alexa Comparative Study of Predictive Value for Different Risk Scores for Predicting Contrast Induced Nephropathy and Short Outcome after Primary Percutaneous Coronary Intervention
ISSN: 2155-9880
Journal of Clinical & Experimental Cardiology

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Comparative Study of Predictive Value for Different Risk Scores for Predicting Contrast Induced Nephropathy and Short Outcome after Primary Percutaneous Coronary Intervention

Moustafa Mokarrab, Abd Elhamid Ismail, Mansour Mostafa, Abd Elaleem Elgendy, Haitham Sabry and Amr Yousry*

Department of Cardiology, Al-Azhar University, Egypt

*Corresponding Author:
Amr Yousry
Department of Cardiology, Al-Azhar University, Egypt
Tel: 0227547310
E-mail: [email protected]

Received date: June 14, 2017; Accepted date: July 14, 2017; Published date: July 21, 2017

Citation: Mokarrab M, Ismail AE, Mostafa M, Elgendy AE, Sabry H, et al. (2017) Comparative Study of Predictive Value for Different Risk Scores for Predicting Contrast Induced Nephropathy and Short Outcome after Primary Percutaneous Coronary Intervention. J Clin Exp Cardiolog 8:535. doi: 10.4172/2155-9880.1000535

Copyright: © 2017 Mokarrab M, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Abstract

Background: Meticulous risk stratification for contrast-induced nephropathy (CIN) is important for patients with ST-segment elevation myocardial infarction (STEMI) and treated with primary percutaneous coronary intervention (PPCI).

Aim of the work: To compare between different risk scores for predicting contrast-induced nephropathy (CIN) and short outcome after primary percutaneous coronary intervention in patients with ST segment elevation myocardial infarction.

Materials and methods: We prospectively enrolled 100 patients who presented with STEMI and treated with Primary PCI. Mehran, Gao, Chen, ACEF or AGEF (age, serum creatinine, or glomerular filtration rate, and ejection fraction); and GRACE (Global Registry for Acute Coronary Events) risk scores were calculated for each patient. The predictive accuracy of the 6 scores for CIN, in-hospital death and major adverse clinical events (MACEs) were assessed by Receiver operating characteristics (ROC) curve. CIN was defined as an absolute increase of serum creatinine by ≥ 0.5 mg/dl or a relative increase of serum creatinine by ≥ 25% from baseline value, at 48-72 h following the exposure to contrast media (CM). The data was analyzed using Chi-square test using SPSS (Statistical package for social science) software.

Results: All risk scores had relatively good predictive accuracy for CIN (Area under the curve (AUC) ranged from 0.671 to 0.829) and performed well for prediction of in-hospital death (AUC ranged from 0.838 to 0.973) and MACEs (AUC ranged from 0.815 to 0.926). The Mehran and Gao risk scores had better predictive accuracy for CIN. While Mehran and GRACE risk scores had better predictive accuracy for in-hospital death and MACEs.

Conclusion: Risk scores for predicting CIN perform well in stratifying the risk of CIN, in-hospital death and MACEs in patients with STEMI undergoing PPCI. The Gao, Mehran risk scores appear to have greater predictive value for CIN. While GRACE and Mehran scores had highest predictive accuracy for in hospital death and MACEs than the other risk scores.

Keywords

Primary PCI; Contrast induced nephropathy; Risk scores

Introduction

Contrast-induced nephropathy (CIN) or Contrast-induced acute kidney injury (CI-AKI) is the term given to iatrogenic renal dysfunction following intravascular (Intravenous or intra-arterial) administration of radiographic contrast media, occurring in absence of any other identifiable cause [1]. CIN is defined as either a greater than 25% increase of serum creatinine or an absolute increase in serum creatinine of 0.5 mg/dl from baseline value, at 48-72 h following the exposure to CM [2].

CIN is normally a transient process, with renal functions reverting to normal within 7-14 days of contrast administration. Less than one-third patients develop some degree of residual renal impairment [3]. CIN continues to be one of the most common major adverse side effects of cardiac catheterization, and is associated with short- and long-term morbidity and mortality [4]. This is particularly true in the population presenting with acute ST-elevation myocardial infarction (STEMI) which was significantly higher compared with patients undergoing non-emergent catheterization [5].

Patients undergoing primary PCI, however, are at high risk of CIN, a complication that has a serious impact on in-hospital outcome and may partially affect the overall benefit of primary PCI. Indeed, in-hospital mortality has been shown to be 20 times higher in patients who experience CIN after primary PCI as compared with those without this complication [6].

Identification and intervention for patients with STEMI with a high risk of CIN are crucial to improve clinical outcomes. Furthermore, last guidelines recommended risk stratification before treating patients with myocardial revascularization, with an evidence level of II b [7]. Therefore, many risk scores have been established for risk assessment of CIN in patients undergoing PCI.

The Mehran risk score was the first to be developed and was derived from a cohort of 8,357 patients treated with PCI. This score, when proposed, was observed to have a c-statistic of 0.67 but excluded patients treated with PPCI and patients in shock [8] However, the Mehran risk score was later tested for patients with STEMI who underwent primary PCI and showed a strong predictive value for CIN (c-statistic: 0.80 to 0.84) [9].

Ando et al., demonstrated that the ACEF risk score which include Age, serum crat is useful to predict CIN in patients with STEMI, while also demonstrating that the modified ACEF (AGEF) score has a similar discriminative ability for CIN [10,11]. In addition, Raposeiras-Roubin et al., [12] reported that the GRACE score is useful for predicting CIN in patients n a cohort of Chinese patients undergoinwith acute coronary syndrome with normal renal function [13]. The Gao and Chen risk scores were established based og PCI, without discrimination based on the underlying condition. They have good discriminative power for CIN in the validation data set [13-15].

Although none of those risk scores were established specifically to identify the risk of poor outcomes in patients with STEMI. Liu et al., [16] showed that the all 6 scores, in addition to prediction of CIN, had been proved to predict the in hospital outcomes [16].

