Renal Function in Patients with Acute Myocardial Infarction: A Current Perspective.

Ischemic heart disease is one of the most prevalent diseases in Western societies, rising, along with other vascular diseases, as the leading cause of death in the developed world. Its presentation as an acute coronary syndrome (ACS) is of particular importance, both because of its morbidity and mortality and because of the high amount of economic, human and healthcare resources it carries ¹.

In the United States, almost 600,000 patients are hospitalized every year with a primary diagnosis of ACS. The figure exceeds one million patients if it is included as a secondary diagnosis ^{2, 3}. In Cuba, in 2017, cardiovascular disease (CVD) remained the leading cause of death with 27 176 deaths, among which 7 982 represented acute myocardial infrction (AMI) with a rate of 71 per 100 000 inhabitants ⁴.

There are several factors that have been related to an unfavorable prognosis in patients with CVD. One of these factors is renal function, which in recent decades has become more evident the importance of its correct evaluation, especially as a result of studies that have shown that this direct relationship between renal function and cardiovascular events already appears in phases of moderate renal dysfunction, and even, mild ⁵. It is currently proposed that this dysfunction occurs in approximately 30-40% of patients with ACS and is associated with a worse prognosis and an increased risk of hospital complications, sometimes due to differences in the presentation of the clinical picture (less frequently chest pain or typical signs on the electrocardiogram), so the diagnosis may be delayed ⁶.

Accurate evaluation of renal function therefore allows early identification of patients at high risk of cardiovascular events, in order to improve their prognosis through early intervention in diagnosis and treatment. In addition, it enables the close monitoring of certain interventions such as the adjustment of drugs and the prevention of nephrotoxicity by various agents in high-risk patients. A poor estimate of renal function can lead to a patient not receiving cardioprotective treatment appropriate to their risk, which leads to an increase in mortality ⁵.

In the ACTION registry (Acute Coronary Treatment and Intervention Outcome Network), 57 700 patients with ACS were evaluated; approximately 1 in every 6 patients with AMI presented acute kidney injury. Patients with ACS type ST without renal dysfunction had a mortality of 2% compared to 32% observed in patients with severe renal failure⁷.

Creatinine has been classically the most used endogenous substance for the evaluation of renal function. However, the creatinine concentration is affected by several factors (muscle mass, sex, race, type of feeding), in addition to others related to the creatinine filtration itself, such as tubular secretion, production and extra renal excretion. Given the disadvantages of plasma creatinine as a marker of renal deterioration, there have been multiple proposed methods to understand renal function, within which the formulas for estimating glomerular filtration are the most commonly used in routine clinical practice because of their relative simplicity ⁵.

There are different formulas to estimate the glomerular filtration in a certain patient. All of them incorporate a series of variables that try to solve the deficiencies of plasma creatinine as the only marker of renal function ⁵.

According to a series of studies found in the literature reviewed, the increase in serum creatinine concentrations or the decrease in glomerular filtration rate estimated in patients with a diagnosis of AMI are associated with increased mortality in the ICU.

In the study Valsartan in Acute Myocardial Infarction Trial (VALIANT) that included patients with ventricular dysfunction or heart failure after an acute myocardial infarction. All major cardiovascular events, such as total cardiovascular mortality, myocardial infarction, heart failure and stroke, were closely related to the degree of renal dysfunction. The incidence of these events doubled or tripled in patients with glomerular filtration <45 mL / min / 1.73m² compared to those with a glomerular filtration rate> 75 mL / min / 1.73m²⁸.

Gutiérrez HB and colleagues in a study conducted with 295 patients admitted with a diagnosis of AMI, found that the distribution of serum creatinine was significantly higher in the group of patients who died compared to the group of survivors. On the other hand, the estimated glomerular filtration rates were significantly lower among those who died in relation to those who did not die. When they compared the cardiovascular prognostic variables with the renal function variables, a better risk stratification was observed in the latter ⁹.

Taking this into account, it is important to point out that stratification predicts precociously after a coronary syndrome, only renal function is evaluated as a risk factor in the GRACE study model ¹⁰ and in the risk score of the CADILLAC study ¹¹, while in others very used as the TIMI scale ¹² no reference is made.

In conclusions, we have that the assessment of renal function through the determination of creatinine and the estimation of glomerular filtration provide useful and valuable information for the evaluation of patients with acute myocardial infarction.

1. 1.Parra Fuertes PJ, SI de la Fuente. (2017) Síndrome coronario agudo sin elevación persistente del segmento ST. En: Montejo CJ,de Lorenzo GA,Marco,P,Ortiz,C.Manual de medicina intensiva.5ta.edición.España:Elsevier.p.105-109.
   Search at Google Scholar

1. 2.Benjamin S M, Morrow A D.Infarto de miocardio con elevación del ST: anatomía patológica, fisiopatología y manifestaciones clínicas. En: Braunwald E. Braunwald Tratado de Cardiología. 10ma edición. España: Elservier;2016 1068-1092.
   Search at Google Scholar

1. 3.Go A S, Mozaffarian D, Roger V L. (2013) . HeartDisease and Stroke Statistics-2013 update: A reportfromthe American HeartAssociation, Circulation 127: e6 .
   Search at Google Scholar

1. 4.Estadísticas de Salud [Internet].(accedió april 06, 2018).Disponible en:http://www.sld.cu/sitios/dne/.
   Search at Google Scholar

1. 5.Flores Blanco JP.. Papel Pronóstico de Nuevos Métodos de Valoración de la Función Renal en Insuficiencia Cardiaca Aguda y Síndrome Coronario Agudo sin Elevación del Segmento ST [Tesis Doctoral]. España: Universidad de Murcia;2016 .
   Search at Google Scholar

1. 6.Ibáñez B, James S, Agewall S, Antunes M J, Bucciarelli-Ducci C et al. (2017) Guía ESC2017sobre el tratamiento del infarto agudo de miocardio en pacientes con elevación del segmento ST. Revista Española de Cardiología.70(12);1082.e1-e61.
   Search at Google Scholar

1. 7.Comignani P, Gambarte G.Insuficiencia renal en situaciones vinculadas con la Unidad Coronaria. PROSAC.2011;. , Módulo 7 Fascículo N 2, 37-46.
   Search at Google Scholar

1. 8.Anavekar N S, McMurray J J, Velazquez E J, Solomon S D, Kober L et al. (2004) Relation between renal dysfunction and cardiovascular outcomesaftermyocardialinfarction. , N Engl J Med 351, 1285-1295.
   PubMed·View article·Search at Google Scholar

1. 9.Gutiérrez H B, FDM Benítez. (2017) Valor pronóstico de la función renal a corto plazo en pacientes con infarto agudo de miocardio. Revista Colombiana de Cardiología.
   Search at Google Scholar

1. 10.Eagle K A, Lim M J, Dabbous O H, Pieper K S, Goldberg R J et al. (2004) A validated prediction model for all forms of acute coronary syndrome: estimating the risk of 6-month postdischarge death in an international registry.GRACE Investigators.JAMA. 291, 2727-33.
   Search at Google Scholar

1. 11.Halkin A, Singh M, Nikolsky E. (2005) Prediction of mortality after primary percutaneouscoronary interventionforacutemyocardialinfarction: the CADILLAC risk score. , J Am CollCardiol 45(9), 1397-405.
   Search at Google Scholar

1. 12.Sánchez A, Pou M, Leiro R, López Gómez D, D Martínez Ruiz M et al. (2009) El grado de insuficiencia renal como predictor de mortalidad tras un síndrome coronario agudo. Nefrología. 29(1), 53-60.
   Search at Google Scholar