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Influence of Renal Dysfunction on Clinical Outcomes in PatientsWith Congestive Heart Failure Complicating

Acute Myocardial Infarction

Chang Seong K,1MD, Min Jee K,1MD, Yong Un K,1MD, Joon Seok C,1MD,

Eun Hui B,1MD, Seong Kwon M,

1MD, Young-Keun A,

1,2MD, Myung Ho J,

1,2MD,

Young Jo K,3MD, Myeong Chan C,

4MD, Chong Jin K,

5MD, andSoo Wan K,

1MD,

for Korea Acute Myocardial Infarction Registry Investigators

S

The clinical course and medical treatment of patients with congestive heart failure (CHF) complicating acute myo-

cardial infarction (AMI) are not well established, especially in patients with concomitant renal dysfunction. We per-

formed a retrospective analysis of the prospective Korean Acute Myocardial Infarction Registry to assess the medical

treatments and clinical outcomes of patients with CHF (Killip classes II or III) complicated by AMI, in the presence or

absence of renal dysfunction. Of 13,498 patients with AMI, 2769 (20.5%) had CHF on admission. Compared to CHF

patients with preserved renal function, in-hospital mortality and major adverse cardiac events were increased both at 1

month and at 1 year after discharge in patients with renal dysfunction (1154; 41.7%). Postdischarge use of aspirin, beta-blockers, calcium channel blockers, angiotensin-converting enzyme inhibitors, or angiotensin II receptor blockers and

statins significantly reduced the 1-year mortality rate for CHF patients with renal dysfunction; such reduction was not

observed for those without renal dysfunction, except in the case of aspirin. Patients with CHF complicating AMI, which

is accompanied by renal dysfunction, are at higher risk for adverse cardiovascular outcomes than patients without renal

dysfunction. However, they receive fewer medications proven to reduce mortality rates. (Int Heart J 2013; 54: 304-310)

Key words:Major adverse cardiac events

P

atients with acute myocardial infarctions (AMIs) fre-

quently show evidence of congestive heart failure

(CHF) and have a high risk of morbidity and mortality.These patients have a 3- to 4-fold increased risk of in-hospital

mortality and have longer hospital stays than patients with

AMIs but no signs of heart failure.1-3)

Furthermore, patients

with heart failure often develop worsening renal function, and

this is associated with poor prognoses.4)In addition, heart and

renal dysfunctions often occur simultaneously because they

share common causes and pathogenetic mechanisms, includ-

ing hypertension, diabetes mellitus, and atherosclerosis, as

well as the activation of the renin-angiotensin-aldosterone sys-

tem (RAAS), the sympathetic nervous system, and oxidative

stress.5-7)

Given these findings, renal dysfunction is one of the most

important comorbidities and may promote adverse clinical out-

comes in patients with CHF complicating AMI. However, theclinical outcomes and medical management of these patients

are less well established, especially in patients with concomi-

tant renal dysfunction; most studies have predominantly re-

cruited populations with preserved renal function.8)

The Korean Acute Myocardial Infarction Registry (KA-MIR) is a Korean prospective multicenter data collection regis-

try reflecting real-world treatment practices and outcomes in

Asian patients diagnosed with AMI. The purpose of this study

was to use this registry to compare differences between demo-

graphic and clinical characteristics, use of medical treatments,

and cardiovascular outcomes in patients with and without renal

dysfunction accompanying CHF after AMI.

M

Study design and patient population: The study population in-

cluded patients enrolled in the nationwide prospective KAMIR

from November 2005 to September 2008. This registry in-volves 52 community and university hospitals with facilities

for primary percutaneous coronary intervention, thrombolytic

From the1Department of Internal Medicine, Chonnam National University Medical School,

2Cardiovascular Research Institute of Chonnam National University,

Gwangju,3Department of Internal Medicine, Yeungnam University, Daegu,

4Department of Internal Medicine, Chungbuk National University, Cheongju, and

5Depart-

ment of Internal Medicine, Kyunghee University, Seoul, Korea.

This research was supported by the National Research Foundation of Korea (NRF) grant (MRC for Gene Regulation, 2011-0030132) funded by the Korea government

(MSIP).

