Study On The Association Of Pulse Pressure With Ciaki And Short Term Clinical Outcomes In Patients Undergoing Coronary Intervention

1.Background and Objective:With the development of diagnosis and treatment of coronary atherosclerosis heart disease,coronary angiography(CAG)and percutaneous coronary intervention(PCI)popularizes unceasingly.Contrast-induced acute kidney injury(CIAKI)is a common complication of procedures requiring the use of iodinated radiographic contrast media.Prolonging hospitalization days and increasing healthcare costs,CIAKI is associated with higher short-and long-term morbidity and mortality rates than which are observed in patients without contrast-induced AKI and has became the third most common cause of acute renal failure in hospitalized patients.At present,clinical commonly use serum creatinine(Scr)as an evaluation biomarker to diagnose CIAKI,but the Scr change often lags behind the pathological damage of kidney and is affected by multiple extra factors,such as nutrition status,sex,age.Therefore,for reducing the incidence of CIAKI and cardiovascular events,it is need to investigate a more sensitive and more reliable biomarks to estimate CIAKI.Pulse pressure(PP),the difference between systolic blood pressure(SBP)and diastolic blood pressure(DBP),is routine measurement indicators in hospitalized patients.Recently,a number of clinical studies have shown that pulse pressure(PP)is an independent predictor of cardiovascular and all-cause mortality.The increase in PP is considered a consequence of stiffening of the arterial system,as shown by its correlation with aortic pulse wave velocity.In addition,the increase in PP may be preferentially transmitted to the glomerulus,affect renal vascular autonomic ability and reduced renal function.Based on the above,we hypothesized that elevated preoperative PP is associated with increased CIN and future cardiovascular events in patients undergoing percutaneous coronary intervention(PCI).This study was undertaken to evaluate the relationship between preoperative PP and the incidence of CIN and the predictive role of PP in clinical outcomes in patients undergoing PCI.2.Methods2.1 SubjectBetween May 2016 to December 2016,a series of 427 consecutive patients with acute coronary syndrome who were admitted for coronary intervention therapy in Qilu Hospital affiliated to Shandong University were enrolled in this study.2.2 Data CollectionEach selected patients clinical data was detail recorded.Before operation,we measured blood pressure parameters every hour,and the mean systolic blood pressure,diastolic blood pressure,mean blood pressure and pulse pressure were recorded.The data of CAG results,the type and volume of contrast media,time and result of operation,preoperative and postoperative transfusion volume was recorded by two cardiovascular interventional physician;We counterchecked renal faction 24-72h after operation and calculated the estimated glomerular filtration rate(eGFR)before and after surgery by using the abbreviated 'Modification of Diet in Renal Disease Study' equation.The patients were divided into CIN group(29 cases)and non CIN group(398 cases).2.3 Short-term Follow-upWe categorized the study population into three groups according to the tertiles of baseline PP,high PP group(PP?90mmHg),intermediate PP group(pp 60-89mmHg),low central PP group(PP<30mmHg)respectively.All study participants were successfully followed up after 1 months and 3 months by telephone or in cardiac outpatients.Major adverse cardiac events(MACE),including all-cause death,revascularization and acute coronary syndrome(including unstable angina and non ST segment elevation acute myocardial infarction and ST elevation acute myocardial infarction),ischemic stroke,end stage renal failure requiring regular dialysis were recorded.2.4 Statistical MethodsBy using SPSS 19.0 software for statistical analysis,clinical characteristics and pulse pressure were compared between CIN group and non CIN group.Significant variables associated with the presence of CIN in univariate analysis were entered into the multivariate regression model.And receiver operation characteristic(ROC)curves were used to identify the optimal sensitivity and specificity for the cutoff of pulse pressure to predicte CIAKI occurrence.In order to determine the independentpredictors of MACE,multivariate logistic regression analysis was performed by adjusting for variables significantly associated with clinical outcomes.A P value of<0.05 was considered to indicate statistical significance.3.Results:3.1 Baseline clinical characteristics:A total of 427 consecutive patients were evaluated,The average age(61.85±9.814)years old,mean BMI(25.74±3.23),the average blood pressure of SBP/DBP(135.76±17.85)/(76.48± 11.31)mmHg,mean PP pulse pressure(59.28±15.73)mmHg;the value of preoperative CCr(73.9±18.21)umol/L,postoperative CCr(74.75±20.46)umol/L,CCr value increased(1.899±9.52umol/L,P<0.01);preoperative eGFR(96.41±21.56)ml/min/1.73m2,postoperative eGFR(94.15±20.98)ml/min/1.73m2,postoperative eGFR decreased(2.25± 11.63ml/min/1.73m2,P<0.01).3.2 Overall,CI-AKI was observed in 29 patients(6.79%),of which males 17(28.62%),female 12(41.38%).Among CIN group and non CIN group,there were significant differences in PP(70.48± 18.45mmHg vs 58.46±15.22mmHg,P<0.01),systolic blood pressure(SBP,144.17±20.17mmHg vs 135.15±17.54mmHg,P=0.008),the amount of contrast agent(183.97±76.28ml vs 148.5±70.2ml,P=0.009),(134.36±17.85g/L vs 140.6 + 16.08g/L,P=0.049),diabetes(48.3%vs27.6%,P=0.018),history of chronic kidney disease(10.3%vs 1.5%,P=0.029).Apart from this,angiotensin-converting enzyme inhibitors were less used at baseline in patients with CIN than in patients without CIN(27.6%vs 48.5%,P=0.029).3.3 Multivariate logistic regression analysis:After adjustment for systolic blood pressure,history of diabetes mellitus and CKD,hemoglobin HBG,contrast volume,usage of ACEI/ARB drugs,PP was still significantly associated with an increased risk of CIN(OR,1.05;95%CI,1.003-1.094;P=0.025).Additionally,contrast volume(OR,1.007;95%CI,1.002-1.013,P=0.025).3.4 The ROC curve analysis:the area under the curve for predicting CIN of PP was 0.705(95%CI,0.597-0.813,P<0.01).The optimum cutoff point of PP was 63.5mmHg,with sensitivity of 75.9%and specificity 70.9%.3.5 All patients were followed up for at least 3 months.A total of 59 MACE(13.8%)occurred,including 2 cases of death(0.5%),40 cases(9.4%)of acute coronary syndrome which is expected to non target vessel revascularization in 3 cases(0.7%),and 16 cases(3.7%)of ischemic stroke.The incidence of MACE events(P<0.01),all-cause mortality(P=0.011)and acute coronary syndrome(P=0.038)in H-PP group and M-PP group were significantly higher than those in L-PP group.After adjustment for age,sex,SBP,DBP,history of hypertension,diabetes and MI,value of postoperative Ccr,medications(including dihydropyridine calcium channel blockers and angiotensin-converting enzyme inhibitors),the odds ratio(OR)for the occurrence of CIN was 5.867(95%CI,1.02-8.51;P<0.01).4.Conclusion:patients with acute coronary syndrome with higher baseline PP had increased incidence of CIN and future MACE after CAG or PCI.Further clinical study may be indicated to determine whether pharmacological modulation on baseline PP could prevent CIN and future MACE after PCI.