Patients and Methods

This was a prospective observational study that was conducted from October 2016 to April 2017 and included 100 patients who presented to the emergency department of the National Heart Institute (NHI) with acute ST-elevation myocardial infarction and were treated with primary PCI. We enrolled patients presented, within 12 hours from symptoms onset mainly with typical chest pain lasting for at least 30 minutes not responsive to nitrates, with ECG showing ST-segment elevation of at least 0.1 mV in 2 or more contiguous leads, or development of new left bundle-branch block. Acute myocardial infarction was diagnosed in patients according to ESC guidelines 2014 [7].

Exclusion criteria were patients who not amenable for primary PCI and had recent exposure to radiographic contrast within one week before procedure. Patients on regular peritoneal or hemodialysis treatment, and who died during PCI were excluded.

The study protocol was approved by Al-Azhar University, Faculty of Medicine. A chart review was perform-ed, and data were collected including patient demographics, medical history, examination, ECG, echocardiography and primary PCI.

History was taken including age, gender, smoking was recognized as a lifetime history of >100 cigarettes in their entire life and had continued smoking in the last 6 months was considered a positive smoking history) 17while ex-smokers were defined having history of smoking at least 100 cigarettes in their entire life and had completely stopped smoking for at least 6 months) [17], Current diabetes mellitus was recognized as having history of DM on admission with the use of oral anti-hyperglycemic full agents or any extended release insulin and confirmed by laboratory HbA1c on admission if more than 6.5% [18], dyslipidemia was defined by total cholesterol ≥ 220 mg/dl, triglyceride ≥ 150 mg/dl, high-density lipoprotein (HDL cholesterol) ≥ 40 mg/dl or current use of anti-hyperlipdemic drug [19-21], hypertension was defined as systolic/diastolic blood pressure ≥ 140/90 mmHg or patients having history of hypertension and current use of any antihypertensive medications [22], Family history of premature coronary artery disease was defined as fatal or non-fatal events in first degree relatives men<55 or women <60 years [19], previous PCI procedures and previous CABG, other co-morbid conditions such as previous cerebrovascular stroke, renal impairment and the presence of peripheral vascular disease.

Serum creatinine was measured before the procedure and at 48 h after the procedure. The eGFR was calculated at the time of admission and at 48 hours after the procedure, using the 4-variable modification of diet in renal disease equation (MDRD) (mL/min/1.73 m2): 186 × (serum creatinine mg/dl) -1.154 × (age) - 0.203 × (0.742 for women) × (1.212 if black) [15]. It worth to be noted that MDRD equation had been validated extensively between the ages of 18 and 70 years old.

Serum creatinine kinas, creatinine kinas-MB, troponin I, complete blood count and electrolytes were measured at admission. Serum level of lipid profiles (low density lipoproteins, high density lipoproteins, total cholesterol and triglycerides) and basal liver functions were measured after the procedure. The left ventricular EF (LVEF) was evaluated by echocardiography in all patients within 24 h after admission.

There are many risk scores that have been established for risk assessment of CIN in patients undergoing PCI. Risk scores were calculated from the initial clinical history, laboratory values, and PCI procedure. A full clinical examination included vital signs, cardiac examination to assess the Killip classification for each patient, patients were ranked by Killip class in the following way: Killip class I (included individuals with no clinical signs of heart failure), Killip class II (included individuals with rales or crackles in the lungs, an S3, and elevated jugular venous pressure), Killip class III (described individuals with frank acute pulmonary edema), and Killip class IV (described individuals in cardiogenic shock or hypotension and evidence of peripheral vasoconstriction (oliguria , cyanosis or sweating) [7]. Hypotension was defined as systolic blood pressure ≤ 90 mmHg requiring inotropic support with medications or intra-aortic balloon pump (IABP). Heart failure included advanced congestive heart failure (New York Heart Association functional class III/IV) or acute heart failure (Killip class II–IV) [7].

All patients were given 600 mg clopidogrel, 300 mg aspirin, UFH/ LMWH (low-dose unfractionated heparin, 50 U/kg (regardless of use of glycoprotein IIb /IIIa antagonists), while the standard-dose of unfractionated heparin is 85 U/kg (60 U/kg with Glycprotein IIb/IIIa antagonists) [7]. During the procedure and continued during hospital stay unless contraindicated, in addition to the conventional anti-ischemic and anti-anginal treatment as nitrates.

Hydration with intravenous normal saline solution was initiated during the procedure and maintained until 6 to 12 hours after completion of the procedure. The hydration rate was 1 ml/kg/hour or 0.5 ml/kg/hour if the LVEF was <40% for patients with eGFR< 60 ml/ min/1.73 m2. Coronary angiography was performed as soon as possible, upon arrival of the on-call team. We started, by catheterization of the artery of the non-infract region, followed by the culprit one. PCI stenting of the culprit lesion(s) was done.

The primary study end point was the occurrence of CIN, defined as either a greater than 25% increase of serum creatinine or an absolute increase in serum creatinine of 0.5 mg/dl from baseline value, at 48-72 h following the exposure to procedure [2]. The secondary end point was the occurrence of in hospital death and in hospital major adverse cardiac (MACEs) which include cardiac death, presence of reinfarction, the onset of heart failure and major bleeding.

For comparison of differences among risk scores, we classified patients into risk categories according to the data presented in Liu et al., [16] who defined patients as low-, moderate- and high-risk for CIN [17].

Reinfarction was defined as the appearance of new myocardial ischemic symptoms or electrocardiographic ischemic changes accompanied by re-elevation of cardiac biomarkers (cTnI). Major bleeding was defined as the composite of intracranial or intraocular bleeding, access site hemorrhage requiring intervenetion, reduction in hemoglobin of 4 g/dl without or 3 g/dl with an overt bleeding source, reoperation for bleeding or blood product transfusion during the follow up.

Data were analyzed using Statistical program for social science (SPSS) version 20.0. Quantitative data were expressed as mean ± standard deviation (SD). Qualitative data were expressed as frequency and percentage. Independent samples t-test of significance was used when comparing between two means. Chi-square (X2) test of significance was used in order to compare proportions between two qualitative parameters. Receiver operating characteristic (ROC curve) analysis was used to find out the overall predictively of parameter in and to find out the best cut-off value with detection of sensitivity and specificity at this cut-off value.