Address for correspondence: Soo Wan Kim, MD, Department of Internal Medicine, Chonnam National University Medical School, 42 Jebongro, Gwangju 501-757,

Korea.

Received for publication February 1, 2013.

Revised and accepted April 4, 2013.

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therapy, and on-site cardiac surgery. Data were collected by an

experienced study coordinator on the basis of a standardized

case report form and protocol. The study protocol was ap-

proved by the ethics committee at each participating institu-

tion, and all patients provided informed consent for their par-

ticipation in the registry. Among the 13,498 consecutive

patients whose discharge diagnosis (based on clinical symp-toms, cardiac enzyme levels, and 12-lead electrocardiogram

results) was AMI, patients were included in the present analy-

sis if they were admitted with Killip class II or III, an estimated

glomerular filtration rate (eGFR) was available, and they had

completed at least 1 year of follow-up. Killip class IV patients

were excluded due to cardiogenic shock. The Killip classifica-

tion has been designed to provide a clinical estimate of the se-

verity of myocardial derangement in the treatment of AMI and

validated in acute heart failure after AMI.9,10)

A final population

of 2769 AMI patients with CHF was analyzed in this study.

Patients were grouped based on the presence or absence of re-

nal dysfunction.

Assessment of renal function: Serum creatinine levels wereanalyzed by the Jaffe method, which has been calibrated to

isotope dilution mass spectrometry. The level of creatinine was

measured prior to angiography, and renal function was as-

sessed based on the eGFR. Renal dysfunction was defined as

an eGFR of < 60 mL/(minute1.73 m2), calculated using the

Chronic Kidney Disease Epidemiology Collaboration (CKD-

EPI) equation as follows: mL/(minute1.73 m2) = 141 mini-

mum (creatinine/, 1)

maximum (creatinine/, 1)-1.209

0.993age

1.018 (if female) 1.159 (if black), where is 0.7

for women and 0.9 for men and is -0.329 for women and

-0.411 for men.11)

Study endpoints: All of the patients underwent regular follow-

up examinations at 1 month and 1 year after discharge from

the hospital. The primary endpoints were major adverse cardi-ac events (MACEs), including a composite of all cause-of-

death, myocardial infarctions, target lesion revascularization,

and coronary artery bypass grafts during the 1-year clinical

follow-up period. Target lesion revascularization was defined

as restenosis or reocclusion within the stent or adjacent 5-mm

border.Statistical analysis: Continuous variables have been presented

as the mean SD, and categorical variables as the number of

cases and percentages. Comparative analyses were performed

using Students t-test for continuous variables and Pearsons

chi-square test or Fishers exact test for categorical variables.

Continuous variables with skewed distributions have been pre-

sented in terms of median values (with 25thand 75

thpercen-

tiles) and have been compared using the Mann-Whitney test.

Event-free survival was estimated by the Kaplan-Meier meth-

od, and the significance levels were assessed by the log-rank

test. Variables found to be significant in univariate analysis and

other variables that have been reported to be associated with

the prognosis of patients with AMI were entered into multivar-

iate logistic regression models and Cox proportional hazard

models. Logistic regression was performed to identify the in-

dependent predictors of mortality at 1-month and 1-year fol-

low-up. Cox proportional hazards analyses were used to iden-

tify the effect of in-hospital and discharge medications on

1-year mortality in patients with CHF complicating AMI, ac-

cording to the presence or absence of renal dysfunction. The

following variables required adjustment: age, gender, tachycar-

dia (heart rate > 100 beats/minute) on admission, history of

hypertension, presence of dyslipidemia, presence of diabetes

mellitus, previous coronary artery disease, Killip class on ad-

mission, multivessel disease, smoking status, ST-segment-ele-

vation acute myocardial infarction, high-sensitivity C-reactive

protein (hs-CRP) level > 2 mg/L, and medications. All statisti-

cal tests were two-tailed, and a P< 0.05 was considered signif-icant. Analyses were performed using the Statistical Package

for Social Sciences software, version 17.0 (SPSS, Chicago, IL,

USA).

