.017
CABG (%) 11 (0.9) 6 (0.7) 0.806
MACE indicates major adverse cardiac event; MI, myocardial infarction; Re-PCI, target lesion revascularization; and
CABG, coronary artery bypass graft.
Figure 1. Kaplan-Meier curves showing the cumulative incidence of sur-
vival in patients with or without renal dysfunction accompanying CHF af-
ter AMI. Survival curve analysis revealed a signifcantly higher mortality
rate in the renal dysfunction group than in the no renal dysfunction group.
308
Int Heart J
September 2013 KIM, ET AL
both decreased LVEFs and creatinine clearance rates were as-
sociated with higher 1-year mortality in patients with chest
pain, without ST elevation, than in patients with normal heart
and renal functions.
23)
The results of our study are consistent
with those fndings. Half of the CHF patients had renal dys-
function after AMI, and these patients had a 3-fold higher rate
of in-hospital mortality as well as longer CCU stays than those
without renal dysfunction. Moreover, 1-month and 1-year
composite MACE were 2.6 and 2.1 times higher, respectively,
among patients with renal dysfunction; those observations re-
flected higher rates of all-cause deaths during the follow-up
period. Also, renal dysfunction was an independent risk factor
for 1-month and 1-year mortality in patients with AMI con-
comitant with CHF. Interestingly, our laboratory findings
showed that the level of hs-CRP was higher in patients with re-
nal dysfunction. An increase in the hs-CRP level is independ-
ently associated with all-cause and cardiovascular mortality
when kidney function has deteriorated
24)
and is a marker of
long-term development of heart failure and mortality in pa-
tients with AMI.
25)
Therefore, elevated hs-CRP levels might be
associated with adverse cardiovascular outcomes in our popu-
lation when accompanying renal dysfunction, but the precise
effects of hs-CRP levels should be further elucidated.
Aspirin, beta-blockers, and ACE inhibitors have been
found to improve survival in patients with CHF complicating
AMI;
3,14)
the use of RAAS inhibitors and statins is also associ-
ated with decreased risks of MACE in those with lower eGFRs
after AMI.
26)
These reports are in line with our results that
showed that the use of aspirin, ACE inhibitors, or ARBs and
statins, during hospitalization, reduced the risk of 1-year mor-
tality in patients with renal dysfunction. However, the use of
diuretics had a deleterious effect on 1-year survival during the
early stage of AMI accompanying CHF, regardless of renal
dysfunction. Furthermore, the postdischarge use of aspirin, be-
ta-blockers, CCBs, statins and RAAS inhibitors, which had
been prescribed at discharge, resulted in signifcantly reduced
1-year mortalities among patients with renal dysfunction,
whereas they did not produce similar benefts for those without
renal dysfunction. Despite markedly reduced mortality, pa-
tients with renal dysfunction were less likely to receive medi-
cations such as aspirin, beta-blockers, statins, and ACE inhibi-
tors. Therefore, it is important to use medications proven to
reduce mortality rates continuously even after discharge from
the hospital in patients with CHF and renal dysfunction after
AMI.
Although this study was not designed to investigate the
Table IV. Multivariate Analysis of 1-month and 1-year Mortality in Patients With CHF Complicating AMI
1-month mortality 1-year mortality
Odd ratio (95% CI) P Odd ratio (95% CI) P
Age (per year) 1.06 (1.03-1.08) < 0.001 1.06 (1.05-1.08) < 0.001
Male 1.59 (1.04-2.43) 0.032 1.57 (1.07-2.30) 0.022
Hypertension 0.99 (0.68-1.43) 0.953 1.05 (0.75-1.47) 0.758
Diabetes mellitus 1.49 (1.03-2.17) 0.035 1.27 (0.91-1.78) 0.167
Dyslipidemia 0.72 (0.37-1.42) 0.348 0.88 (0.50-1.54) 0.657
History of smoking 0.77 (0.51-1.16) 0.211 0.70 (0.48-1.01) 0.058
Previous CAD 0.95 (0.61-1.48) 0.834 1.10 (0.74-1.63) 0.635
Heart rate > 100 (beats/minute) 1.61 (1.08-2.41) 0.020 1.73 (1.20-2.50) 0.003
Multi-vessel disease 0.95 (0.64-1.43) 0.818 1.12 (0.77-1.63) 0.562
hs-CRP > 2 (mg/L) 1.61 (1.13-2.30) 0.009 2.02 (1.46-2.80) < 0.001
STEMI 1.53 (1.05-2.23) 0.028 1.18 (0.84-1.66) 0.333
Renal dysfunction* 2.91 (1.93-4.37) < 0.001 2.53 (1.77-3.61) < 0.001
*Estimated GFR of < 60 mL/(minute1.73 m
2
), calculated using the Chronic Kidney Disease Epidemiology Collaboration equation.
