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Impact of Renal Dysfunction on Real-world Outcome of the ESC 0/1-hour Algorithm

Session Poster Session 2

Speaker Raphael Twerenbold

Event : ESC Congress 2019

  • Topic : cardiovascular disease in special populations
  • Sub-topic : Renal Failure and Cardiovascular Disease
  • Session type : Poster Session

Authors : R Twerenbold (Basel,CH), JP Costabel (Buenos Aires,AR), R Campos (Buenos Aires,AR), M Cortes (Buenos Aires,AR), T Nestelberger (Basel,CH), J Boeddinghaus (Basel,CH), C Puelacher (Basel,CH), J Du Fay De Lavallaz (Basel,CH), J Walter (Basel,CH), M Meier (Basel,CH), B Hafner (Basel,CH), F Lambardi (Buenos Aires,AR), S Resi (Buenos Aires,AR), M Trivi (Buenos Aires,AR), C Mueller (Basel,CH)

Authors:
R. Twerenbold1 , J.P. Costabel2 , R. Campos2 , M. Cortes2 , T. Nestelberger1 , J. Boeddinghaus1 , C. Puelacher1 , J. Du Fay De Lavallaz1 , J. Walter1 , M. Meier1 , B. Hafner1 , F. Lambardi2 , S. Resi2 , M. Trivi2 , C. Mueller1 , 1University Hospital Basel - Basel - Switzerland , 2Cardiovascular Institute of Buenos Aires (ICBA), Cardiology - Buenos Aires - Argentina ,

Citation:
European Heart Journal ( 2019 ) 40 ( Supplement ), 882

Background: The ESC recommends the use of a 0/1h-algorithm for rapid triage of patients with suspected non-ST-elevation myocardial infarction (NSTEMI) using high-sensitivity cardiac troponin (hs-cTn) concentrations irrespective of renal function. Patients with renal dysfunction (RD, defined as a GFR <60ml/min) are at higher risk of NSTEMI and are presenting more often with elevated levels of hs-cTn even in absence of NSTEMI, which may contribute to an impaired efficacy and safety of the ESC 0/1h-algorithm.

Purpose: We aimed to assess and directly compare the real-world adherence, effectiveness, efficacy, and ultimately safety of the ESC 0/1h-algorithm when applied in patients with RD and normal renal function.

Methods: In a prospective international multicenter study enrolling unselected patients presenting with suspected NSTEMI to the ED, patients were assessed according to the ESC 0/1h-algorithm embedded in routine clinical care. Safety was quantified by the 30-day incidence of major adverse cardiac events (MACE, defined as the composite of cardiovascular death and myocardial infarction including the index event) in the rule-out group and in outpatients.

Results: Among 2296 enrolled patients, RD was present in 129 (6%) patients. NSTEMI prevalence was substantially higher in RD as compared with normal renal function (19% versus 9%, p<0.001). Adherence to the ESC 0/1h-algorithm protocol was excellent with no violations observed in patients with RD as compared with 132 (6%) violations in patients with normal renal function (p=0.004). Effectiveness was very high in RD and comparable to normal renal function: 94% of patients triaged towards rule-out by the ESC 0/1h-algorithm did not require additional cardiac investigations including hs-cTnT measurements at later time points (e.g. 3–12h) or coronary CT-angiography in the ED as compared with 98% in normal renal function. Median time to discharge or transfer from the ED was significantly longer in RD (285 minutes [q1174, q3392]) as compared with normal renal function (150 minutes [q1132, q3222]). Efficacy of the ESC 0/1h-algorithm was lower in RD as it triaged 13% of patients towards rule-out and 34% towards rule-in of NSTEMI as compared with 65% and 12% in normal renal function, respectively (p<0.001). Overall, 30% of patients with RD underwent outpatient management as compared with 73% in normal renal function (p<0.001). Safety of rule-out and outpatient management were excellent in RD with a 30-day MACE incidence of both 0% and comparable with 0.2% and 0.1% in normal renal function, respectively (p=0.010).

Conclusions: These real-world data document for the first time the excellent adherence, effectiveness, and safety of the ESC 0/1h-algorithm when routinely applied in patients with RD. Compared with patients with normal renal function, fewer patients with RD could be triaged towards rule-out or were treated as outpatients, most likely due to the higher prevalence of NSTEMI and comorbidities in RD.

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