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Patients with Chronic Kidney Disease/Diabetes Mellitus: The High-Risk Profile in Acute Coronary Syndrome

  • Management of Acute Coronary Syndromes (R Mehran, Section Editor)
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Abstract

Chronic kidney disease (CKD) and diabetes mellitus (DM) are highly prevalent, morbid diseases that are very common among patients presenting with acute coronary syndromes (ACS). Despite significant reductions in cardiovascular morbidity and mortality over the last half century, residual vascular risk remains disproportionately high in these populations. In large part, this is attributable to pre-existing vascular morbidity and substantial enrichment of traditional risk factors among those with either CKD or DM. Other factors, such as less aggressive therapeutic intervention and a unique atherothrombotic phenotype, are also contributory. The introduction of novel antiplatelet and antithrombotic agents over the last several years provides fresh opportunities to improve the adverse prognosis among patients with CKD or DM and concomitant ACS.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of outstanding importance

  1. Herrick JB. Landmark article (JAMA 1912). Clinical features of sudden obstruction of the coronary arteries. By James B. Herrick. JAMA. 1983;250(13):1757–65.

    Article  PubMed  CAS  Google Scholar 

  2. Julian DG. Treatment of cardiac arrest in acute myocardial ischaemia and infarction. Lancet. 1961;2(7207):840–4.

    Article  PubMed  CAS  Google Scholar 

  3. •• Nabel EG, Braunwald E. A tale of coronary artery disease and myocardial infarction. N Engl J Med. 2012;366(1):54–63. This review is a well-written comprehensive summary of significant innovations and advances in cardiovascular medicine during the 20th century.

    Article  PubMed  CAS  Google Scholar 

  4. Kannel WB, Dawber TR, Kagan A, et al. Factors of risk in the development of coronary heart disease–six year follow-up experience. The Framingham Study. Ann Intern Med. 1961;55:33–50.

    Article  PubMed  CAS  Google Scholar 

  5. Goble AJ, Sloman G, Robinson JS. Mortality reduction in a coronary care unit. Br Med J. 1966;1(5494):1005–9.

    Article  PubMed  CAS  Google Scholar 

  6. Ford ES, Ajani UA, Croft JB, et al. Explaining the decrease in U.S. deaths from coronary disease, 1980-2000. N Engl J Med. 2007;356(23):2388–98.

    Article  PubMed  CAS  Google Scholar 

  7. Coresh J, Selvin E, Stevens LA, et al. Prevalence of chronic kidney disease in the United States. JAMA. 2007;298(17):2038–47.

    Article  PubMed  CAS  Google Scholar 

  8. Cowie CC, Rust KF, Ford ES, et al. Full accounting of diabetes and pre-diabetes in the U.S. population in 1988-1994 and 2005-2006. Diabetes Care. 2009;32(2):287–94.

    Article  PubMed  Google Scholar 

  9. •• Fox CS, Muntner P, Chen AY, et al. Use of evidence-based therapies in short-term outcomes of ST-segment elevation myocardial infarction and non-ST-segment elevation myocardial infarction in patients with chronic kidney disease: a report from the National Cardiovascular Data Acute Coronary Treatment and Intervention Outcomes Network registry. Circulation. 2010;121(3):357–65. This report provides a detailed contemporary assessment of acute coronary syndrome management in patients with chronic kidney disease.

    Article  PubMed  CAS  Google Scholar 

  10. Franklin K, Goldberg RJ, Spencer F, et al. Implications of diabetes in patients with acute coronary syndromes. The Global Registry of Acute Coronary Events. Arch Intern Med. 2004;164(13):1457–63.

    Article  PubMed  Google Scholar 

  11. Centers for disease Control and Prevention. National Diabetes Fact Sheet: National Estimates and General Information on diabetes and Prediabetes in the United States, 2011. Atlanta, GA: US Department of Health and Human Services, Centers for diseae Control and Prevention; 2011.

    Google Scholar 

  12. US Renal Data System. USRDS 2012 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal disease. Bethesda, MD: National INstitutes of Health, National Institute of Diabetes and Digestive and Kidney Disease; 2012.

    Google Scholar 

  13. Kannel WB, McGee DL. Diabetes and cardiovascular risk factors: the Framingham study. Circulation. 1979;59(1):8–13.

    Article  PubMed  CAS  Google Scholar 

  14. Go AS, Chertow GM, Fan D, et al. Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization. N Engl J Med. 2004;351(13):1296–305.