Results

This was a prospective cross sectional observational study that involved 100 patients who presented to the emergency department of the National Heart Institute (NHI) with acute ST- elevation myocardial infarction and treated with primary PCI, within the period between October 2016 and May 2017.

All patients were subjected to history taking and full clinical examination, venous samples were withdrawn, coronary angiography was recorded and intervention was done, then they were followed during hospital stay.

The mean age of study group was 54.69 ± 11.77 years (ranged from 28-82 years), the number of patients who are seventy or older was 11 (11%), while the number of patients who are below seventy was 89 (89%). Males represented 84% (84 patients) of the study population and the male to female ratio was (5.25:1). Thirty two percent of study group (32 patients) were diabetic, while 41% (41 patients) were hypertensive and 64% (64 patients) were smokers. 5% of study group (5 patients) were dyslipidemic and one patient had family history of premature coronary artery disease. Regarding the past history, 5% of study group (5 patients) had history of prior PCI, 8% of patients had history of prior MI and one patient had history of CABG (Tables 1 and 2).

  Variable Score   variable Score
Mehran Age ≥ 75 years 4 GRACE Age
Anemia 3 <30 0
Diabetes mellitus 3 30-39 8
Chronic heart failure 5 40-49 25
Intra-aortic balloon pump 5 50-59 41
Hypotension 5 60-69 58
 CM material  1 for each 100 cc 70-79 75
eGFR ≤ 20  ml/min/1.73 m2 6 80-89 91
eGFR 20- 40 ml/min/1.73 m2 4 >90 100
eGFR 40-60 ml/min/1.73 m2 2 Heart rate (beats/min)
CHEN Age >70 years 4 <50 0
History Of  MI 5 50-69 3
Diabetes mellitus 4 70-89 9
Hypotension 6 90-109 15
LV  EF  ≤ 45% 4 110-149 24
Anemia* 3 150-199 38
eGFR <60 ml/min/1.73  m2 7 >200 46
HDL <1 mmol/L 3    
ACEF Age /Left ventricular EF (%) Yrs/EF%                  Systolic BP (mm Hg)
if serum creatinine >2.0 mg/dl Add 1 <80 58
AGEF Age /Left ventricular EF (%) Yrs/EF% 80-99 53
If  eGFR ≤60 mL/min/1.73 m2 Add 1 100-119 43
Gao Age >60 years 2 120-139 34
Hypertension 2 140-159 24
Acute myocardial infarction 2 160-199 10
Heart failure 2 >200 0
Use of intra-aortic balloon pump 4 Creatinine (mg/dl)
eGFR 89 to 70 ml/min/1.73  m2 1 0-0.39 1
eGFR69 to 50 ml/min/1.73 m2 2 0.4-0.79 4
eGFR49 to 30 ml/min/1.73 m2 3 0.8-1.19 7
eGFR<30  ml/min/1.73 m2 6 1.2-1.59 10
Contrast volume 100 to 300 ml 1 1.6-1.99 13
Contrast volume  ?300 ml 3 2-3.99 21
  >4 28
Killip’s classification
 *Anemia was defined as hemoglobin (HB%) <12 gm/dl (16)
  
I 0
II 20
III 39
IV 59
   Cardiac arrest at admission      39
Increased cardiac markers 14
ST  Segment deviation 14

Table 1: Variables in risk scores evaluated.

Risk score Low Moderate High
Mehran <7.8 7.8-11.99 ≥ 12
Chen <7 7-12.99 ≥ 13
GRACE  <141 141-159.9 ≥ 160
ACEF  <0.99 0.99-1.29 ≥ 1.30
AGEF <1.0 1.0-1.36 ≥ 1.37
Gao <5 5.-8.0 ≥ 8.0

Table 2: definition of low, moderate and high risk patients for CIN according to different risk scores.

As regard clinical examination, the mean of heart rate of study group was 89.76 ± 16.06 bpm, while the mean of systolic blood pressure was 118 ± 29 mmHg and the mean of diastolic blood pressure was 72 ± 17 mmHg. Concerning Killip class at presentation, 6 % of patients presented with Killip class IV, while 3% of patients presented with Killip class III and 91% of patients presented with Killip class I.

All patients presented with typical chest pain, 2% presented with diabetic ketoacidosis (DKA) and 3% (3 patients) presented with cardiac arrest and had successful cardiopulmonary resuscitation (CPR) receiving DC shock. Two patients presented with 2nd degree heart block and one patient presented with complete heart block. Majority of patients presented with anterior STEMI 61% (Table 3).

Demographic data
Sex
Female 16 (16.0%)
Male 84(84.0%)
Age (years) Range 28-82 (54.69 ± 11.77)
Diabetes 32 (32 %)
Hypertension 41 (41%)
Smoker 64 (64 %)
Dyslipidemia 5 (5 %)
Family history of IHD 1 (1 %)
Past history 
Prior PCI 5 (5%)
Prior MI 8 (8 %)
Prior CABG 1 (1%)
Examination
Heart Rate (bpm) 40-140 (89.76 ± 16.06)
Systolic blood pressure (mmHg)  60-220  (118.24 ± 29.21
Diastolic blood pressure (mmHg) 40-120 (72.79 ± 17.16)
Killip class
I 91 (91%)
II 0 (0%)
III 3 (3%)
IV 6 (6%)
Presentations
Onset of chest pain in hours–Range 1-12 (6.59 ± 3.21)
Chest pain  100 (100%)
DKA  2 (2.0%)
DC Shock( tachyarrhythmia)  3 (3.0%)
Brady arrhythmia 3 (3.0%)
Cardiac arrest 3 (3.0%)
ECG
Anterior STEMI 61 (61.0%)
Lateral STEMI 3 (3.0 %)
Inferior STEMI 35 (35.0%)
Septal STEMI 1 (1.0 %)
Laboratory before PCI
Serum creatinine (mg/dl) 0.4-2.1 (0.94 ± 0.31)
eGFR (mL/min/1.73 m2 ) 26.13-180.64 (90.95 ± 33.61)
Serum urea (mg/dl) 11-95 (34.50 ± 15.59)
Hemoglobin % (gm/dl) 9.6-17.5 (13.39 ± 1.56)
RBS (mg/dl) 90-600 (201.77 ± 122.67)
Labs after 48 h
Serum creatinine (mg/dl) 0.4-4.1 (1.10 ± 0.63)
eGFR (ml/min/m2) 15.34-180.64 (81.38 ± 30.45)
Serum urea (mg/dl) 15-143 (40.62 ± 20.0)
Lipid Profile
Total cholesterol (mg/dl) 139-280 (205.40 ± 25.63)
Triglycerides (mg/dl)  85-616  (184.05 ± 71.24)
HDL (mg/dl) 21-50 (37.03 ± 6.04)
LDL (mg/dl) 14-212 (135.26 ± 25.72)
Ejection fraction 25%-65% (46.16 ± 8.69)

Table 3: Baseline characteristics of the study population.

