Quality of Care and Outcomes Among Patients With Acute Myocardial Infarction by Level of Kidney Function at Admission: Report From the Get With The Guidelines Coronary Artery Disease Program

Background: Many patients admitted for acute myocardial infarction (AMI) have chronic renal insufficiency. We studied the impact of chronic renal insufficiency on mortality and quality of inpatient care for AMI from the American Heart Association's Get With The Guidelines–Coronary Artery Disease Program. Hypothesis: We hypothesized that mortality and quality of inpatient care would not vary with renal function. Methods: We examined in‐hospital AMI performance measures by renal function based on glomerular filtration rate (GFR). Severity of renal insufficiency was categorized as normal (GFR ≥ 90 mL/min/1.73 m 2 ), mild (GFR 60–90 mL/min/1.73 m 2 ), moderate (GFR 30–60 mL/min/1.73 m 2 ), severe (GFR 15–30 mL/min/1.73 m 2 ), and kidney failure (GFR ≤ 15 mL/min/1.73 m 2 or dialysis). A total of 21721 patients from 291 sites were studied, with most data collected in 2008 to 2009. Multivariable regression analysis after adjusting for patient characteristics was performed and generalized estimating equations were used to account for within‐hospital clustering. In‐hospital mortality and quality of inpatient care were assessed. Results: Renal insufficiency was present in 82.0 percent of AMI patients. The adjusted odds ratio vs normal renal function for mortality increased with worsening renal function: 1.45 for mild renal insufficiency (95% confidence interval [CI]: 1.03–2.05, P = 0.03); 3.36 for moderate renal insufficiency (95% CI: 2.31–4.89, P < 0.0001); 5.43 for severe renal insufficiency (95% CI: 3.70–7.95, P < 0.0001); and 6.35 for kidney failure (95% CI: 4.48–9.01, P < 0.0001). Patients with renal insufficiency received less inpatient and discharge guideline‐recommended therapy for AMI. Conclusions: Among AMI patients, mortality and guideline‐recommended inpatient therapy correlated inversely with renal function. Adjusted mortality was equally poor among patients with severe renal dysfunction and on dialysis. Clin. Cardiol. 2012 doi: 10.1002/clc.22021 Christopher P. Cannon, MD, has received research grants/support from Accumetrics, AstraZeneca, GlaxoSmithKline, Intekrin Therapeutics, Merck, and Takeda; is a member of the advisory board (funds donated to charity) of Bristol‐Myers Squibb/Sanofi, Novartis, and Alnylam; received an honorarium for development of independent educational symposia from Pfizer and AstraZeneca; and is a clinical advisor with equity in Automedics Medical Systems. Gregg C. Fonarow, MD, is a consultant for Novartis and Pfizer. W. Frank Peacock, MD, has received research grants (>$10000) from Abbott, Alere, Brahms, Corthera, EKR, Nanosphere, and The Medicines Company; is a consultant (<$10000) for Abbott, Alere, Beckman Coulter, Electrocore, and The Medicines Company; participates in the speakers' bureau (<$10000) with Abbott and Alere; and has an ownership interest (<$10000) in Comprehensive Research Associates LLC, Vital Sensors, and Emergencies in Medicine LLC. Lee H. Schwamm, MD, is a consultant for Stroke Systems and Medtronic. Deepak L. Bhatt, MD, MPH, discloses the following relationships ‐ Advisory Board: Medscape Cardiology; Board of Directors: Boston VA Research Institute, Society of Chest Pain Centers; Chair: American Heart Association Get With The Guidelines Science Subcommittee; Honoraria: American College of Cardiology (Editor, Clinical Trials, Cardiosource), Duke Clinical Research Institute (clinical trial steering committees), Slack Publications (Chief Medical Editor, Cardiology Today Intervention), WebMD (CME steering committees); Research Grants: Amarin, AstraZeneca, Bristol‐Myers Squibb, Eisai, Ethicon, Medtronic, Sanofi Aventis, The Medicines Company; Unfunded Research: FlowCo, PLx Pharma, Takeda. Sylvia E. Rosas has received a research grant from Abbott Laboratories and honorarium from Genzyme. The Get With The Guidelines‐Coronary Artery Disease (GWTG‐CAD) program was provided by the American Heart Association. The GWTG‐CAD program was supported in part through the American Heart Association Pharmaceutical Roundtable and an unrestricted educational grant from Merck. The authors have no other funding, financial relationships, or conflicts of interest to disclose. Additional Supporting Information may be found in the online version of this article.