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Premature cardiovascular disease (CVD) is the single largest cause of death in patients with progressive chronic kidney disease (CKD), accounting for 43% of all cause mortality and over one third of hospitalisations in those with end stage renal failure (ESRF). This, along with the recognition of renal dysfunction as a predictor of cardiovascular morbidity and mortality in patients with ischaemic heart disease, has led cardiologists and nephrologists to focus on the effective management of cardiovascular complications of renal failure.
Most evidence based practice guidelines regarding the diagnosis and treatment of coronary artery disease (CAD) are based on trials performed in patients without renal impairment. The resultant lack of direct clinical evidence has meant that patients with renal failure are less likely to leave hospital on appropriate secondary prevention after acute myocardial infarction (AMI) and are less likely to receive thrombolysis or percutaneous coronary intervention (PCI).
The aim of this article is to present the current available evidence regarding both medical and interventional management strategies for CAD in patients with CKD, focusing on patients with stage IV–V renal failure (glomerular filtration rate (GFR) <15 ml/min). We will concentrate on three key areas where cardiologists are most involved in the investigation and management of such patients: the treatment of acute coronary syndromes (ACS); the investigation and management of chronic symptomatic angina; and screening for CAD in high risk renal transplant candidates.
EPIDEMIOLOGY OF CAD IN PATIENTS WITH CKD
Patients with progressive primary renal diseases—the most common of which are glomerulonephritis, chronic pyelonephritis, diabetic nephropathy, and inherited diseases such as adult polycystic kidney disease—exhibit slow deterioration of renal excretory function over a period of years to decades. Only a relatively small proportion of these patients ultimately require renal replacement therapy (RRT) with dialysis, and a further small proportion go on to receive a renal transplant. The “take on” rate for …