In the present study, serum creatinine level on admission was ≤ 1.4 mg/dl in a quite high proportion of patients (92.0%) and the eGFR on admission was ≥ 60 mL/min/1.73 m2 in 80% of study population.

The infarct related artery (culprit artery) was right coronary artery (RCA) in 29 patients, left anterior descending artery (LAD) in 63 patients and left circumflex (LCX) in 5 patients, obtuse marginal (OM1) in 3 patients. We had 48% (48 patients) with single vessel disease, 34% (34 patients) with two vessel disease and 18% (18 patients) with multivessel disease (Tables 4 and 5).

Culprit vessel (s)
LAD 63      (63%)
Isolated 57
With other 6
RCA 29      (29%)
Isolated 27
With other 2
LCX 5 (5%)
 Isolated 4
With other 1
OM (3%)
Vessel disease
Single vessel disease 48 (48 %)
Two vessel disease 34 (33 %)
Three vessel 18 (18 %)
Total revascularization 57 (57 %)
Femoral Approach 100 (100%)
Number of stents
One 69 (69 %)
Two 30 (30 %)
Three 1 (1 %)
Total 100 (100 %)
Time to vascular access ( Secs) Range 1-4   (1.37 ± 0.65)
Contrast volume (ml) Range 100-400  (221.80 ± 64.52)
Radiation Exposure Time (min) – Range 30-90 (51.40 ± 10.83)
Complications
Dissection 3         (3 %)
Stroke 1         (1 %)
No-Reflow 6         (6 %)
CPR 10 minutes 1         (1 %)
No complications 89      (89 %)
Glycoprotein II b III a  antagonists use
No 83       (83%)
Yes 17      (17%)
Total 100     (100%)
Decisions after PCI
For Elective PCI to non-culprit vessel (s)   31       (31 %)
For CABG after viability test   3         (3 %)
Medical TTT Only 66        (66 %)
Total 100      (100%)

Table 4: Technical data of primary PCI.

 Follow up (days) Range [Mean ± SD] 2-21 (3.81 ± 2.24)
CIN
No 90      (90%)
Yes 10      (10%)
Total 100   (100%)
Hospital stay  mean ± SD  5.2 ± 2.4 days 
Time to CIN   mean ± SD  2 ± 0.63 days                                        
MACE (s)
No 93      ( 93%)
Yes 7        (7%)
Total 100    (100%)
All in hospital MACE (s) (N=7)
Death 6        (6%)
Re-infarction 1        (1%)
Time to MACES (days)  Range    2-21 (7.57 ± 6.8)
Death
No 94      (94%)
Yes 6        (6%)
Total 100   (100%)
Time to death (days)  Range (Mean ± SD) 2-21 (7.71 ± 7.3)
CIN and Dialysis
No 99      (99%)
Yes 1         (1%)
Total 100   (100%)
Time to dialysis 6 days

Table 5: Follow up and in hospital outcomes

Regarding contrast volume used and radiation exposure time, we used 221.80 ± 64.2 ml of contrast and the mean of exposure to radiation time was 51.4 ± 10.8 minutes. We used one stent in 69% of study group (69 patients), two stents in 30% (30 patients) and three stents only in one patient. Two interventions complicated with dissections and 6% with no-reflow. One patient had stroke and another had successful CPR in cath lab. Glycoprotein IIb IIIa antagonists were used in 17% of study population. Twenty seven percent of study group were recommended for elective PCI for non-culprit in another session and 3% (3 patients) for CABG.

Complete inhospital follow up during was achieved in 100% of patients with mean 3.81 ± 2.24 days (range 1-21 days). The incidence of CIN in was 10%, the patients with CIN had poor in-hospital outcome. Their hospital stay was significantly prolonged with a mean 5.2 ± 2.4 days. The incidence of in hospital MACEs was 7% and 6% for in hospital death. Only one patient underwent dialysis.

For CIN, there was statistical significant relation between CIN according to serum creatinine ≥ 2 mg/dl at admission (p value=0.003), with serum urea (p value<0.001), systolic blood pressure <90 mmHg at admission (p value=0.007), with Killip class at admission (p value<0.001), with anterior STEMI (p value =0.049), with contrast volume used ≥ 200 ml (p value =0.048) and radiation exposure time (p value=0.042) (Table 6 and Figure 1).

