Chronic Kidney Disease in Patients with Non–ST-Segment Elevation Acute Coronary Syndromes

doi:10.1016/j.amjmed.2005.08.057

The American Journal of Medicine

Volume 119, Issue 3, March 2006, Pages 248-254

https://doi.org/10.1016/j.amjmed.2005.08.057 Get rights and content

Abstract

Purpose

Chronic kidney disease has been linked to high mortality rates in patients with ST-segment elevation myocardial infarction but has not been well described for patients with non–ST-segment elevation acute coronary syndromes. We examined the treatment and outcomes of patients with both non–ST-segment elevation acute coronary syndromes and moderate to severe chronic kidney disease.

Subjects and Methods

We evaluated 45 343 patients with non–ST-segment elevation acute coronary syndromes enrolled in the CRUSADE Quality Improvement Initiative and compared treatments and outcomes in patients with and without moderate to severe chronic kidney disease.

Results

Patients presenting with moderate to severe chronic kidney disease (n = 6560) were older, more often diabetic, and more likely to present with signs of congestive heart failure. Adherence to Class IA/IB guidelines recommendations was lower in patients with moderate to severe chronic kidney disease, who were significantly less likely to be treated with medications, undergo invasive cardiac procedures, and be given discharge counseling. Moderate to severe chronic kidney disease was associated with a 50% increased risk of mortality and a 70% increased likelihood of transfusion. Despite having a higher risk of adverse outcomes, patients with moderate to severe chronic kidney disease were treated less aggressively than patients with normal renal function.

Conclusions

These findings suggest that, in patients with moderate to severe chronic kidney disease, safety concerns about adverse outcomes and the absence of trial data for this population may limit the use of guidelines-recommended therapies and interventions for non–ST-segment elevation acute coronary syndromes. The decreased use of discharge counseling in patients with moderate to severe chronic kidney disease and non–ST-segment elevation acute coronary syndromes may represent therapeutic nihilism.

Section snippets

Overall Population

From January 1, 2001, to December 31, 2003, a total of 88 097 patients with non–ST-segment elevation acute coronary syndromes were enrolled in the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress ADverse outcomes with Early Implementation of the American College of Cardiology/American Heart Association guidelines) Quality Improvement Initiative. During the study period, 465 US hospitals located in 45 states participated in CRUSADE. The inclusion and exclusion criteria

Clinical Characteristics of the Study Population

Of the 45 343 patients meeting inclusion criteria, 6560 patients (14.5%) were classified as having moderate to severe chronic kidney disease. Patients with moderate to severe chronic kidney disease were older and more likely to have diabetes mellitus, congestive heart failure, and previous coronary artery disease (Table 1). In addition, patients with moderate to severe chronic kidney disease were more likely to present with signs of congestive heart failure and hemodynamic instability.

Early Management and In-Hospital Outcomes

After

Discussion

Our analysis of the CRUSADE Quality Improvement Initiative database shows that patients with moderate to severe chronic kidney disease and non–ST-segment elevation acute coronary syndromes are more likely to have in-hospital complications and less likely to receive American College of Cardiology/American Heart Association guidelines-recommended therapies in the acute setting.

The relationship between impaired creatinine clearance and an increase in post-acute myocardial infarction mortality has

Limitations

Moderate to severe chronic kidney disease was treated as a dichotomous variable; actual serum creatinine values or proteinuria were not recorded, making it impossible to assess the impact of the varying degrees of chronic kidney disease on treatment and outcomes. Similarly, dialysis status was not recorded. Previous studies have reported that only 5.0% to 13.1% of patients with moderate chronic kidney disease to kidney failure are on dialysis.2, 3 As a result, the presence of patients on

Conclusions

Patients with moderate to severe chronic kidney disease and non–ST-segment elevation acute coronary syndromes are at higher risk for death, blood transfusions not related to coronary artery bypass grafting, and cardiogenic shock. Despite these high-risk characteristics, patients with moderate to severe chronic kidney disease are less likely to be treated with antithrombotics, antiplatelets, and invasive procedures. Lack of adherence to the American College of Cardiology/American Heart

