Anavekar NS et al. (2004) Relation between renal dysfunction and cardiovascular outcomes after myocardical infarction. N Engl J Med 351: 1285–1295

Following myocardial infarction, the risk of further cardiovascular events is increased by the presence of renal failure. It is not clear whether milder renal impairment is also a significant risk factor. Anavekar et al. have investigated this role as part of the Valsartan in Acute Myocardial Infarction Trial (VALIANT).

The study randomized 14,527 high-risk survivors of acute myocardial infarction to receive captopril, valsartan or both, in a 1:1:1 ratio. As inhibitors of the renin-angiotensin system, these drugs are nephroprotective and reduce cardiovascular risk. The patients were categorized according to their baseline renal function—as indicated by the glomerular filtration rate (GFR)—and comparisons were made between these groups.

Baseline GFR measurements suggested that approximately a third of the patients had chronic kidney disease. Those in the lowest GFR category (<45.0 ml per minute per 1.73 m2) had the highest prevalence of coexisting risk factors. These patients were the least likely to have received other cardiovascular pharmacotherapies or to have undergone coronary revascularization. Mortality and cardiovascular risk were higher in patients with lower estimated GFR values at baseline: below 81.0 ml per minute per 1.73 m2, each 10-unit reduction in GFR brought a 10% increase in the relative risk of death or nonfatal cardiovascular complications. This was the case in all treatment groups.

Anavekar et al. conclude that any degree of renal disease should be viewed as a significant independent risk factor in patients with myocardial infarction.