 Variables CIN Chi-square test
No [n=90] Yes [n=10] x2       p- value
Age  (years)
≤ 70 years 82 (91.1%) 9 (90.0%) 0.014 0.907
>70 years 8 (8.9%) 1 (10.0%)
Age   (years)
<60 years 61 (67.8%) 6 (60%) 0.246 0.62
>60 years 29 (32.2%) 4 (40%)
Hypertension        
No 54 (60%) 5 (50%) 0.372 0.542
Yes 36 (40%) 5 (50%)
Diabetes
No 63 (70.0%) 5 (50.0%) 1.654 0.198
Yes 27 (30.0%) 5 (50.0%)
Prior PCI        
No 86 (95.6%) 9 (90%) 0.585 0.444
Yes 4 (4.4%) 1 (10%)
Prior MI        
No 83 (92.2%) 9 (90%) 0.06 0.806
Yes 7 (7.8%) 1 (10%)
Level of heart rate (bpm)
≤ 100 62 (68.9%) 7 (70.0%) 0.005 0.943
>100 28 (31.1%) 3 (30.0%)
Systolic blood pressure  (mmHg) admission
<90 9 (10.0%) 4 (40.0%) 7.162 0.007
≥ 90 81 (90.0%) 6 (60.0%)
Killip class
1 85 (94.4%) 6 (60.0%) 13.655 <0.001
3 2 (2.2%) 1 (10.0%)
4 3 (3.3%) 3 (30.0%)
Random blood sugar >300 mg/dl
<300 64 (71.1%) 6 (60%) 0.529 0.467
>300 26 (28.9%) 4 (40%)
Serum urea 32.13  ±  12.88 55.80  ±  21.75 25.96 <0.001
Serum Creatinine   (mg/dl)
≤ 2 90 (100.0%) 9 (90.0%) 9.091 0.003
>2 0 (0.0%) 1 (10.0%)
eGFR  ml/min/1,73 m2
<60 16 (17.8%) 4 (40.0%) 2.778         0.096
>60 74 (82.2%) 6 (60.0%)
HDL ( (mg/dl) 37.10 ± 6.14 36.40 ± 5.25 0.12 0.73
LDL  (mg/dl) 137.9 ± 24.58 134.97 ± 25.96 0.367 0.716
T. cholesterol 203.6 ± 27.26 205.6 ± 25.6 0.239 0.812
TGs (mg/dl) 164.4 ± 24 186.23 ± 74.43 1.248 0.219
HB% (mg/dl) 12.79 ± 1.95 13.46 ± 2.07 1.054 0.299
Ejection Fraction<45%
<45% 33 (36.7%) 6 (60%) 2.06 0.151
>45% 57 (63.3%) 4 (40%)
Type of STEMI
Anterior 54 (60%) 7 (70%) 12.621 0.049
Lateral 0% 0 (0%)
Inferior 32 (35.6%) 3 (30%)
Septal 1 (1.1%) 0 (0%)
Time to vascular access  (min)   0.92 0.821
1 65 (72.2%) 6 (60.0%)
2 19 (21.1%) 3 (30.0%)
3 5 (5.6%) 1 (10.0%)
4 1 (1.1%) 0 (0.0%)
Number of stents     0.612   0.736
1 63 (70.0%) 6 (60.0%)
2 26 (28.9%) 4 (40.0%)
3 1 (1.1%) 0 (0.0%)
  Complications     0.741      0.946
CPR 1 (1.1%) 0 (0%)
Dissection 2 (2.2%) 0 (0%)
No complications 81 (90%) 9 (90%)
No-Reflow 5 (5.6%) 1 (10%)
Stroke 1 (1.1%) 0 (0%)
Contrast volume (ml)   3.904 0.048
<200 26 (28.9%) 0 (0.0%)
≥ 200 64 (71.1%) 10 (100.0%)
Total revascularization   0.041    0.84
No 39 (43.3%) 4 (40.0%)
Yes 51 (56.7%) 6 (60.0%)
Radiation exposure Time  (min) 4.265   0.042
  50.67  ±  10.84 58.00  ±  8.56
p-value <0.05 S; p-value <0.001 HS; p-value >0.05 NS

Table 6: Relation between CIN (Yes and No) and potential predictor variables.

clinical-experimental-cardiology-Overall-scores

Figure 1: Overall scores distribution of the study group (N=100).

On the other hand, there was no significant relation with Age ≥ 70 years, presence of diabetes, history of hypertension, prior MI, prior PCI, EF<45%, RBS >300 mg/dl, eGFR<60 ml/min/1.73 m2, lipid profile (LDL, HDL, total cholesterol and triglycerid- es), time to vascular access, heart rate on admission, number of stents used and total revascularization (Tables 6 and 7).

Scores No. %
Chen    
High 21 21.0
Moderate 36 36.0
Low 43 43.0
Range (Mean ± SD)        0-27 (7.97 ± 5.55)
ACEF    
High 39 39.0
Moderate 34 34.0
Low 27 27.0
Range (Mean ± SD) 0.6-2.31 (1.24 ± 0.38)
AGEF    
High 41 41.0
Moderate 33 33.0
Low 26 26.0
  0.6-3.2 (1.43 ± 0.62)
GRACE    
High 24 24.0
Moderate 31 31.0
Low 45 45.0
Range (Mean ± SD) 86-268 (145.08 ± 33.73)
GAO    
High 31 31.0
Moderate 31 31.0
Low 38 38.0
Range (Mean ± SD) 4-13 (6.26 ± 2.28)
Mehran    
High 11 11.0
Moderate 12 12.0
Low 77 77.0
Range (Mean ± SD) 1-22 (5.67 ± 4.24)

Table 7: Overall Scores distribution of the study group (N=100).

Our study demonstrated that there was statistically significant difference between CIN [No or Yes] according to level of all 6 risk scores (Table 8 and Figure 2).

Level of Scores CIN Chi-square
No  (n=90) Yes  (n=10) x2 p-value
Chen score        
High 17 (18.9%) 4 (40.0%) 8.466 0.015*
Moderate 30 (33.3%) 6 (60.0%)
Low 43 (47.8%) 0 (0.0%)
         
ACEF        
High 32 (35.6%) 7 (70.0%) 6.568 0.042*
Moderate 32 (35.6%) 2 (20.0%)
Low 26 (28.9%) 1 (10.0%)
     
AGEF        
High 35 (38.9%) 6 (60.0%) 5.103 0.035*
Moderate 30 (33.3%) 3 (30.0%)
Low 25 (27.8%) 1 (10.0%)
     
GRACE        
High 18 (20.0%) 6 (60.0%) 9.028 0.011*
Moderate 28 (31.1%) 3 (30.0%)
low 44 (48.9%) 1 (10.0%)
     
GAO        
High 24 (26.7%) 7 (70.0%) 9.677 0.008*
Moderate 28 (31.1%) 3 (30.0%)
Low 38 (42.2%) 0 (0.0%)
Mehran        
High 8 (8.9%) 3 (30.0%) 8.622 0.013*
Moderate 9 (10.0%) 3 (30.0%)
Low 73 (81.1%) 4 (40.0%)
p-value <0.05 S*; p-value <0.001 HS*; p-value >0.05 NS.

