Chronic Kidney Disease and Acute Coronary Syndrome: A Common Scenario, but More Evidence Necessary | Ten Points to Remember

Washam JB, Herzog CA, Beitelshees AL, et al.
Pharmacotherapy in Chronic Kidney Disease Patients Presenting With Acute Coronary Syndrome: A Scientific Statement From the American Heart Association. Circulation 2015;Feb 23:[Epub ahead of print].

The following are 10 points to remember about chronic kidney disease (CKD) in patients presenting with acute coronary syndrome (ACS):

  1. Data from the National Cardiovascular Data Registry–Acute Coronary Treatment and Intervention Outcomes Network (NCDR-ACTION) reported CKD prevalence rates of 30.5% among patients presenting with ST-segment elevation myocardial infarction (STEMI) and 42.9% among patients presenting with non-STEMI (NSTEMI).
  2. There is a ‘relative lack of evidence and potential for uncertainty in selecting medication’ in CKD patients presenting with ACS.
  3. CKD is a powerful independent predictor of cardiovascular morbidity, cardiovascular mortality, and all-cause mortality.
  4. Although traditional schema for defining different stages of CKD rely on the estimated glomerular filtration rate, the Kidney Disease: Improving Global Outcomes (KDIGO) group has recommended altering the classification scheme to include urinary albumin excretion.
  5. The clinical presentation of ACS among patients with CKD is often different from that of patients without CKD. The prevalence of chest pain among patients with ACS is inversely related to stage of CKD. The use of evidence-based therapy is lower among patients with CKD; the atypical presentation in CKD patients increases the likelihood that patients will be correctly identified as having ACS.
  6. While chronic troponin elevations in clinically stable patients with renal failure have been observed (and likely represent nonischemic myocardial injury), this biomarker should be used for the diagnosis of MI in CKD patients.
  7. When primary percutaneous coronary intervention is not available, fibrinolytic therapy should be considered a treatment strategy for CKD patients presenting with STEMI. That said, increasing rates of intracerebral hemorrhage are seen with worsening renal function in those patients who receive a fibrinolytic agent. Current models used to estimate the risk of intracerebral hemorrhage with fibrinolytic therapy do not include CKD as a risk factor.
  8. Although clopidogrel should be considered as a treatment option in ACS patients with CKD, prasugrel and ticagrelor may also be considered in those patients not considered to be at high risk of bleeding. It should be noted that patients with end-stage renal disease have been excluded from the landmark trials of the new agents.
  9. Stage 4 and 5 CKD patients are underrepresented in randomized controlled trials, and there are limited data on anticoagulation therapy in CKD patients presenting with ACS. Enoxaparin should be used cautiously in this population. Fondaparinux and bivalirudin are options that may be associated with lower rates of bleeding in patients with stage 3 and 4 CKD.
  10. Improved representation of patients with CKD in randomized clinical trials will be necessary to characterize risks and benefits of medical therapies in this population to inform evidence-based decisions.

Clinical Topics: Acute Coronary Syndromes, Anticoagulation Management, ACS and Cardiac Biomarkers, Anticoagulation Management and ACS

Keywords: Acute Coronary Syndrome, Kidney Failure, Chronic, Renal Insufficiency, Chronic, Cerebral Hemorrhage, Myocardial Infarction, Fibrinolytic Agents, Thrombolytic Therapy, Biological Markers, Peptide Fragments, Albumins, Glomerular Filtration Rate, Registries, Risk, Risk Factors

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