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Management of acute coronary syndrome in chronic kidney disease
1Cath Lab, Fortis-Escorts Heart Institute, Okhla Road, New Delhi 110025.
Insights
Patients with chronic kidney disease (CKD) face worse outcomes from acute coronary syndromes (ACS). Aggressive treatment, including revascularization, may improve survival, but more research is needed for optimal management strategies.
Area of Science:
- Cardiology
- Nephrology
- Clinical Trials
Background:
- Management guidelines for coronary heart disease (CHD) in chronic kidney disease (CKD) lack robust trial data, relying on meta-analyses and subgroup analyses.
- Patients with CKD, particularly those with reduced estimated glomerular filtration rate (eGFR), have a worse prognosis following acute coronary syndromes (ACS).
- Cardiovascular event rates and mortality risk are inversely proportional to eGFR, increasing even in early stages of CKD.
Purpose of the Study:
- To review the current understanding of acute coronary syndromes (ACS) management in patients with chronic kidney disease (CKD).
- To highlight the challenges and potential benefits of aggressive cardiovascular treatment in CKD patients.
- To identify the need for further randomized controlled trials (RCTs) in this population.
Main Methods:
- Review of existing literature, including meta-analyses, subgroup analyses, and registry data concerning ACS management in CKD.
- Analysis of outcomes based on renal function (eGFR) and treatment strategies (e.g., revascularization, medical therapy).
- Discussion of safety concerns and treatment disparities in CKD patients.
Main Results:
- Patients with moderate-to-severe CKD are often undertreated compared to those with normal renal function, receiving less aspirin, clopidogrel, beta-blockers, and revascularization procedures.
- Registry data indicates that in-hospital revascularization is associated with improved survival in ACS patients, regardless of eGFR.
- While short-term risks of coronary artery bypass grafting (CABG) are higher in CKD, long-term outcomes may be superior to medical treatment or percutaneous coronary intervention (PCI) in some analyses, though recent data shows no significant difference.
Conclusions:
- Aggressive management of ACS in CKD patients, including revascularization, warrants further investigation.
- Current treatment disparities and safety concerns may contribute to worse outcomes in CKD patients with ACS.
- Randomized controlled trials are essential to establish optimal, evidence-based treatment strategies for ACS in patients with renal dysfunction.
Abstract:
Few trials have addressed the management of acute coronary syndromes (ACS) in chronic kidney disease (CKD). Hence guidelines for the management of coronary heart disease (CHD) in CKD are based on meta-analysis, subgroup analyses, small prospective studies or retrospective analyses of controlled trials and registry data. The short-term as well as long-term prognosis of ACS patients with poor renal function is worse than those with normal renal function. The risk of cardiovascular (CV) events and mortality is inversely proportional to the estimated glomerular filtration rate (eGFR). Nevertheless, CV event rates increase even in early CKD. Contrast induced nephropathy (CIN) occurs in 15% of patients following diagnostic or therapeutic invasive procedures; less than 1% of these require dialysis. While treatment of CIN is not so effective, it is predictable and can be largely prevented. Despite a higher risk of adverse outcomes, patients with moderate-severe CKD are often treated less aggressively than patients with normal renal function due to safety concerns. Patients with CKD are less likely to receive aspirin, clopidogrel, or beta blockers and are less likely to undergo reperfusion or revascularization. Conservative treatment of ACS may partially account for worse outcome in CKD. Large registry data suggests that in-hospital revascularization is associated with improved survival, irrespective of eGFR. It is not clear whether coronary artery bypass grafting (CABG) surgery or percutaneous coronary intervention (PCI) leads to better outcomes in patients suitable for either procedure. While short-term risk of CABG in CKD is high, its long-term results have been better than medical treatment or PCI in registry data. Recent data suggest no differentials in outcomes with CABG or PCI. Randomized controlled trials involving patients with renal dysfunction are needed to confirm whether aggressive treatment of ACS will improve clinical outcomes.
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