Table 8: Comparison between CIN (No and Yes) according to level of scores.

clinical-experimental-cardiology-level-scores

Figure 2: Comparison between CIN [Yes and No] according to level of scores.

In this study, there was statistically significant difference between MACE(s) [No or Yes] according to level of all risk scores (Table 9 and Figure 3).

Level of Scores MACE (s) Chi-square
No  (n=93) Yes  (n=7) x2 p-value
Chen        
High 16 (17.2%) 5 (71.4%) 12.467 0.002*
Moderate 34 (36.6%) 2 (28.6%)
Low 43 (46.2%) 0 (0.0%)
     
ACEF        
High 32 (34.4%) 7 (100.0%) 11.773 0.003*
Moderate 34 (36.6%) 0 (0.0%)
Low 27 (29.0%) 0 (0.0%)
     
AGEF        
High 34 (36.6%) 7 (100.0%) 10.831 0.004*
Moderate 33 (35.5%) 0 (0.0%)
Low 26 (28.0%) 0 (0.0%)
     
GRACE        
High 18 (19.4%) 6 (85.7%) 16.010 <0.001*
Moderate 30 (32.3%) 1 (14.3%)
low 45 (48.4%) 0 (0.0%)
     
GAO        
High 25 (26.9%) 6 (85.7%) 10.807 0.005*
Moderate 30 (32.3%) 1 (14.3%)
Low 38 (40.9%) 0 (0.0%)
     
Mehran        
High 6 (6.5%) 5 (71.4%) 28.182 <0.001*
Moderate 12 (12.9%) 0 (0.0%)
Low 75 (80.6%) 2 (28.6%)
p-value <0.05 S*; p-value <0.001 HS*; p-value >0.05 NS.

Table 9: Comparison between MACE (s) (No and Yes) according to level of scores.

clinical-experimental-cardiology-according-level

Figure 3: Comparison between MACE(s) [Yes and No] according to level of scores.

There was statistically significant difference between death [No or Yes] according to level of all risk scores (Table 10 and Figure 4).

Level of Scores Death Chi-square
No  (n=94) Yes  (n=6) x2 p-value
Chen        
High 16 (17.0%) 5 (83.3%) 15.217 <0.001*
Moderate 35 (37.2%) 1 (16.7%)
Low 43 (45.7%) 0 (0.0%)
     
ACEF        
High 33 (35.1%) 6 (100.0%) 9.984 0.007*
Moderate 34 (36.2%) 0 (0.0%)
Low 27 (28.7%) 0 (0.0%)
     
AGEF        
High 35 (37.2%) 6 (100.0%) 9.185 0.010*
Moderate 33 (35.1%) 0 (0.0%)
Low 26 (27.7%) 0 (0.0%)
     
GRACE        
High 18 (19.1%) 6 (100.0%) 20.213 <0.001*
Moderate 31 (33.0%) 0 (0.0%)
low 45 (47.9%) 0 (0.0%)
     
GAO        
High 26 (27.7%) 5 (83.3%) 8.488 0.014*
Moderate 30 (31.9%) 1 (16.7%)
Low 38 (40.4%) 0 (0.0%)
     
Mehran        
High 6 (6.4%) 5 (83.3%) 34.144 <0.001*
Moderate 12 (12.8%) 0 (0.0%)
Low 76 (80.9%) 1 (16.7%)
p-value <0.05 S*; p-value <0.001 HS*; p-value >0.05 NS

Table 10: Comparison between died and survived according to level of scores.

clinical-experimental-cardiology-died-alive

Figure 4: Comparison between died and alive according to level of scores.

All risk scores showed relatively good predictive accuracy for CIN (ranged from 82.9%-67.1%). Mehran score has the highest predictive accuracy for CIN (82.9%) with 100% sensitivity and 46% specificity (Tables 11-13 and Figures 5-7).

Score Cut-off Sen. 100-spec. Spe. PPV NPV AUC Accuracy
Chen >8 80% 32% 68% 22% 97% 0.777     77.7%
ACEF >1.7 50% 10% 90% 36% 94% 0.697 69.7%
AGEF >1.7 60% 24% 76% 21% 94% 0.671 67.1%
GRACE >149 90% 30% 70% 25% 98% 0.780 78.0%
GAO >5 100% 54% 46% 17% 100% 0.798 79.8%
Mehran >5 90% 34% 66% 23% 98% 0.829 82.9%

Table 11: Performance of scores in discrimination of CIN (No and Yes).

Score Cut-off Sen. 100-spe Spe. PPV NPV AUC Accuracy
Chen >7 100% 37% 63% 17% 100% 0.863 86.3%
ACEF >1.4 100% 27% 73% 22% 100% 0.849 84.9%
AGEF >1.7 60% 24% 76% 21% 94% 0.815 81.5%
GRACE >171 86% 9% 91% 43% 99% 0.915 91.5%
GAO >6 100% 35% 65% 18% 100% 0.899 89.9%
Mehran >6 100% 23% 77% 25% 100% 0.926        92.6%

Table 12: Performance of scores in discrimination of MACEs (No and Yes).

Score Cut-off Sen. 100-spec Spe. PPV NPV AUC Accuracy
Chen >9 100% 30% 70% 18% 100% 0.900 90.0%
ACEF >1.4 100% 28% 72% 19% 100% 0.856 85.6%
AGEF >1.4 100% 35% 65% 15% 100% 0.838 83.8%
GRACE >171 100% 9% 91% 43% 100% 0.973 97.3%
GAO >6 100% 38% 64% 15% 100% 0.885 88.5%
Mehran >11 83% 6% 94% 46% 99% 0.949 94.9%

Table 13: Performance of scores in discrimination of Death (No and Yes).

clinical-experimental-cardiology-ROC-curve

Figure 5: ROC curve shows sensitivity, specificity and performance of scores in discrimination of CIN (No and Yes).

clinical-experimental-cardiology-performance-scores

Figure 6: ROC curve shows sensitivity, specificity and performance of scores in discrimination of MACE(s) (No and Yes).

clinical-experimental-cardiology-discrimination-Death

Figure 7: ROC curve shows sensitivity, specificity and performance of scores in discrimination of Death (Yes or No).