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Chronic kidney disease patients are at increased risk of cardiovascular disease, which is the leading cause of mortality among this population. In addition, chronic kidney disease is a major risk factor for the development of coronary artery disease and is widely regarded as a coronary artery disease risk equivalent. Medical therapy is the cornerstone of coronary artery disease management in the general population. However, there are few trials to guide medical therapy of coronary artery disease in chronic kidney disease, with most data extrapolated from clinical trials of mainly non-chronic kidney disease patients, which were not adequately powered to evaluate this subgroup. There is some evidence to suggest that the efficacy of certain therapies such as aspirin and statins is attenuated with declining estimated glomerular filtration rate, with questionable benefit among end-stage renal disease (ESRD) patients. Furthermore, chronic kidney disease and ESRD patients are at higher risk of potential side effects with therapy, which may limit their use. In this review, we summarize the available evidence supporting the safety and efficacy of medical therapy of coronary artery disease in chronic kidney disease and ESRD patients. We also discuss the data on new emerging therapies, including PCSK9i, SGLT2i, GLP1 receptor agonists, and nonsteroidal mineralocorticoid receptor antagonists, which show promise at reducing risk of cardiovascular events in the chronic kidney disease population and may offer additional treatment options. Overall, dedicated studies directly evaluating chronic kidney disease patients, particularly those with advanced chronic kidney disease and ESRD, are greatly needed to establish the optimal medical therapy for coronary artery disease and improve outcomes in this vulnerable population.
2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines
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The guideline for coronary artery revascularization replaces the 2011 coronary artery bypass graft surgery and the 2011 and 2015 percutaneous coronary intervention guidelines, providing a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization as well as the supporting documentation to encourage their use.
A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered.
Coronary artery disease remains a leading cause of morbidity and mortality globally. Coronary revascularization is an important therapeutic option when managing patients with coronary artery disease. The 2021 coronary artery revascularization guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with coronary artery disease who are being considered for coronary revascularization, with the intent to improve quality of care and align with patients’ interests.
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CA-AKI was associated with an increased relative risk for 90-day death, need for dialysis, or persistent kidney impairment (odds ratio: 3.93; 95% confidence interval: 2.82 to 5.49; p < 0.0001). The incidence of clinically significant CA-AKI was 1.2% (53 of 4,418 patients). CA-AKI was not a mediator of the association of pre-angiography estimated glomerular filtration rate with the primary outcome.
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Impaired renal function is associated with adverse outcomes in patients with chest pain discharged from internal medicine wards
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Citation Excerpt :
Although patients with chest pain deemed safe enough for discharge from an internal medicine ward may still be at risk for adverse outcomes, relatively little is known regarding predictors for poor prognosis in this relatively low risk population. Chronic kidney disease has been associated with both short and long-term adverse outcomes in patients with various cardiovascular conditions including acute coronary syndrome [3,4], congestive heart failure [5] and stroke [6]. A large study covering a community based population of >1.1 million ambulatory patients demonstrated an independent graded association between reduced estimated glomerular filtration rate (eGFR) and the risk of death, cardiovascular events and hospitalizations [7].
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Included in the study were12,337 patients who were divided into 3 groups according to renal function. Considering patients with an eGFR ≥ 60 ml/min/1.73m² as the reference group yielded adjusted hazard ratios for the composite of 30-day all-cause mortality and hospital admission for ACS that increased with reduced eGFR (HR = 2, 95%CI = 1.3–3.3, HR = 4.8, 95%CI = 3–7.6, for patients with eGFR of 45 to 59.9 or <45 ml/min/1.73m², respectively, p < 0.001). Similarly, reduced renal function was associated with increased 1-year all-cause mortality (HR = 1.6, 95%CI = 1.2–2.2, HR = 4.5, 95%CI = 3.4–5.9, for patients with eGFR of 45–59.9 or <45 ml/min/1.73m², respectively, p < 0.001).
We found an independent graded association between lower eGFR and the risk of death and ACS among patients with chest pain who were discharged from internal medicine wards following an ACS rule-out. The eGFR may be combined in the risk stratification of patients with chest pain.
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: CRUSADE is funded by Millennium Pharmaceuticals, Inc., Cambridge, MA, and Schering Corporation, Kenilworth, NJ. Bristol-Myers Squibb (Plainsboro, NJ)/Sanofi Pharmaceuticals (New York, NY) Partnership provides additional funding support.

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Clinical research studyChronic Kidney Disease in Patients with Non–ST-Segment Elevation Acute Coronary Syndromes

Abstract

Purpose

Subjects and Methods

Results

Conclusions

Section snippets

Overall Population

Clinical Characteristics of the Study Population

Early Management and In-Hospital Outcomes

Discussion

Limitations

Conclusions

Am J Kidney Dis

Am J Kidney Dis

J Am Coll Cardiol

Am Heart J

J Am Coll Cardiol

Am J Kidney Dis

Am Heart J

J Am Coll Cardiol

Am J Cardiol

Am Heart J

J Am Coll Cardiol

Am J Cardiol

Am J Cardiol

Kidney Int

Am J Cardiol

Am J Kidney Dis

Poor long-term survival after acute myocardial infarction among patients on long-term dialysis

N Engl J Med

Acute myocardial infarction and renal dysfunctiona high-risk combination

Ann Intern Med

Association of renal insufficiency with treatment and outcomes after myocardial infarction in elderly patients

Ann Intern Med

Clinical research study
Chronic Kidney Disease in Patients with Non–ST-Segment Elevation Acute Coronary Syndromes