Обзор американских кардиологических журналов за неделю (ссылки)

[Chevychelov]

Title: Efficacy of Rosuvastatin Among Men and Women With Moderate Chronic Kidney Disease and Elevated High-Sensitivity C-Reactive Protein: A Secondary Analysis From the JUPITER (Justification for the Use of Statins in Prevention-an Intervention Trial Evaluating Rosuvastatin) Trial
Topic: Prevention/Vascular
Date Posted: 4/23/2010
Author(s): Ridker PM, MacFadyen J, Cressman M, Glynn RJ.
Citation: J Am Coll Cardiol 2010;55:1266-1273.
Clinical Trial: No
Related Resources
JACC Article: Efficacy of Rosuvastatin Among Men and Women With Moderate Chronic Kidney Disease and Elevated High-Sensitivity C-Reactive Protein: A Secondary Analysis From the JUPITER Trial
Trial: Justification for the Use of Statins in Prevention: An Intervention Trial Evaluating Rosuvastatin (JUPITER)

Study Question: What is the efficacy of statin therapy in primary prevention among individuals with moderate chronic kidney disease (CKD)?
Methods: The authors performed a secondary analysis within JUPITER (Justification for the Use of Statins in Prevention–an Intervention Trial Evaluating Rosuvastatin) comparing cardiovascular and mortality outcomes among those with moderate CKD at study entry (n = 3,267) with those with baseline estimated glomerular filtration rate (eGFR) ≥60 ml/min/1.73 m2 (n = 14,528). JUPITER is the primary prevention trial of rosuvastatin 20 mg compared with placebo among men and women free of cardiovascular disease who had low-density lipoprotein cholesterol (LDL-C) <130 mg/dl and high-sensitivity C-reactive protein (hs-CRP) ≥2 mg/L.
Results: Study participants with moderate CKD were older (70 years vs. 65 years), more likely to be female, more likely to have a family history of premature atherothrombosis, and less likely to smoke. Among those with reduced eGFR, 3,253 had stage 3 impairment (eGFR between 30 and 59 ml/min/1.73 m2) and 14 had stage 4 impairment (eGFR between 15 and 29 ml/min/1.73 m2). Median follow-up was 1.9 years (maximum 5 years). Compared with an eGFR ≥60 ml/min/1.73 m2, JUPITER participants with moderate CKD had higher vascular event rates (hazard ratio [HR], 1.54; 95% confidence interval [CI], 1.23-1.92; p = 0.0002). Among those with moderate CKD, rosuvastatin was associated with a 45% reduction in risk of myocardial infarction, stroke, hospital stay for unstable angina, arterial revascularization, or confirmed cardiovascular death (HR, 0.55; 95% CI, 0.38-0.82; p = 0.002) and a 44% reduction in all-cause mortality (HR, 0.56; 95% CI, 0.37-0.85; p = 0.005). Median LDL-C and hs-CRP reductions as well as side effect profiles associated with rosuvastatin were similar among those with and without CKD. Median eGFR at 12 months was marginally improved among those allocated to rosuvastatin, as compared with placebo.
Conclusions: Rosuvastatin reduces first cardiovascular events and all-cause mortality among men and women with LDL-C <130 mg/dl, elevated hs-CRP, and concomitant evidence of moderate CKD.
Perspective: The data on efficacy of statins for primary prevention in patients with CKD are mixed. This secondary analysis of JUPITER supports use of 20 mg of rosuvastatin even in those who are at relatively low risk based upon LDL-C if the hs-CRP is >2 mg/dl. It is important to consider that the results were achieved with rosuvastatin dosing that lowered the LDL-C by 52% and hs-CRP by 37%, which are considerably greater effects than achieved with standard statin dosing. Unfortunately, a creatinine >2 mg/dl was an exclusion criterion in JUPITER, so the relative benefit in patients with more severe CKD remains unclear. Melvyn Rubenfire, M.D., F.A.C.C.

Title: Pre-Procedural Glucose Levels and the Risk for Contrast-Induced Acute Kidney Injury in Patients Undergoing Coronary Angiography
Topic: Interventional Cardiology
Date Posted: 4/23/2010
Author(s): Stolker JM, McCullough PA, Rao S, et al.
Citation: J Am Coll Cardiol 2010;55:1433-1440.
Clinical Trial: No
Related Resources
JACC Article: Pre-Procedural Glucose Levels and the Risk for Contrast-Induced Acute Kidney Injury in Patients Undergoing Coronary Angiography

Study Question: What is the relationship between hyperglycemia and risk of contrast-induced acute kidney injury (CI-AKI) in patients undergoing coronary angiography for myocardial infarction (MI)?
Methods: The authors evaluated the association between preprocedural glucose level and CI-AKI in 6,358 patients with acute MIs undergoing coronary angiography. Patients were stratified into five preprocedural glucose groups: <110 mg/dl, 110 to <140 mg/dl, 140 to <170 mg/dl, 170 to <200 mg/dl, and ≥200 mg/dl. The primary outcome was CI-AKI and was defined as a rise in serum creatinine of ≥0.3 mg/dl absolute or ≥50% relative serum creatinine increase 48 hours after the procedure.
Results: There was no relationship between preprocedural glucose and CI-AKI in patients with known prior diabetes mellitus. There was a significant association between glucose and CI-AKI risk in patients without diabetes (CI-AKI rates across the five glucose groups from lowest to highest: 8.2%, 9.9%, 12.4%, 14.9%, and 24.3%; p < 0.001). The association between CI-AKI and preprocedural glucose in nondiabetics remained significant after adjusting for differences in baseline confounders (odds ratio [OR] 1.31, 95% confidence interval [CI] 1.00-1.71 for glucose 110 to <140 mg/dl; OR 1.51, 95% CI 1.11-2.10 for glucose 140 to <170 mg/dl; OR 1.58, 95% CI 1.03-2.43 for glucose 170 to <200 mg/dl; and OR 2.14, 95% CI 1.46-3.14 for glucose >200 mg/dl.
Conclusions: Elevated preprocedural glucose is associated with greater risk for CI-AKI in nondiabetic patients who undergo coronary angiography for acute MI.
Perspective: New-onset renal dysfunction is common in patients undergoing primary percutaneous coronary intervention, although it is not certain if contrast media is the sole mediator of the so-called CI-AKI. This study found that hyperglycemia is a risk factor for this entity in nondiabetics, but not in diabetics. This suggests that hyperglycemia is likely a marker, but not a mediator of renal dysfunction in patients undergoing angiography for acute MI. It may be reasonable to consider measures to reduce the risk of renal dysfunction in hyperglycemic patients undergoing angiography (minimizing contrast volume and ensuring adequate prehydration). Hitinder S. Gurm, M.B.B.S., F.A.C.C