Reperfusion Strategy and Mortality in ST-Elevation Myocardial Infarction among Patients with and without Impaired Renal Function

Introduction: Several randomised controlled trials have demonstrated better outcomes with primary percutaneous coronary intervention (PCI) over fi brinolytic therapy in the treatment of patients with ST-segment elevation myocardial infarction (STEMI) and normal renal function. Whether this benefi t extends to patients with impaired renal function is uncertain. Materials and Methods: We studied 1672 patients with STEMI within 12 hours of symptom onset who were admitted to 2 major public hospitals in Singapore from 2000 to 2002. All patients received either upfront fi brinolytic or PCI as determined by the attending cardiologist. Serum creatinine was measured on admission and the glomerular fi ltration rate (GFR) was determined using the Modifi cation of Diet in Renal Disease equation. The impact of reperfusion strategy on 30-ay mortality was then determined for patients with GFR ≥60 mL min-¹ 1.73 m-² and GFR <60 mL min-¹ 1.73 m-². Results: The mean age was 56 ± 12 years (85% male) and mean GFR was 81 ± 30 mL min-¹ 1.73 m-². Unadjusted 30-day mortality rates for fi brinolytic-treated vs primary PCI-treated patients were 29.4% vs 17.9%, P <0.05, in the impaired renal function group and 5.4% vs 3.1%, P <0.05, in the normal renal function group. After adjusting for covariates, primary PCI was associated with a signifi cantly lower mortality in the normal renal function group [odds ratio (OR), 0.41; 95% confi dence interval (CI), 0.19-0.89] but not in the impaired renal function group [OR, 0.70; 95% CI, 0.31-1.60]. Conclusions: Primary PCI was associated with improved 30-day survival among patients with normal renal function but not among those with impaired renal function. Randomised trials are needed to study the relative effi cacy of both reperfusion strategies in patients with impaired renal function. Ann Acad Med Singapore 2010;39:179-84