    Article  PubMed  CAS  Google Scholar 

  15. Wallentin L, Becker RC, Budaj A, et al. Ticagrelor versus clopidogrel in patients with acute coronary syndromes. N Engl J Med. 2009;361(11):1045–57.

    Article  PubMed  CAS  Google Scholar 

  16. Mehran R, Nikolsky E, Lansky AJ, et al. Impact of chronic kidney disease on early (30-day) and late (1-year) outcomes of patients with acute coronary syndromes treated with alternative antithrombotic treatment strategies: an ACUITY (Acute Catheterization and Urgent Intervention Triage strategY) substudy. JACC Cardiovasc Interv. 2009;2(8):748–57.

    Article  PubMed  Google Scholar 

  17. Davies MJ, Woolf N, Robertson WB. Pathology of acute myocardial infarction with particular reference to occlusive coronary thrombi. Br Heart J. 1976;38(7):659–64.

    Article  PubMed  CAS  Google Scholar 

  18. Sosnov J, Lessard D, Goldberg RJ, et al. Differential symptoms of acute myocardial infarction in patients with kidney disease: a community-wide perspective. Am J Kidney Dis. 2006;47(3):378–84.

    Article  PubMed  Google Scholar 

  19. Acharya DU, Shekhar YC, Aggarwal A, Anand IS. Lack of pain during myocardial infarction in diabetics–is autonomic dysfunction responsible? Am J Cardiol. 1991;68(8):793–6.

    Article  PubMed  CAS  Google Scholar 

  20. Chiariello M, Indolfi C, Cotecchia MR, et al. Asymptomatic transient ST changes during ambulatory ECG monitoring in diabetic patients. Am Heart J. 1985;110(3):529–34.

    Article  PubMed  CAS  Google Scholar 

  21. Fergus TS, Fazel R, Fang J, et al. Presentation, management, and outcomes of diabetic patients compared to non-diabetic patients admitted for acute coronary syndromes. Heart. 2004;90(9):1051–2.

    Article  PubMed  CAS  Google Scholar 

  22. Wallace TW, Abdullah SM, Drazner MH, et al. Prevalence and determinants of troponin T elevation in the general population. Circulation. 2006;113(16):1958–65.

    Article  PubMed  CAS  Google Scholar 

  23. Han JH, Chandra A, Mulgund J, et al. Chronic kidney disease in patients with non-ST-segment elevation acute coronary syndromes. Am J Med. 2006;119(3):248–54.

    Article  PubMed  Google Scholar 

  24. Granger CB, Goldberg RJ, Dabbous O, et al. Predictors of hospital mortality in the global registry of acute coronary events. Arch Intern Med. 2003;163(19):2345–53.

    Article  PubMed  Google Scholar 

  25. Tang EW, Wong CK, Herbison P. Global Registry of Acute Coronary Events (GRACE) hospital discharge risk score accurately predicts long-term mortality post acute coronary syndrome. Am Heart J. 2007;153(1):29–35.

    Article  PubMed  Google Scholar 

  26. Baber U, Mann D, Shimbo D, et al. Combined role of reduced estimated glomerular filtration rate and microalbuminuria on the prevalence of peripheral arterial disease. Am J Cardiol. 2009;104(10):1446–51.

    Article  PubMed  CAS  Google Scholar 

  27. Nagashima M, Hagiwara N, Koyanagi R, et al. Chronic kidney disease and long-term outcomes of myocardial infarction. Int J Cardiol. 2012. doi:10.1016/j.ijcard.2012.04.049.

  28. Nguyen HL, Goldberg RJ, Gore JM, et al. Age and sex differences, and changing trends, in the use of evidence-based therapies in acute coronary syndromes: perspectives from a multinational registry. Coron Artery Dis. 2010;21(6):336–44.

    Article  PubMed  Google Scholar 

  29. Motivala AA, Cannon CP, Srinivas VS, et al. Changes in myocardial infarction guideline adherence as a function of patient risk: an end to paradoxical care? J Am Coll Cardiol. 2011;58(17):1760–5.

    Article  PubMed  Google Scholar 

  30. Marso SP, Amin AP, House JA, et al. Association between use of bleeding avoidance strategies and risk of periprocedural bleeding among patients undergoing percutaneous coronary intervention. JAMA. 2010;303(21):2156–64.