CHF indicates congestive heart failure; AMI, acute myocardial infarction; CI, confdence interval; CAD, coronary artery disease; hs-
CRP, high-sensitivity C-reactive protein; and STEMI, ST-segment-elevation acute myocardial infarction.
Figure 2. Adjusted hazard ratios for the effect of in-hospital (A) and dis-
charge (B) medications on 1-year mortality rates in patients with CHF
complicating AMI, according to the presence or absence of renal dysfunc-
tion. Adjusted for factors included age, gender, history of hypertension,
dyslipidemia, diabetes mellitus, previous coronary artery disease, HR >
100 beats/minute, Killip class, multivessel disease, smoking, STEMI, hs-
CRP > 2mg/L, and medications. RD indicates renal dysfunction.
A.
B.
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No 5 CHF AND RENAL DYSFUNCTION IN AMI
reasons for lower prescription rates of useful medications,
there are several possible reasons for this observation, includ-
ing the lack of evidence for therapeutic strategies to reduce
mortality in CHF patients with renal impairment, especially in
the AMI cohort. Most clinical studies of heart failure have pre-
dominantly excluded patients with deteriorated renal func-
tion,
8)
and thus, optimal pharmacotherapy remains poorly de-
fined in these patients. In addition, the risk of potential side
effects of medical treatments might tend to be overestimated in
the presence of renal dysfunction. Even if ACE inhibitors and
ARBs are associated with risks of hyperkalemia or transiently
decreased renal function, they have been proven to reduce
mortality in practice.
27,28)
Thus, physicians should carefully
weigh the long-term survival benefts of these medical treat-
ments in the populations described.
The present study has several limitations. First, although
we adjusted for multiple confounding factors, it is possible that
some confounders were excluded. Second, the assessment of
kidney function was based on a single measurement of serum
creatinine levels, obtained at the time of admission to the hos-
pital. Thus, this value could have been affected by patient he-
modynamic or metabolic status. Third, because of the method-
ological limitations of retrospective analysis, the data regarding
the duration of medications were not available. Nevertheless,
analyses of the effects in-hospital and discharge medications
on clinical outcomes among patients with renal dysfunction
were performed in an attempt to overcome this confounding
factor. Furthermore, patients after AMI, by its nature, were en-
couraged to maintain the essential medications including aspi-
rin, beta-blockers, ACE inhibitors, ARBs and statins, unless
there was a contraindication or severe complication. Despite
the limitations of our study, this should not undermine the sur-
vival benefts of these medications, especially in renal dysfunc-
tion.
In conclusion, our study demonstrated that patients with
CHF complicated with AMI accompanied by renal dysfunc-
tion are at higher risk for adverse cardiovascular outcomes
than those without renal dysfunction. Nonetheless, medica-
tions that have proven benefits with respect to mortality are
underused in these patients. Therefore, early identifcation of
patients with renal dysfunction and intensive medical treatment
for this population may reduce cardiovascular outcomes and
mortality.
Appendix
Korea Acute Myocardial infarction Registry (KAMIR) Investiga-
tors: Myung Ho Jeong, MD, Young Keun Ahn, MD, Sung Chull Chae,
MD, Jong Hyun Kim, MD, Seung Ho Hur, MD, Young Jo Kim, MD, In
Whan Seong, MD, Dong Hoon Choi, MD, Jei Keon Chae, MD, Taek Jong
Hong, MD, Jae Young Rhew, MD, Doo Il Kim, MD, In Ho Chae, MD,
Jung Han Yoon, MD, Bon Kwon Koo, MD, Byung Ok Kim, MD, My-
oung Yong Lee, MD, Kee Sik Kim, MD, Jin Yong Hwang, MD, Myeong
Chan Cho, MD, Seok Kyu Oh, MD, Nae Hee Lee, MD, Kyoung Tae
Jeong, MD, Seung Jea Tahk, MD, Jang Ho Bae, MD, Seung Woon Rha,
MD, Keum Soo Park, MD, Chong Jin Kim, MD, Kyoo Rok Han, MD,
Tae Hoon Ahn, MD, Moo Hyun Kim, MD, Ki Bae Seung, MD, Wook
Sung Chung, MD, Ju Young Yang, MD, Chong Yun Rhim, MD, Hyeon
Cheol Gwon, MD, Seong Wook Park, MD, Young Youp Koh, MD, Seung
Jae Joo, MD, Soo Joong Kim, MD, Dong Kyu Jin, MD, Jin Man Cho,
MD, Byung Ok Kim, MD, Sang-Wook, Kim, MD, Jeong Kyung, Kim,
MD, Tae Ik Kim, MD, Deug Young Nah, MD, Si Hoon Park, MD, Sang
Hyun Lee, MD, Seung Uk Lee, MD, Hang-Jae Chung, MD, Jang Hyun
Cho, MD, Seung Won Jin, MD, Yang Soo Jang, MD, Jeong Gwan Cho,
MD, and Seung Jung Park, MD.
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