State of the art paper Treatment of non-ST-elevation myocardial infarction and ST-elevation myocardial infarction in patients with chronic kidney disease

Abstract

Renal dysfunction is frequent in patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS). Chronic kidney disease (CKD) is associated with very poor prognosis and is an independent predictor of early and late mortality and major bleeding in patients with NSTE-ACS. Patients with NSTE-ACS and CKD are still rarely treated according to guidelines. Medical registers reveal that patients with CKD are usually treated with too high doses of antithrombotics, especially anticoagulants and inhibitors of platelet glycoprotein (GP) IIb/IIIa receptors, and therefore they are more prone to bleeding. Drugs which are excreted mainly or exclusively by the kidney should be administered in a reduced dose or discontinued in patients with CKD. These drugs include enoxaparin, fondaparinux, bivalirudin, and small molecule inhibitors of GP IIb/IIIa inhibitors. In long-term treatment of patients after myocardial infarction, anti-platelet therapy, lipid-lowering therapy and β-blockers are used. Chronic kidney disease patients before qualification for coronary interventions should be carefully selected in order to avoid their use in the group of patients who could not benefit from such procedures. This paper presents schemes of non-ST and ST-segment elevation myocardial infarction treatment in CKD patients in accordance with the current recommendations of the European Society of Cardiology (ESC).

Lipid, blood pressure and kidney update 2013

“…CKD is associated with CVD even in the early stages, and a large number of patients die before developing advanced CKD [26, 55–58]. The available data suggest that efforts to reduce mortality in the CKD population should be focused on treatment and prevention of, among others, CAD and congestive heart failure [58–61].…”

Is kidney function affecting the management of myocardial infarction? A retrospective cohort study in patients with normal kidney function, chronic kidney disease stage III–V, and ESRD

“…1 Despite recognizing this high-risk group, patients with CKD have been largely excluded from randomized controlled trials and management guidelines are not established. 1 ACS diagnosis is based on the clinical presentation of ischemic symptoms, cardiac biomarkers, and electrocardiogram changes. Compared with general population, CKD patients commonly have atypical presentation as in elderly and diabetic; in addition, diagnostic markers have low predictive value since many patients have elevated troponins without having ACS.…”

“…Compared with general population, CKD patients commonly have atypical presentation as in elderly and diabetic; in addition, diagnostic markers have low predictive value since many patients have elevated troponins without having ACS. 1,2 In fact, CKD patients have better outcomes when evidencebased therapy is adopted. 2 Analysis of data from large clinical trials demonstrated that the implementation of invasive treatment is associated with better prognosis in patients with endstage renal disease (ESRD) and moderate CKD.…”

“…CKD in acute coronary syndrome (ACS) is independently associated with increased morbidity and mortality. 1 Traditional and unique risk factors are prevalent putting patients with CKD at higher risk of developing coronary artery disease (CAD) and constitute challenges for the standard of care. 1 Despite recognizing this high-risk group, patients with CKD have been largely excluded from randomized controlled trials and management guidelines are not established.…”

“…1 Traditional and unique risk factors are prevalent putting patients with CKD at higher risk of developing coronary artery disease (CAD) and constitute challenges for the standard of care. 1 Despite recognizing this high-risk group, patients with CKD have been largely excluded from randomized controlled trials and management guidelines are not established. 1 ACS diagnosis is based on the clinical presentation of ischemic symptoms, cardiac biomarkers, and electrocardiogram changes.…”