Secondary Prevention in Concurrent Coronary Artery, Cerebrovascular, and Chronic Kidney Disease: Focus on Pharmacological Therapy

Abstract

Patients with coronary artery disease (CAD) commonly have varying degrees of coexisting cerebrovascular disease (CVD) and chronic kidney disease (CKD), and proper management is complicated partly because of a lack of unifying guidelines. The aim of this article is to review the current literature and propose the optimal treatment regimen in patients with all three disease states. Angiotensin‐converting enzyme inhibitors (ACE‐I) should be universally administered. High‐dose statin therapy to reach a target low‐density lipoprotein (LDL) of 70–100 mg/dL is advocated, although patients with a history of cerebral bleeding must be carefully monitored for possible recurrence. Beta‐blockers are appropriate after a recent coronary event, and amlodipine or thiazide diuretics should be used after a recent stroke (within 6 months). Patients with a history of stroke (with or without coexisting CAD and CKD) should receive aspirin (75–150 mg/day) indefinitely. Clopidogrel or aspirin plus extended‐release dipyridamole (ER‐DP) may be prescribed in patients allergic or resistant to aspirin. If stroke is attributable to cardiogenic embolism, anticoagulation is indicated. In patients with acute coronary syndromes (ACS) (excluding ST‐elevated myocardial infarct) who undergo percutaneous coronary intervention (PCI), aspirin plus clopidogrel is indicated for secondary prevention for up to 12 months. There are no data supporting the use of aspirin plus clopidogrel in patients with CKD who develop ACS. Aspirin plus clopidogrel is contraindicated for stroke prevention.

Using published criteria to develop a list of potentially inappropriate medications for elderly patients in Taiwan

“…With a multidisciplinary approach, the rating of some PIMs in the preliminary list can be more heterogeneous, particularly for medications commonly prescribed in certain specialties. In Table , dipyridamole was rated lower than expected because of its potential role in secondary prevention in coronary artery, cerebrovascular, and chronic kidney diseases . Furthermore, theophylline and aminophylline are still often prescribed to treat chronic obstructive pulmonary disease in Taiwan.…”

“…Because of their low cost and ease of use in older adults, many experts were reluctant to include them as PIMs. In Table , aspirin prescribed for patients with chronic kidney disease was not considered as inappropriate as well …”

Estimate of the prevalence of subjects with chronic diseases in a province of Northern Italy: a retrospective study based on administrative databases

“…The codes for ticket exemption and for hospital discharge were identified from the Ministry of Health website 13 14. The ATC codes for drug prescriptions were collected from some articles found in literature 15–26…”

“…13 14 The ATC codes for drug prescriptions were collected from some articles found in literature. [15][16][17][18][19][20][21][22][23][24][25][26]…”

MR Imaging of the Coronary Vasculature

“…Some CAD patients may have varying degrees of co-existing kidney dysfunction 11 . Therefore, noncontrast coronary MRA techniques may provide added benefits in that patient population by avoiding nephrotoxic contrast agents and risk of Nephrogenic Systemic Fibrosis (NSF).…”