CARDIOVASCULAR MEDICINE

Creatinine clearance and adverse hospital outcomes in patients with acute coronary syndromes: findings from the global registry of acute coronary events (GRACE)

J J Santopinto. 1, K A A Fox. 2, R J Goldberg . 3, A Budaj. 4, G Piñero. 1, A Avezum. 5, D Gulba. 6,
J Esteban. 3, J M Gore. 3, J Johnson. 3 and E P Gurfinkel. 7 on behalf of the GRACE Investigators*

1. Intensive Care Unit, Leonidas Lucero's Hospital, Bahia Blanca, Argentina
2 . The Royal Infirmary of Edinburgh, Edinburgh, UK
3 . University of Massachusetts Medical School, Worcester, Massachusetts, USA
4 . Grochowsky Hospital, Warsaw, Poland
5 . CTI-A Hospital Albert Einstein, São Paulo, Brazil
6 . Krankenhaus Düren Medizinische Klinik, Düren, Germany
7 . Favaloro University, Buenos Aires, Argentina

Correspondence to:
Dr J J Santopinto, Intensive Care Unit, Hospital Municipal de Bahia Blanca, Estomba 968 (8000) Bahia Blanca, Provincia de Buenos Aires, Argentina;
jsantopinto@infovia.com.ar

Objective: To determine whether creatinine clearance at the time of hospital admission is an independent predictor of hospital mortality and adverse outcomes in patients with acute coronary syndromes (ACS).

Design: A prospective multicentre observational study, GRACE (global registry of acute coronary events), of patients with the full spectrum of ACS.

Setting: Ninety four hospitals of varying size and capability in 14 countries across four continents.
Patients: 11 774 patients hospitalised with ACS, including ST and non-ST segment elevation acute myocardial infarction and unstable angina.

Main outcome measures: Demographic and clinical characteristics, medication use, and in-hospital outcomes were compared for patients with creatinine clearance rates of > 60 ml/min (normal and minimally impaired renal function), 30-60 ml/min (moderate renal dysfunction), and < 30 ml/min (severe renal dysfunction).

Results: Patients with moderate or severe renal dysfunction were older, were more likely to be women, and presented to participating hospitals with more comorbidities than those with normal or minimally impaired renal function. In comparison with patients with normal or minimally impaired renal function, patients with moderate renal dysfunction were twice as likely to die (odds ratio 2.09, 95% confidence interval 1.55 to 2.81) and those with severe renal dysfunction almost four times more likely to die (odds ratio 3.71, 95% confidence interval 2.57 to 5.37) after adjustment for other potentially confounding variables. The risk of major bleeding episodes increased as renal function worsened.

Conclusion: In patients with ACS, creatinine clearance is an important independent predictor of hospital death and major bleeding. These data reinforce the importance of increased surveillance efforts and use of targeted intervention strategies in patients with acute coronary disease complicated by renal dysfunction.

Keywords: creatinine clearance; renal dysfunction; acute coronary syndromes; prognosis.

Abbreviations: ACE, angiotensin converting enzyme; ACS, acute coronary syndromes; GRACE, global registry of acute coronary events; NSTEMI, non-ST segment elevation myocardial infarction; STEMI, ST segment elevation myocardial infarction; TRACE, trandolapril cardiac evaluation; UA, unstable angina.