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The implications of renal impairment among patients undergoing percutaneous coronary intervention
1Section of Clinical Pharmacology and Hypertension, Division of Nephrology, Medical College of Virginia, Virginia Commonwealth University, Richmond, Virginia, USA.
Insights
Mild kidney dysfunction significantly increases risks during percutaneous coronary interventions (PCI). Optimal anticoagulation strategies are needed to manage peri-procedural ischemic events in these high-risk patients.
Area of Science:
- Cardiology
- Nephrology
- Thrombosis
Background:
- Mild renal impairment is often overlooked in percutaneous coronary interventions (PCI).
- Renal insufficiency is associated with a pro-thrombotic, inflammatory state, increasing cardiovascular risks.
- Existing data on managing anticoagulation in renal impairment during PCI is limited.
Purpose of the Study:
- To review the pathophysiological changes in renal impairment relevant to PCI.
- To evaluate current therapeutic options for adjunctive anticoagulation in renal failure patients undergoing PCI.
- To highlight the need for evidence-based strategies for managing peri-procedural ischemic events.
Main Methods:
- Review of pathophysiological changes associated with renal impairment.
- Analysis of existing clinical evidence for adjunctive anticoagulation in PCI.
- Discussion of hemostatic derangements including platelet activity and thrombin generation.
Main Results:
- Renal insufficiency reduces procedural success and increases peri-procedural myocardial infarction (MI), late mortality, ischemia, and target vessel revascularization.
- Vessel stenting improves revascularization rates but not ischemic events in renal failure patients.
- Hemostatic changes include decreased platelet aggregation and increased thrombin generation.
Conclusions:
- A rational, evidence-based approach to anticoagulation is crucial for managing peri-procedural ischemic events in renal impairment.
- Current recommendations lack robust clinical trial data.
- Further research is needed to establish optimal adjunctive anticoagulation strategies.
Abstract:
The clinical implications of even mild impairment of renal function in percutaneous coronary interventions (PCI) have, to date, been poorly appreciated. The progressive loss of renal function is marked by the onset of a thrombo-inflammatory state not unlike what occurs in progressive coronary artery disease (CAD). In the presence of renal insufficiency, procedural success is reduced, peri-procedural myocardial infarction (MI) is more frequent and increased late mortality, myocardial ischemia and target vessel revascularization are more common. Vessel stenting reduces the rate of target vessel revascularization in renal failure patients, but fails to impact the frequency of peri-procedural ischemic events. Consequently, a rational, evidence-based approach to adjunctive anticoagulation in renal failure patients undergoing PCI is warranted if per-procedural ischemic events are to be better managed. Unfortunately, current recommendations are hampered by a paucity of clinical trial evidence specifically examining the efficacy of available therapies. In an attempt to go beyond this lack of clinical evidence, some therapeutic insight may be drawn from the known hemostatic derangements associated with renal impairment. These changes include a well-described decreased in platelet aggregatory activity and an increase in thrombin generation. While more definitive clinical trial evidence of adjunctive anticoagulation efficacy among patients with renal impairment is in process, this article will briefly review the pathophysiological changes associated with renal impairment, as well as the evidence supporting each of the current therapeutic options available to the interventional cardiologist.