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ACT

  1. 1. ACT OVMC LANDMARK TRIALS SERIES "Acetylcysteine for Prevention of Renal Outcomes in Patients Undergoing Angiography". Circulation. 2011. 124:1250-1259.
  2. 2. Acetylcysteine for Contrast-Induced Nephropathy Trial (ACT)
  3. 3. BACKGROUND SOME FACTS:  Acetylcysteine reduces oxidative stress and may improve renal hemodynamics  However, it remains uncertain whether Acetylcysteine can prevent contrast induced AKI PRIOR TO THIS TRIAL:  Many studies prior to the ACT trial have shown conflicting results on the role of acetylcysteine and the benefits
  4. 4. CLINICAL QUESTION  For patients undergoing angiography (coronary and peripheral vascular), does acetylcysteine reduce the risk of contrast- induced acute kidney injury?
  5. 5. DESIGN  Analysis: Intention-to-treat  Multicenter, randomized, triple-blinded, randomized control trial  N=2308  Acetylcysteine (n=1172)  Placebo (n=1136)  Setting: Brazil, 46 sites  Enrollment: 2008-2010  Follow-up: 30 days (up to 96 hours for the primary outcome)  Primary outcome: Contrast-induced acute kidney injury 48-96h post-angiography
  6. 6. POPULATION Inclusion Criteria  Undergoing coronary or peripheral arterial diagnostic intravascular angiography or PCI  ≥1 risk factor for CI-AKI:  Age >70 years  CKD, defined by creatinine > 1.5 mg/dL  Diabetes  Clinical evidence of HF or LVEF <45%  Hypotension (not further defined) Exclusion Criteria  Patients on dialysis  STEMI undergoing PCI (could not receive hydration procedure 6h pre-procedure)  Women who were pregnant, breastfeeding, <45 years without use of contraception
  7. 7. INTERVENTIONS  All groups received hydration 6-12 hours pre and post angiography  0.9% saline at 1 mL/kg/h was recommended but could be substituted  Acetylcysteine arm received:  1200mg acetylcysteine q12h for 2 doses before and after the procedure  Placebo arm received:  powder that had the same appearance, taste, and smell as acetylcysteine powd
  8. 8. CRITICISMS  Lower proportion of the primary outcome than expected  The average volume of contrast used was low (100mL) and may have prevented CI-AKI  Relatively short duration of acetylcysteine use
  9. 9. BOTTOM LINE Acetylcysteine DOES NOT prevent contrast-induced acute kidney injury in patients undergoing angiography
  10. 10. DISCUSSION QUESTIONS  What type of patients were excluded in the ACT study?  What question did the ACT address?  For a patient undergoing PCI (who dose not have a STEMI), should he/she receive acetylcysteine to protect against contrast induced nephropathy?
  11. 11. DISCUSSION QUESTIONS/ANSWERS  What type of patients were excluded in the ACT study?  ANSWER: Patient undergoing dialysis, STEMI patients (unable to get fluid hydration prior to PCI), pregnant/breastfeeding  What question did the ACT address?  ANSWER: For patients undergoing angiography, should acetylcysteine be given to prevent contrast nephropathy  For a patient undergoing PCI (who dose not have a STEMI), should he/she receive acetylcysteine to protect against contrast induced nephropathy?  ANSWER: According to ACT, no because data does not show benefit
  12. 12. BOARD-LIKE QUESTION 81yo M, hospitalized for NSTEMI and scheduled for PCI in AM. Patient has a history of HTN, HLD, DM2, and CKD. Medications include Lisinopril, Atorvastatin, Insulin, Aspirin. On PE, HR 78, BP 148/82. JVP 6. CV showed RRR. Lungs clear. LE with 1+ pitting edema. Labs: Creatinine 2.7 (baseline) GFR 31 UA showed 2+ protein (QUESTION ADAPTED from MKSAP 17) QUESTION What would help prevent kidney injury in this patient? A. Start IV fluids B. Give oral N-acetylcysteine C. Discontinue Aspirin D. Discontinue Lisinopril
  13. 13. BOARD-LIKE QUESTION Educational Objective: Recognition and Management of patients who are at risk for contrast-induced nephropathy (CIN) Key Point: - Risk factors for CIN include: >75yo, DM2, CKD, decreased renal perfusion, concurrent use of nephrotoxic drugs - IV NS be started prior to contrast exposure (but also be vigilant of rate of fluids in patients with heart failure) - N-acetylcysteine in patients at risk for CIN remains inconsistent and are not recommended ANSWER What would help prevent kidney injury in this patient? A. Start IV fluids B. Give oral N-acetylcysteine C. Discontinue Aspirin D. Discontinue Lisinopril

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