R

Baseline characteristics: Between November 2005 and Sep-

tember 2008, a total of 13,498 patients presenting with AMI

were enrolled. Of these, 2769 (20.5%) patients (mean age

standard deviation, 67.7 12.2 years; 62.2% men) had CHF

on admission and were included in the present study. In the

present study population, 1154 (41.7%) patients had renal dys-function. Baseline clinical characteristics of patients are shown

in Table I. Patients with renal dysfunction were older and more

likely to be female and had a higher prevalence of diabetes,

hypertension, dyslipidemia, history of previous coronary artery

disease, multivessel disease, and elevated hs-CRP levels. These

patients also presented with higher heart rates and a higher Kil-

lip class (Killip class II, 49.9%; Killip class III, 50.1%) and

had lower left ventricular ejection fractions (LVEF) than pa-

tients without renal dysfunction. Although there were no sig-

nificant differences in the admission rates to cardiac care units

(CCU), patients with renal dysfunction had longer CCU stays

than those without renal dysfunction (6.1 7.8 versus 4.3

7.8, P< 0.001, respectively).

Medications: Patients with renal dysfunction were less likelyto receive aspirin, beta-blockers, statins, and angiotensin-con-

verting enzyme (ACE) inhibitors but were more likely to re-

ceive diuretics, calcium channel blockers (CCBs), and angi-

otensin II receptor blockers (ARBs) than those without renal

dysfunction during hospitalization. Similarly, discharge medi-

cations such as aspirin, nitrates beta-blockers, statins, and ACE

inhibitors were less likely to be prescribed; diuretics, CCBs,

and ARBs were more frequently prescribed at the time of dis-

charge to patients with renal dysfunction (Table II).Clinical events and outcomes: Clinical events during the

1-year follow-up period are listed in Table III. Patients present-

ing with renal dysfunction experienced more adverse clinical

events. In-hospital mortality was 3 times higher for patients

with renal dysfunction than for those without renal dysfunction

(15.2% versus 4.7%, P< 0.001). Moreover, 1-month and

1-year composite MACEs for patients with renal dysfunction

were significantly higher (24.8% versus 9.4%, P< 0.001;

38.3% versus 18.1%, P< 0.001, respectively) than for those

without renal dysfunction. Kaplan-Meier survival curves,

based on the presence or absence of renal dysfunction, are pre-

sented in Figure 1 and show a significantly higher mortality

rate for patients with renal dysfunction (log-rank P< 0.001)

than for those without renal dysfunction.Multivariate analysis: We performed multivariate logistic re-

gression analysis to identify the independent predictors of

1-month and 1-year mortality in patients with CHF complicat-

ing AMI. Multivariate analysis showed that age, male gender,

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diabetes mellitus, heart rate > 100 (beats/minute), hs-CRP > 2

(mg/L), ST-segment-elevation acute myocardial infarction, and

renal dysfunction were significantly associated with 1-month

mortality in patients with CHF complicating AMI. Also, age,

male gender, heart rate > 100 (beats/minute), hs-CRP > 2 (mg/

L), and renal dysfunction were predictors of 1-year mortality

in this population (Table IV).

Cox proportional hazards analysis was performed to

identify the effect of in-hospital and discharge medications on

1-year mortality rates in patients with CHF complicating AMI,

according to the presence or absence of renal dysfunction.

These rates were adjusted for potential confounding factors

(Figure 2). The in-hospital use of aspirin and ACE inhibitors or

ARBs was associated with significantly reduced 1-year mortal-

Table I. Baseline Clinical Characteristics

Congestive heart failure

PNo renal dysfunction

(n= 1,615)

Renal dysfunction

(n= 1,154)

