Abstract
As the rates of obesity and diabetes continue to rise sharply in the United States, there is a secondary epidemic of diabetic nephropathy, chronic kidney disease, and end-stage renal disease requiring renal replacement therapy. Cardiovascular disease is the leading cause of death in patients with renal disease. Many sources of information support the concept that the metabolic condition caused by renal failure is an independent cardiac risk factor with a direct relationship to the pathogenesis of atherosclerosis, acute coronary syndromes (ACS), heart failure, and arrhythmias. An estimated glomerular filtration rate less than 60 mL/min/1.73 m2 has consistently been shown to be the most powerful predictor of adverse outcomes in ACS. This paper focuses on ACS and highlights the major issues with respect to diagnosis and treatment in patients with underlying renal failure. Because patients with renal disease are routinely excluded from clinical trials of ACS, we draw upon a variety of clinical data sets to gather an evidenced-based approach to this important and growing population of patients.
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References and Recommended Reading
McCullough PA: Cardiorenal risk: an important clinical intersection. Rev Cardiovasc Med 2002, 3:71–76. This paper presents the four explanations for increased cardiac risks in CKD: 1) excess comorbidities, 2) therapeutic nihilism, 3) toxicities of commonly used therapies, and 4) renal failure-induced vascular pathobiology.
National Kidney Foundation: Clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Am J Kidney Dis 2002, 2(Suppl 1):S46-S75.
McCullough PA, Soman SS, Shah SS, et al.: Risks associated with renal dysfunction in patients in the coronary care unit. J Am Coll Cardiol 2000, 36:679–684.
Beattie JN, Soman SS, Sandberg KR, et al.: Determinants of mortality after myocardial infarction in patients with advanced renal dysfunction. Am J Kidney Dis 2001, 37:1191–1200.
Szczech LA, Best PJ, Crowley E, et al.:, for the Bypass Angioplasty Revascularization Investigation (BARI) Investigators: Outcomes of patients with chronic renal insufficiency in the bypass angioplasty revascularization investigation. Circulation 2002, 105:2253–2258.
Shlipak MG, Heidenreich PA, Noguchi H, et al. Association of renal insufficiency with treatment and outcomes after myocardial infarction in elderly patients. Ann Intern Med 2002, 137:555–562. This is the largest study to date from the Cardiovascular Cooperative Project (n = 130,099) showing excess risk of cardiac events below CrCl of 60 mL/min, and demonstrating benefit with aspirin, β-blockers, and angiotensin-converting enzyme inhibitors, despite their underutilization in patients with CKD.
Braunwald E, Antman EM, Beasley JW, et al.: American College of Cardiology/American Heart Association. Committee on the Management of Patients With Unstable Angina. ACC/ AHA 2002 guideline update for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction--summary article: a report of the American College of Cardiology/American Heart Association task force on practice guidelines. J Am Coll Cardiol 2002, 40:1366–1374.
Hannan EL, Racz MJ, Arani DT, et al.: Short-and long-term mortality for patients undergoing primary angioplasty for acute myocardial infarction. J Am Coll Cardiol 2000, 36:1194–1201.
Herzog CA, Ma JZ, Collins AJ: Long-term survival of renal transplant recipients in the United States after acute myocardial infarction. Am J Kidney Dis 2000, 36:145–152.
Sica D: The implications of renal impairment among patients undergoing percutaneous coronary intervention. J Invasive Cardiol 2002, 14(Suppl B):30B-37B.
Weigert AL, Schafer AI: Uremic bleeding: pathogenesis and therapy. Am J Med Sci 1998, 316:94–104.
McCullough PA, Wolyn R, Rocher LL, et al.: Acute renal failure after coronary intervention: incidence, risk factors, and relationship to mortality. Am J Med 1997, 103:368–375.
Levey AS, Beto JA, Coronado BE, et al.: Controlling the epidemic of cardiovascular disease in chronic renal disease: what do we know? What do we need to learn? Where do we go from here? National Kidney Foundation Task Force on Cardiovascular Disease. Am J Kidney Dis 1998, 32:853–906.
Foley RN, Parfrey PS, Sarnak MJ: Clinical epidemiology of cardiovascular disease in chronic renal disease. Am J Kidney Dis 1998, 32(5 Suppl 3):S112-S119.
Ashley EA, Raxwal V, Finlay M, Froelicher V: Diagnosing coronary artery disease in diabetic patients. Diabetes Metab Res Rev 2002, 18:201–208.
Aronow WS, Ahn C, Mercando AD, Epstein S: Prevalence of coronary artery disease, complex ventricular arrhythmias, and silent myocardial ischemia and incidence of new coronary events in older persons with chronic renal insufficiency and with normal renal function. Am J Cardiol 2000, 86:1142–1143.
Deegan PB, Lafferty ME, Blumsohn A, et al.: Prognostic value of troponin T in hemodialysis patients is independent of comorbidity. Kidney Int 2001, 60:2399–2405.
McCullough PA, Nowak RM, Foreback C, et al.: Emergency evaluation of chest pain in patients with advanced kidney disease. Arch Intern Med 2002, 162:2464–2468.
McCullough PA, Nowak RM, Foreback C, et al.: Performance of multiple cardiac biomarkers measured in the emergency department in patients with chronic kidney disease and chest pain. Acad Emerg Med 2002, 9:1389–1396.
McCullough PA, Sandberg KR, Borzak S, et al.: Benefits of aspirin and beta-blockade after myocardial infarction in patients with chronic kidney disease. Am Heart J 2002, 144:226–232.
McCullough PA, Sandberg KR, Yee J, Hudson MP: Mortality benefit of angiotensin converting enzyme inhibitors after cardiac events in patients with end-stage renal disease. J Renin Angiotensin Aldosterone Syst 2002, 3:188–191.
Schiffrin EL: Vascular and cardiac benefits of angiotensin receptor blockers. Am J Med 2002, 113:409–418.
Januzzi JL Jr, Snapinn SM, DiBattiste PM, et al.: Benefits and safety of tirofiban among acute coronary syndrome patients with mild to moderate renal insufficiency: results from the Platelet Receptor Inhibition in Ischemic Syndrome Management in Patients Limited by Unstable Signs and Symptoms (PRISM-PLUS) trial. Circulation 2002, 105:2361–2366. This paper demonstrated benefit with unfractionated heparin and tirofiban (glycoprotein IIb/IIIa receptor antagonist) at all levels of renal dysfunction, although at a CrCl less than 30 mL/min, excess bleeding risks were observed.
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McCullough, P.A. Acute coronary syndromes in patients with renal failure. Curr Cardiol Rep 5, 266–270 (2003). https://doi.org/10.1007/s11886-003-0061-9
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DOI: https://doi.org/10.1007/s11886-003-0061-9