All 6 risk scores showed high predictive accuracy for in hospital MACEs (ranged from 92.6 to 81.5%). Mehran risk score showed highest predictive accuracy in hospital with 100% sensitivity and 77% specificity.

All 6 risk scores showed high predictive accuracy for in hospital death (ranged from 97.3% to 83%). GRACE risk score showed the highest predictive accuracy for in hospital death with 100% sensitivity and 91% specificity.

Discussion

This was a prospective observational study conducted in the National Heart Institute (NHI) and involved 100 patients who presented with acute STEMI that was treated using primary PCI.

The present study aimed to compare between different risk scores for predicting CIN and short outcome after primary PCI in patients with STEMI. In addition to prediction of CIN, we demonstrated that those different risk scores performed well for predicting in hospital MACEs and death.

The observed incidence of CIN after primary PCI differs greatly among various studies, largely because of varying definitions and associated variable risk factors. Not surprisingly, the frequency of CIN in our study was about 10%, which is lower than the results observed by Marenzi et al., [4], who studied 208 consecutive patients admitted to coronary care unit for STEMI who were treated with primary PCI. CIN was observed in approximately 19% of STEMI patients who underwent primary PCI. Our data may be related to the close collaboration with the local nephrologist in our institution that may have reduced the risk of CIN development as the result of a prompt activation of the hydration protocol.

However, Raposeiras-Roubin et al., [12] studied 202 consecutive patients presented with acute myocardial infarction (STEMI and NSTEMI) and with normal kidney function (eGFR>60/mL/min/ 1.7 m2) undergoing coronary angiography and follow up during hospital stay. The incidence of CIN was 6% which was lower than our study, as we did not exclude patients presented with renal dysfunction from the study as 20% of our study population presented with renal dysfunction (eGFR<60 ml/min/1.73 m2).

In this study only 1% of patients who had CIN underwent dialysis and this was concordant with McCullough et al., [20], who demonstrated that the occurrence of acute renal failure requiring dialysis after coronary intervention is rare (1%).

This study showed that, in STEMI patients undergoing primary PCI, CIN was a significant and independent predictor of poor in-hospital outcome. This was concordant with Liu et al., [16], who may be the first to compare between those 6 risk models for CIN in patients with STEMI, prospectively enrolled 422 consecutive patients with STEMI undergoing primary PCI and showed that CIN was a highly significant predictor for in hospital mortality (p value=0.001).

In this study, the incidence of in-hospital death was 6% of study population while Liu et al., [16], who showed that the incidence of in hospital death was 4%. Our data may due to late presentation of study population.

MACEs occurred in 7% of our study population while Liu et al., [16] showed that the incidence of MACEs was 17% of study population. This was due they enrolled major adverse cardiac and non-cardiac events in their study.

Univariate Analysis between Different Potential Predictor Variables and in Hospital Outcomes

CIN:

Our study concluded that there was statistically significant relation between CIN and following predictor variables:

Baseline serum creatinine ≥ 2 mg/dl at admission (p value=0.003), which was concordant with Ando et al., 10 who studied 481 patients with STEMI underwent primary PCI including patients with cardiogenic shock and demonstrated that baseline Serum creatinine ≥ 1.5 mg/dl was highly significant predictor for CIN (p value ≤ 0.001).

Systolic blood pressure <90 mmHg at admission (p value=0.007) , which was concordant with Chen et al., [13], who retrospectively studied 1500 consecutive Asian patients who underwent PCI for ACS and demonstrated that the hypotension at admission was a highly significant predictor for CIN (p value ≤ 0.001).

Killip class at admission (p value ≤ 0.001), which was concordant with Raposeiras-Roubín et al., [12], who showed that Killip class >I at admission was highly significant predictor for CIN (p value=0.001).

Contrast volume used ≥ 200 ml (p value=0.048), which was consistent with Gao et al., [14], who retrospectively studied 3945 Asian patients undergoing coronary angiography or PCI and demonstrated that the contrast volume used >200 mL was associated with a significantly higher risk of CIN and the CIN risk would be increased with the increment of contrast volume.

Anterior STEMI (p value=0.049), this was concordant with Marenzi et al., [4] who found a that patients presented with anterior STEMI were at a higher risk for CIN (p value=0.0015).

In-hospital stay (p value 0.03), this was consistent with study Ando et al., [11], who found that patients with CIN had a significant prolonged in-hospital stay (p value ≤ 0.001).

On the other hand, we found that there was no statistically significant relation of the following factors and CIN:

Age ≥ 70 years (p value=0.907), which was in disagreement with Chen et al., [13], who found that the age of >70 years was an independent predictor of CIN because a number of structural and functional degenerative changes in kidneys could make old persons prone to CIN. Our data may due to the fact that we had only 11% of our study population with age of seventy or older. However, Raposeiras- Roubín et al., [12] found that Age ≥ 75 years was not a significant risk factor for CIN (p value= 0.365).

Diabetes (p value= 0.198), this was discordant with Chen et al., [13], who found that diabetes was a predictor of CIN (p value ≤ 0.001). But In 2006, the CIN Consensus Working Panel stated that it is not clear whether the risk of CIN is significantly increased in patients with diabetes who do not have renal impairment and the updated contrast Media Safety Committee (CMSC) of European Society of Urogenital Radiology guidelines published in 2011 also hold the same opinion [2].

The eGFR<60 ml/min/ 1.73 m2 at admission (p value=0.096), which was inconsistent with Gao et al., [14], who found that the baseline renal function was one of the strongest predictors for CIN development. This may be due to the renal function in a quite high proportion of our patients (80.0%) was normal (i.e., eGFR >60 mL/min/1.73 m2). Because the compensatory capacity of kidney diminished in the patients with renal insufficiency, it is easier to develop acute kidney injury affected by nephrotoxic agents, including contrast media.