Age (years) 64 12 73 10 < 0.001

Male (%) 1128 (69.9) 579 (51.8) < 0.001HR (beats/minute) 81 26 87 26 < 0.001

Systolic blood pressure (mmHg) 128 27 128 34 0.916

Diastolic blood pressure (mmHg) 78 16 76 19 0.017

History of smoking (%) 912 (56.8) 442 (38.8) < 0.001

Diabetes mellitus (%) 442 (27.4) 537 (46.6) < 0.001

Previous hypertension (%) 684 (42.5) 768 (66.6) < 0.001

Previous dyslipidemia (%) 120 (7.5) 131 (11.4) < 0.001

Previous CAD (%) 239 (14.8) 306 (26.6) < 0.001

Multi-vessel disease (%) 847 (58.7) 676 (77.0) < 0.001

Killip class

II (%) 1099 (68.2) 576 (49.9) < 0.001

III (%) 516 (32.0) 578 (50.1) < 0.001

hs-CRP (mg/L) 1.12 (0.23,5.24) 2.69 (0.59,11.69) < 0.001

LVEF (%) 48 13 44 14 < 0.001

STEMI (%) 1041 (64.5) 538 (46.7) < 0.001

Non-STEMI (%) 573 (35.5) 613 (53.3) < 0.001Admission rate of CCU (%) 1339 (82.9) 968 (83.9) 0.158

Lengths of CCU stay (days) 4.3 7.8 6.1 7.8 < 0.001

Kidney function

Serum creatinine (mg/dL) 0.9 0.2 2.3 3.3 < 0.001

Estimated GFR (mL/minute/1.73m2) 82 16 38 16 < 0.001

Data are presented as mean SD values or number of patients (percentage). Variables that were not normally distribut-

ed have been described in terms of the median (25thand 75

thpercentiles). HR indicates heart rate; CAD, coronary artery

disease; hs-CRP, high-sensitivity C-reactive protein; LVEF, left ventricular ejection fraction; STEMI, ST-segment-ele-

vation acute myocardial infarction; CCU, cardiac care unit; and GFR, glomerular filtration rate.

Table II. In-hospital and Discharge Medications

Congestive heart failure

PNo renal dysfunction

(n= 1,615)

Renal dysfunction

(n= 1,154)

In hospital medication (%)

Diuretics 730 (45.6) 772 (67.2) < 0.001

Nitrate 1147 (71.6) 797 (69.4) 0.203

Aspirin 1578 (98.6) 1120 (97.5) 0.046

Beta-blockers 1152 (72.0) 741 (64.5) < 0.001

CCB 207 (12.9) 244 (21.2) < 0.001

Statins 1138 (71.1) 738 (64.2) < 0.001

ACE inhibitors 1120 (70.0) 723 (62.9) < 0.001

ARB 259 (16.2) 246 (21.4) 0.001

Discharge medications (%)

Diuretics 480 (29.7) 493 (42.7) < 0.001

Nitrate 702 (43.5) 442 (38.3) 0.007

Aspirin 1463 (90.6) 863 (74.8) < 0.001

Beta-blockers 1019 (63.1) 601 (52.1) < 0.001

CCB 140 (8.7) 157 (13.6) < 0.001 Statins 1095 (67.8) 612 (53.0) < 0.001

ACE inhibitors 934 (57.8) 507 (43.9) < 0.001

ARB 297 (17.3) 235 (20.4) 0.042

CCB indicates calcium channel blocker; ACE, angiotensin-converting enzyme; and ARB, angiotensin II receptor

blocker.

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ity, after adjusting for multiple risk factors, while diuretics in-

creased the risk of 1-year mortality, regardless of renal dys-

function. In-hospital use of statins was associated with more

significant reductions in 1-year mortality rates in patients with

renal dysfunction than in those without renal dysfunction

(Hazard ratio [HR], 0.63; 95% confidence interval [CI], 0.44

0.90; P= 0.012; and HR, 0.64; 95% CI, 0.391.07; P= 0.092,

respectively). Although postdischarge use of aspirin, beta-

blockers, CCBs, ACE inhibitors, or ARBs and statins, which

had been prescribed at discharge, appeared to favor the survival

of patients who had CHF complicating AMI and did not have

renal dysfunction, no statistically significant improvement was

observed in survival for any of the medications, except for as-

pirin. However, in patients with renal dysfunction, significant

beneficial effects were obtained for 1-year mortality for those

medications.

