Acute coronary syndrome in ESRD patients

Abstract

A 55-year-old male with end-stage renal disease (ESRD) secondary to diabetic nephropathy on hemodialysis for 2 years via a tunneled catheter line was admitted to the Brigham & Women's Hospital with chest pain. The chest pain was localized to the midline, radiated to the left arm, and was present at rest with no diaphoresis. His cardiac enzymes were elevated (troponin-I of 11.46 ng/ml and creatinine kinase-MB of 30.7 ng/ml) and his electrocardiogram (EKG) showed nonspecific ST-T wave changes that were unchanged from previous EKG 6 months earlier. He had a history of coronary artery disease (CAD) status post coronary artery bypass graft (CABG) 10 months earlier, type 1 diabetes mellitus since the age of 6 years, and peripheral neuropathy, blindness secondary to proliferative retinopathy, gastroparesis, neurogenic bladder, peripheral vascular disease (above-knee amputation of right limb), hypertension, and hypercholesterolemia. He had a failed living-related renal transplant because of recurrent diabetic nephropathy and chronic allograft nephropathy after 15 years. He had no history of stroke. His medications included aspirin, metoprolol, simvastatin, gemfibrozil, insulin, calcium acetate, sevelamer, epoeitin alfa, methadone, and hydromorphone hydrochloride. There was no significant family history of cardiovascular or renal disease. On physical examination, he was alert and afebrile, with a blood pressure of 135/60 mmHg, heart rate of 70 beats per minute, respiratory rate of 14 breaths per minute, with an oxygen saturation of 100% on room air and jugular venous pressure of 7 cm. His tunneled catheter site on the right side of the neck was clean, with no tenderness or erythema. Cardiac examination revealed distant heart sounds with no murmurs. The rest of the examination was unremarkable. CLINICAL DIAGNOSISA clinical diagnosis of acute coronary syndrome (ACS) (a non-ST-elevation myocardial infarction (MI)) was made.

Troponin I Levels in Asymptomatic Hemodialysis Patients

“…Moreover, symptomatic ischemia may ensue during HD. Since ESRD patients are more likely to have atypical symptoms and chronic baseline EKG abnormalities that may mask acute ischemic changes [18,19], it should be helpful, from a diagnostic point of view, to define the effects of the HD treatment on cTnI levels.…”

Cardiovascular complications in chronic dialysis patients

“…According to USRDS data, approximately 17% of deaths in ESRD are attributable to ACS. CAD prevalence in the same population was 36%, but some estimates suggest that >60% of new dialysis patients have evidence of coronary atherosclerosis [22–23]. Results from the GRACE registry showed that non-ST segment elevation myocardial infarction is the most common presentation for ACS in dialysis patients [24].…”

“…ACS diagnosis may be challenging in dialysis patients [22]. Chest pain is absent on admission in more than 50% of dialysis patients who present with an ACS, likely due to autonomic and/or uremic neuropathy [26–27].…”

“…However, conservative approaches appear to be associated with a significantly higher one-year mortality [34]. Although, confounding by indication cannot be ruled out in the majority of retrospective analyses, it seems reasonable to treat ACS in dialysis patients according to the standard guidelines used for non-dialysis patients (Table 1) [22]. …”

Impact of impaired glomerular filtration rate and revascularization strategy on one-year cardiovascular events in acute coronary syndrome: data from Taiwan acute coronary syndrome full spectrum registry

“…Furthermore cardiovascular death is the leading cause of mortality in the CKD population. Among the patients admitted due to acute coronary syndrome (ACS), those with CKD consistently have a poorer prognosis [7,8]. Although recent major clinical trials have shown aggressive medication treatment can improve cardiovascular outcome in patients suffering from ACS, only few patients with impaired glomerular filtration rate (IGFR) were enrolled.…”