Heart rate >100 bpm at admission (p value=0.943), which was consistent with Ando et al., [10], who found that heart rate at admission was not a predictor of CIN (p value=0.06).

Depressed EF <45% (p value=0.151), which was concordant with Raposeiras-Roubín et al., [12] who demonstrated that depressed EF was not a predictor of CIN (p value=0.541).

History of HTN (p value=0.542), which was consistent with Gao et al., [14], who demonstrated that history of hypertension was significant predictor of CIN (p value=0.001)

Patients who had multivessel disease and this was discordant with Gao et al., [14], who found that patients with multivessel disease were at high risk for CIN (p value=0.002).

History of prior PCI and prior CABG and this was concordant with Gao et al., [14], who found that patients with past history of CABG or PCI were not at risk for CIN (p value =0.529).

Number of stents used (p value=0.736).

Patients who underwent total revascularization (p value=0.840).

Death and MACEs

Our study concluded that there was significant relation between in hospital outcomes and the following predictor variables:

CIN which was an independent predictor for in hospital death. This was concordant with Ando et al., [10], who found that CIN was a significant risk predictor for in hospital mortality as 66% of deaths had CIN.

Heart rate ≥ 100 bpm (p value=0.004), SBP<90 mmHg (p value ≤ 0.001) and Killip class on admission (p value ≤ 0.001). This consistent with previous study [12].

On the other hand, our study showed that there was no significant relation between in hospital death and the following; Age ≥ 70 years (this was inconsistent with Valente et al., [23], who demonstrated that age ≥ 75 years was a predictor of death in patients presented with STEMI complicated with cardiogenic shock treated with primary PCI with p value=0.002), presence of diabetes, history of hypertension (this was discordant with Valente et al., [23], who demonstrated that history of HTN was a predictor of death with p value=0.003), prior MI, prior PCI, serum creatinine >2 mg/dl at admission (this was discordant with Valente et al., [23], who demonstrated that serum creatinine >1.5 mg/ dl at admission was a predictor of death with p value=0.003), random blood sugar (RBS) >300 mg/dl at admission (this was discordant with Valente et al., [23], who demonstrated that RBS >200 mg/dl was a predictor of death with p value=0.002), eGFR<60 ml/min/1.73 m2 on admission, HDL level, time to vascular access, number of stents used, total revascularization and with complications of PCI

Comparison between Different Risk Scores Predicting in Hospital Outcomes:

Receiver operating characteristic curve (ROC) analysis was used to find out the overall predictivity of parameter in and to find out the best cut-off value with detection of sensitivity and specificity at this cut-off value.

CIN

This study demonstrated that all six risk scores showed relatively good predictive accuracy for CIN (ranged from 82.9%-67.1%), which was concordant with Liu et al., [16], who showed that the predictive accuracy of all six scores for CIN were ranged from 87.6%-74.6%.

Our study showed that Mehran score had the highest predictive accuracy for CIN (82.9%), with 90% sensitivity and 66% specificity. while The ACEF and AGEF score showed the lowest predictive accuracy for CIN (69.7%, 67.1% respectively). On the other hand, Liu et al., [16], who demonstrated that Gao, ACEF and AGEF scores had the highest predictive accuracy for CIN-narrow (87.6%, 87.3% and 87.1% respectively). While Chen score had the lowest predictive value for CIN (74.6%) [16].

In hospital MACEs

Our Study demonstrated that the All six risk scores showed high predictive accuracy for in hospital MACEs (ranged from 92.6 to 81.5%), which was higher than the results published by Liu et al., [16] in which predictive accuracy for MACEs was ranged from 76.3% to 68.5%. [16].

This study showed that Mehran risk score showed the highest predictive accuracy for MACEs with 100% sensitivity and 77% specificity. While the ACEF and AGEF score showed the lower predictive accuracy for MACEs (84.9%, 81.5% respectively). On the other hand, Liu et al., [16] showed that the ACEF and AGEF scores had the highest predictive accuracy for MACEs (76.3%, 75.8% respectively) and Mehran showed the lowest predictive accuracy for MACEs 68.5% [16].

In hospital death

This study demonstrated that All six risk scores showed high predictive accuracy for in hospital death (ranged from 97.3% to 83%), which was concordant with Liu et al., [16], who showed that the predictive accuracy of all 6 scores for in hospital death was ranged from 93.6 % to 78.4% [16].

This study showed that GRACE risk score had the highest predictive accuracy for in hospital death with 100% sensitivity and 91% specificity. While the ACEF and AGEF score had the lowest predictive accuracy (85.6%, 83.8% respectively for MACEs). On the other hand, Liu et al., [16] demonstrated that ACEF and AGEF had the highest predictive accuracy for in hospital death (92.5%, 93.6% respectively), while Chen score had the lowest predictive accuracy 78.4% [16].

Conclusion

Risk scores for predicting CIN perform well in stratifying the risk of CIN and in-hospital death or MACEs in patients with STEMI undergoing PPCI. In this study, the Mehran and Gao scores was observed to have the higher predictive accuracy for CIN than the other risk scores, all of which are exclusive of procedural factors. While GRACE and Mehran scores had highest predictive accuracy for in hospital death and MACEs than the other risk scores.

Recommendations

This study recommends risk stratification for CIN before treating patients with myocardial revascularization using different risk scores especially Mehran and Gao risk scores as identification and intervention for patients with STEMI with a high risk of CIN are crucial to improve clinical outcomes.

This study recommends starting hydration before and after PCI, as well as an optimized choice of contrast medium, for the prevention of CIN. On the other hand, renal function should always be monitored in patients with AMI after catheterization, even in patients with GFR >60 mL/min/1.73 m.

The observed different predictive values were exclusive to patients with STEMI, and we recommend to do a research for other patients who undergoing elective PCI.

Study Limitations

This study had several potential limitations. First, the study was performed at a single center with a relatively small study population; thus, results should be interpreted with caution. Second, the different predictive values observed were exclusive to patients with STEMI, and caution should be taken in generalizing the findings for other patient populations. Third, we did not include all risk scores developed for CIN because we believe that those risk scores not included are excessively complicated or have been proved in other patient populations.

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