D

This study demonstrated that the presence of renal dys-

function is associated with adverse clinical cardiovascular

prognoses in patients who develop CHF after AMI. Patients

with renal dysfunction were more likely to be older and female

and have a prior history of cardiovascular and other comorbid

diseases. We observed that renal dysfunction was associated

with reduced in-hospital or discharge prescriptions for aspirin,

beta-blockers, statins, and RAAS inhibitors (ie, ACE inhibitors

and ARBs); these medications are known to reduce cardiovas-

cular mortality.12-15)

Among the total AMI population, CHF occurred in20.5% of the individuals, which is consistent with previous

studies showing CHF in approximately 1525% of AMI pa-

tients.16,17)

Since Killip and Kimball demonstrated that in-

creased hospital mortality is associated with a greater degree

of CHF severity (higher Killip class),9)the concurrence of heart

failure in patients with AMI has been consistently recognized

as a strong predictor of morbidity and mortality. As shown in

previous studies, reduced LVEFs, or signs of heart failure, after

AMI are associated with a relatively high incidence of in-hos-

pital mortality18)

and complications and of long-term mortali-

ty.1,3)

In addition, both heart failure and renal dysfunction are

well-known independent risk factors for cardiovascular and

all-cause mortality after myocardial infarction.19,20)

Moreover,

adjusted all-cause mortality increases in patients with any renal

impairment from the heart failure population.21)

Taken together, these results indicate that renal dysfunc-

tion might be regarded as one of the most important risk fac-

tors for cardiovascular outcomes in patients with AMI, espe-

cially in those with concomitant CHF. However, only a few

studies have addressed the clinical outcomes and medical treat-

ment of patients with concomitant renal dysfunction and CHF

after AMI; thus, clinical outcomes and medical treatment in

this population have not been well characterized. Palmer, et al

showed that a combination of increased N-terminal prohor-

mone of brain natriuretic peptide levels or depressed LVEFs

with lower eGFRs results in increased rates of long-term mor-

tality and heart failure after myocardial infarction.

22)

Similarly,

Table III. Clinical Outcomes During the In-hospital Period and Follow-up

Congestive heart failure

PNo renal dysfunction

(n= 1,615)

Renal dysfunction

(n= 1,154)

In-hospital outcomes (n= 2769)

In-hospital death (%) 76 (4.7) 175 (15.2) < 0.0011-month outcomes

Composite MACE (%) 135 (9.4) 248 (24.8) < 0.001

Death (%) 103 (7.2) 228 (22.8) < 0.001

MI (%) 8 (0.6) 10 (1.0) 0.234

Re-PCI (%) 18 (1.3) 6 (0.6) 0.114

CABG (%) 6 (0.4) 4 (0.4) 0.947

12-month outcomes

Composite MACE (%) 225 (18.1) 337 (38.3) < 0.001

Death (%) 135 (10.9) 288 (32.7) < 0.001

MI (%) 9 (0.7) 13 (1.5) 0.126

Re-PCI (%) 70 (5.6) 30 (3.4) 0.017

CABG (%) 11 (0.9) 6 (0.7) 0.806

MACE indicates major adverse cardiac event; MI, myocardial infarction; Re-PCI, target lesion revascularization; and

CABG, coronary artery bypass graft.

Figure 1. Kaplan-Meier curves showing the cumulative incidence of sur-

vival in patients with or without renal dysfunction accompanying CHF af-

ter AMI. Survival curve analysis revealed a significantly higher mortality

rate in the renal dysfunction group than in the no renal dysfunction group.

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both decreased LVEFs and creatinine clearance rates were as-

sociated with higher 1-year mortality in patients with chest

pain, without ST elevation, than in patients with normal heart

and renal functions.23)

The results of our study are consistent

with those findings. Half of the CHF patients had renal dys-

function after AMI, and these patients had a 3-fold higher rate

of in-hospital mortality as well as longer CCU stays than those

without renal dysfunction. Moreover, 1-month and 1-year

composite MACE were 2.6 and 2.1 times higher, respectively,

among patients with renal dysfunction; those observations re-

flected higher rates of all-cause deaths during the follow-up

period. Also, renal dysfunction was an independent risk factor

for 1-month and 1-year mortality in patients with AMI con-

comitant with CHF. Interestingly, our laboratory findings

showed that the level of hs-CRP was higher in patients with re-

nal dysfunction. An increase in the hs-CRP level is independ-

ently associated with all-cause and cardiovascular mortality

when kidney function has deteriorated24)

and is a marker of

long-term development of heart failure and mortality in pa-tients with AMI.

