ConclusionsConclusions

ConclusionsConclusions

-In patients undergoing primary angioplasty, prophylactic -In patients undergoing primary angioplasty, prophylactic treatment with treatment with N-acetylcysteineN-acetylcysteine seems to reduce the rate seems to reduce the rate of contrast-medium induced nephropathy when of contrast-medium induced nephropathy when compared with post-procedure hydration alonecompared with post-procedure hydration alone

-In terms of prevention of contrast medium induced -In terms of prevention of contrast medium induced nephropathy, higher doses of nephropathy, higher doses of N-acetylcysteineN-acetylcysteine seem to seem to be more beneficial, suggesting a dose-dependent effectbe more beneficial, suggesting a dose-dependent effect

-Notably, the rate of contrast medium induced nephropathy -Notably, the rate of contrast medium induced nephropathy was independently related to the presence of baseline was independently related to the presence of baseline renal function impairment and more depressed left renal function impairment and more depressed left ventricular dysfunctionventricular dysfunction

ConclusionsConclusions

-Suggestion that because preventive and dose--Suggestion that because preventive and dose-dependent effects were seen in and throughout dependent effects were seen in and throughout the spectrum of renal function ventricular the spectrum of renal function ventricular function, that function, that N-acetylcysteineN-acetylcysteine may have a may have a broader range of kidney-protective effectsbroader range of kidney-protective effects

ImplicationsImplications

- Based on previous studies we know that primary Based on previous studies we know that primary angioplasty carries a considerable risk of angioplasty carries a considerable risk of contrast-medium induced nephropathy contrast-medium induced nephropathy suggesting high-dose suggesting high-dose N-acetylcysteine N-acetylcysteine may play may play a significant role in decreasing the morbidity and a significant role in decreasing the morbidity and mortality associated with primary angioplastymortality associated with primary angioplasty

- We should consider pre- and post- hydration the We should consider pre- and post- hydration the standard of care when patient are suspected of standard of care when patient are suspected of having to undergo angioplastyhaving to undergo angioplasty

- May suggest that pre- and post hydration be the May suggest that pre- and post hydration be the standard when dealing with any patient standard when dealing with any patient exposure to contrast mediumexposure to contrast medium

StrengthsStrengths

--N-acetylcysteineN-acetylcysteine not previously studied in primary not previously studied in primary angioplastyangioplasty

N-acetylcysteineN-acetylcysteine can be administer quickly and in can be administer quickly and in bolus form unlike typically hydration schedulesbolus form unlike typically hydration schedules

--N-acetylcysteineN-acetylcysteine seems to have few side effects seems to have few side effects and possibly added cardioprotective benefitsand possibly added cardioprotective benefits

-Almost all of the in-hospital deaths were from -Almost all of the in-hospital deaths were from cardiac causes with the exception of multiorgan cardiac causes with the exception of multiorgan failure and arrhythmias failure and arrhythmias

WeaknessesWeaknesses

-not specific about blinding-not specific about blinding

-limited demographic distribution-limited demographic distribution

-not matched for smoking -not matched for smoking

-all patients received post-hydration but question -all patients received post-hydration but question of whether any difference in time to hydration of whether any difference in time to hydration after contrast exposure amongst groups after contrast exposure amongst groups

-adjuvant therapy was not standardized-adjuvant therapy was not standardized

-ECHOs were obtained for all patients within 24 -ECHOs were obtained for all patients within 24 hours but over no standardized time periodhours but over no standardized time period

WeaknessesWeaknesses

-question of whether creatinine clearance versus -question of whether creatinine clearance versus creatinine may have been a better marker of creatinine may have been a better marker of acute renal failureacute renal failure

-primary end point was occurrence of contrast--primary end point was occurrence of contrast-medium induced nephropathy not mortality and medium induced nephropathy not mortality and composite end of death, acute renal failure composite end of death, acute renal failure requiring temporary dialysis or the need for requiring temporary dialysis or the need for mechanical ventilation seemed arbitrary and ad mechanical ventilation seemed arbitrary and ad hochoc

-baseline creatinine may not be an accurate -baseline creatinine may not be an accurate baselinebaseline

Discussion PointsDiscussion Points

How reproducible and generalizable is this How reproducible and generalizable is this study?study?

How does this study affect our clinical How does this study affect our clinical care?care?

Can we extrapolate from this data and Can we extrapolate from this data and justify the use of justify the use of N-acetylcysteineN-acetylcysteine in all in all patients being exposed to contrast patients being exposed to contrast medium? medium?