Reperfusion therapy in renal dysfunction patients presenting with STEMI: Which is better in the Tunisian context?

Abstract

Patients with renal insufficiency experience worse prognosis after STEMI. Current guidelines do not clearly draw specific strategies for renal dysfunction (RD) patients, and most clinical trials exclude them from the study population. To compare primary PCI (PPCI) and thrombolysis (using Strepokinase) results as well as in-hospital mortality after successful reperfusion between patients with or without RD. From January 1995 to October 2011, 1388 patients admitted for STEMI were enrolled in the MIRAMI (MonastIR’s Acute Myocardial Infarction) registry. Two reperfusion groups were identified: PPCI (315 patients) and thrombolysis (379 patients). Patients who underwent rescue PCI were excluded. Due to lacking clearance data, we used a serum creatinine level >130 μmol/l to define RD patients. We compared in each reperfusion group: (1) The success of revascularization (TIMI III flow restoring with <20% residual stenosis after PPCI, pain relief with ST regression >50% 60 min after thrombolysis) and (2) the in-hospital mortality rate after reperfusion success between the RD patients (RD+) and normal renal function patients (RD−). Ninety patients (13%) had RD, 50% of which underwent PPCI, and 50% received thrombolytics. Among RD+ and RD- groups, baseline characteristics were similar between the two reperfusion groups. In the PPCI group, although TIMI flow was similar before angioplasty ( p = 0.82 ), TIMI III restoring was significantly lower in the RD+ group (78.6% vs 91.8%, p = 0.013 ). Suboptimal result was also higher in the RD+ group (13.6% vs 2.7%, p < 0.001 ), but ST regression after TIMI III achievement was similar in the 2 groups ( p = 0.43 ) reflecting probably no microvascular damage. In the thrombolysis group, successful reperfusion was also significantly lower when RD exists (58% vs 74%, p = 0.03 ). After successful reperfusion, in-hospital mortality is higher among RD+ patients in the PPCI group (33.3% vs 4.3%, p < 0.001 ), whereas it is similar after successful thrombolysis (2.6% vs 0%, p = 0.42 ). RD reduces either PPCI or thrombolysis success, with no proven microvascular damage after PPCI. In-hospital prognosis is however worse in RD group only after successful PPCI, but not after successful Streptokinase thrombolysis.