25)Therefore, elevated hs-CRP levels might be

associated with adverse cardiovascular outcomes in our popu-

lation when accompanying renal dysfunction, but the precise

effects of hs-CRP levels should be further elucidated.

Aspirin, beta-blockers, and ACE inhibitors have been

found to improve survival in patients with CHF complicating

AMI;3,14)

the use of RAAS inhibitors and statins is also associ-

ated with decreased risks of MACE in those with lower eGFRs

after AMI.26)

These reports are in line with our results that

showed that the use of aspirin, ACE inhibitors, or ARBs and

statins, during hospitalization, reduced the risk of 1-year mor-

tality in patients with renal dysfunction. However, the use of

diuretics had a deleterious effect on 1-year survival during the

early stage of AMI accompanying CHF, regardless of renal

dysfunction. Furthermore, the postdischarge use of aspirin, be-

ta-blockers, CCBs, statins and RAAS inhibitors, which had

been prescribed at discharge, resulted in significantly reduced

1-year mortalities among patients with renal dysfunction,

whereas they did not produce similar benefits for those without

renal dysfunction. Despite markedly reduced mortality, pa-

tients with renal dysfunction were less likely to receive medi-

cations such as aspirin, beta-blockers, statins, and ACE inhibi-

tors. Therefore, it is important to use medications proven to

reduce mortality rates continuously even after discharge from

the hospital in patients with CHF and renal dysfunction after

AMI.

Although this study was not designed to investigate the

Table IV. Multivariate Analysis of 1-month and 1-year Mortality in Patients With CHF Complicating AMI

1-month mortality 1-year mortality

Odd ratio (95% CI) P Odd ratio (95% CI) P

Age (per year) 1.06 (1.03-1.08) < 0.001 1.06 (1.05-1.08) < 0.001

Male 1.59 (1.04-2.43) 0.032 1.57 (1.07-2.30) 0.022

Hypertension 0.99 (0.68-1.43) 0.953 1.05 (0.75-1.47) 0.758Diabetes mellitus 1.49 (1.03-2.17) 0.035 1.27 (0.91-1.78) 0.167

Dyslipidemia 0.72 (0.37-1.42) 0.348 0.88 (0.50-1.54) 0.657

History of smoking 0.77 (0.51-1.16) 0.211 0.70 (0.48-1.01) 0.058

Previous CAD 0.95 (0.61-1.48) 0.834 1.10 (0.74-1.63) 0.635

Heart rate > 100 (beats/minute) 1.61 (1.08-2.41) 0.020 1.73 (1.20-2.50) 0.003

Multi-vessel disease 0.95 (0.64-1.43) 0.818 1.12 (0.77-1.63) 0.562

hs-CRP > 2 (mg/L) 1.61 (1.13-2.30) 0.009 2.02 (1.46-2.80) < 0.001

STEMI 1.53 (1.05-2.23) 0.028 1.18 (0.84-1.66) 0.333

Renal dysfunction* 2.91 (1.93-4.37) < 0.001 2.53 (1.77-3.61) < 0.001

*Estimated GFR of < 60 mL/(minute1.73 m2), calculated using the Chronic Kidney Disease Epidemiology Collaboration equation.

CHF indicates congestive heart failure; AMI, acute myocardial infarction; CI, confidence interval; CAD, coronary artery disease; hs-

CRP, high-sensitivity C-reactive protein; and STEMI, ST-segment-elevation acute myocardial infarction.

Figure 2. Adjusted hazard ratios for the effect of in-hospital (A) and dis-

charge (B) medications on 1-year mortality rates in patients with CHF

complicating AMI, according to the presence or absence of renal dysfunc-

tion. Adjusted for factors included age, gender, history of hypertension,

dyslipidemia, diabetes mellitus, previous coronary artery disease, HR >

100 beats/minute, Killip class, multivessel disease, smoking, STEMI, hs-

CRP > 2mg/L, and medications. RD indicates renal dysfunction.

