Transcript Lauder
Conclusions Conclusions -In patients undergoing primary angioplasty, prophylactic treatment with N-acetylcysteine seems to reduce the rate of contrast-medium induced nephropathy when compared with post-procedure hydration alone -In terms of prevention of contrast medium induced nephropathy, higher doses of N-acetylcysteine seem to be more beneficial, suggesting a dose-dependent effect -Notably, the rate of contrast medium induced nephropathy was independently related to the presence of baseline renal function impairment and more depressed left ventricular dysfunction Conclusions -Suggestion that because preventive and dosedependent effects were seen in and throughout the spectrum of renal function ventricular function, that N-acetylcysteine may have a broader range of kidney-protective effects Implications Based on previous studies we know that primary angioplasty carries a considerable risk of contrast-medium induced nephropathy suggesting high-dose N-acetylcysteine may play a significant role in decreasing the morbidity and mortality associated with primary angioplasty - We should consider pre- and post- hydration the standard of care when patient are suspected of having to undergo angioplasty - May suggest that pre- and post hydration be the standard when dealing with any patient exposure to contrast medium - Strengths -N-acetylcysteine not previously studied in primary angioplasty N-acetylcysteine can be administer quickly and in bolus form unlike typically hydration schedules -N-acetylcysteine seems to have few side effects and possibly added cardioprotective benefits -Almost all of the in-hospital deaths were from cardiac causes with the exception of multiorgan failure and arrhythmias Weaknesses -not specific about blinding -limited demographic distribution -not matched for smoking -all patients received post-hydration but question of whether any difference in time to hydration after contrast exposure amongst groups -adjuvant therapy was not standardized -ECHOs were obtained for all patients within 24 hours but over no standardized time period Weaknesses -question of whether creatinine clearance versus creatinine may have been a better marker of acute renal failure -primary end point was occurrence of contrastmedium induced nephropathy not mortality and composite end of death, acute renal failure requiring temporary dialysis or the need for mechanical ventilation seemed arbitrary and ad hoc -baseline creatinine may not be an accurate baseline Discussion Points How reproducible and generalizable is this study? How does this study affect our clinical care? Can we extrapolate from this data and justify the use of N-acetylcysteine in all patients being exposed to contrast medium?