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 dose- dependent 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 contrast- medium 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?