A.

B.

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reasons for lower prescription rates of useful medications,

there are several possible reasons for this observation, includ-

ing the lack of evidence for therapeutic strategies to reduce

mortality in CHF patients with renal impairment, especially in

the AMI cohort. Most clinical studies of heart failure have pre-

dominantly excluded patients with deteriorated renal func-

tion,8)and thus, optimal pharmacotherapy remains poorly de-fined in these patients. In addition, the risk of potential side

effects of medical treatments might tend to be overestimated in

the presence of renal dysfunction. Even if ACE inhibitors and

ARBs are associated with risks of hyperkalemia or transiently

decreased renal function, they have been proven to reduce

mortality in practice.27,28)

Thus, physicians should carefully

weigh the long-term survival benefits of these medical treat-

ments in the populations described.

The present study has several limitations. First, although

we adjusted for multiple confounding factors, it is possible that

some confounders were excluded. Second, the assessment of

kidney function was based on a single measurement of serum

creatinine levels, obtained at the time of admission to the hos-pital. Thus, this value could have been affected by patient he-

modynamic or metabolic status. Third, because of the method-

ological limitations of retrospective analysis, the data regarding

the duration of medications were not available. Nevertheless,

analyses of the effects in-hospital and discharge medications

on clinical outcomes among patients with renal dysfunction

were performed in an attempt to overcome this confounding

factor. Furthermore, patients after AMI, by its nature, were en-

couraged to maintain the essential medications including aspi-

rin, beta-blockers, ACE inhibitors, ARBs and statins, unless

there was a contraindication or severe complication. Despite

the limitations of our study, this should not undermine the sur-

vival benefits of these medications, especially in renal dysfunc-

tion.In conclusion, our study demonstrated that patients with

CHF complicated with AMI accompanied by renal dysfunc-

tion are at higher risk for adverse cardiovascular outcomes

than those without renal dysfunction. Nonetheless, medica-

tions that have proven benefits with respect to mortality are

underused in these patients. Therefore, early identification of

patients with renal dysfunction and intensive medical treatment

for this population may reduce cardiovascular outcomes and

mortality.

A

Korea Acute Myocardial infarction Registry (KAMIR) Investiga-

tors: Myung Ho Jeong, MD, Young Keun Ahn, MD, Sung Chull Chae,

MD, Jong Hyun Kim, MD, Seung Ho Hur, MD, Young Jo Kim, MD, In

Whan Seong, MD, Dong Hoon Choi, MD, Jei Keon Chae, MD, Taek Jong

Hong, MD, Jae Young Rhew, MD, Doo Il Kim, MD, In Ho Chae, MD,

Jung Han Yoon, MD, Bon Kwon Koo, MD, Byung Ok Kim, MD, My-

oung Yong Lee, MD, Kee Sik Kim, MD, Jin Yong Hwang, MD, Myeong

Chan Cho, MD, Seok Kyu Oh, MD, Nae Hee Lee, MD, Kyoung Tae

Jeong, MD, Seung Jea Tahk, MD, Jang Ho Bae, MD, Seung Woon Rha,

MD, Keum Soo Park, MD, Chong Jin Kim, MD, Kyoo Rok Han, MD,

Tae Hoon Ahn, MD, Moo Hyun Kim, MD, Ki Bae Seung, MD, Wook

Sung Chung, MD, Ju Young Yang, MD, Chong Yun Rhim, MD, Hyeon

Cheol Gwon, MD, Seong Wook Park, MD, Young Youp Koh, MD, Seung

Jae Joo, MD, Soo Joong Kim, MD, Dong Kyu Jin, MD, Jin Man Cho,

MD, Byung Ok Kim, MD, Sang-Wook, Kim, MD, Jeong Kyung, Kim,

MD, Tae Ik Kim, MD, Deug Young Nah, MD, Si Hoon Park, MD, Sang

Hyun Lee, MD, Seung Uk Lee, MD, Hang-Jae Chung, MD, Jang Hyun

Cho, MD, Seung Won Jin, MD, Yang Soo Jang, MD, Jeong Gwan Cho,

MD, and Seung Jung Park, MD.

R

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