    Article  PubMed  CAS  Google Scholar 

  31. Norhammar A, Lindback J, Ryden L, et al. Improved but still high short- and long-term mortality rates after myocardial infarction in patients with diabetes mellitus: a time-trend report from the Swedish Register of Information and Knowledge about Swedish Heart Intensive Care Admission. Heart. 2007;93(12):1577–83.

    Article  PubMed  Google Scholar 

  32. Gitt AK, Schiele R, Wienbergen H, et al. Intensive treatment of coronary artery disease in diabetic patients in clinical practice: results of the MITRA study. Acta Diabetol. 2003;40 Suppl 2:S343–7.

    Article  PubMed  Google Scholar 

  33. Malik S, Lopez V, Chen R, et al. Undertreatment of cardiovascular risk factors among persons with diabetes in the United States. Diabetes Res Clin Pract. 2007;77(1):126–33.

    Article  PubMed  Google Scholar 

  34. Parikh NI, Hwang SJ, Larson MG, et al. Cardiovascular disease risk factors in chronic kidney disease: overall burden and rates of treatment and control. Arch Intern Med. 2006;166(17):1884–91.

    Article  PubMed  Google Scholar 

  35. Singla A, Antonino MJ, Bliden KP, et al. The relation between platelet reactivity and glycemic control in diabetic patients with cardiovascular disease on maintenance aspirin and clopidogrel therapy. Am Heart J. 2009;158(5):784.e1–6.

    Google Scholar 

  36. Leblond F, Guevin C, Demers C, et al. Downregulation of hepatic cytochrome P450 in chronic renal failure. J Am Soc Nephrol. 2001;12(2):326–32.

    PubMed  CAS  Google Scholar 

  37. Noris M, Benigni A, Boccardo P, et al. Enhanced nitric oxide synthesis in uremia: implications for platelet dysfunction and dialysis hypotension. Kidney Int. 1993;44(2):445–50.

    Article  PubMed  CAS  Google Scholar 

  38. Sagripanti A, Cupisti A, Baicchi U, et al. Plasma parameters of the prothrombotic state in chronic uremia. Nephron. 1993;63(3):273–8.

    Article  PubMed  CAS  Google Scholar 

  39. Baber, U.: Independent and Combined Impact of Diabetes Mellitus and Chronic Kidney Disease on Platelet Reactivity. Presented at ACC Scientific Sessions, New Orleans LA, 2011.

  40. Shlipak MG, Katz R, Cushman M, et al. Cystatin-C and inflammatory markers in the ambulatory elderly. Am J Med. 2005;118(12):1416.

    Article  PubMed  Google Scholar 

  41. Barazzoni R, Zanetti M, Davanzo G, et al. Increased fibrinogen production in type 2 diabetic patients without detectable vascular complications: correlation with plasma glucagon concentrations. J Clin Endocrinol Metab. 2000;85(9):3121–5.

    Article  PubMed  CAS  Google Scholar 

  42. King DE, Mainous 3rd AG, Buchanan TA, Pearson WS. C-reactive protein and glycemic control in adults with diabetes. Diabetes Care. 2003;26(5):1535–9.

    Article  PubMed  Google Scholar 

  43. Rauch U, Crandall J, Osende JI, et al. Increased thrombus formation relates to ambient blood glucose and leukocyte count in diabetes mellitus type 2. Am J Cardiol. 2000;86(2):246–9.

    Article  PubMed  CAS  Google Scholar 

  44. Osende JI, Badimon JJ, Fuster V, et al. Blood thrombogenicity in type 2 diabetes mellitus patients is associated with glycemic control. J Am Coll Cardiol. 2001;38(5):1307–12.

    Article  PubMed  CAS  Google Scholar 

  45. Baber, U.: Physiologic Impact of Chronic Kidney Disease on Whole Blood Clot Kinetics and Strength. Presented at ACC Scientific Sessions, Chicago IL, 2012.

  46. Keltai M, Tonelli M, Mann JF, et al. Renal function and outcomes in acute coronary syndrome: impact of clopidogrel. Eur J Cardiovasc Prev Rehabil. 2007;14(2):312–8.

    Article  PubMed  Google Scholar 

  47. Mather AN, Crean A, Abidin N, et al. Relationship of dysglycemia to acute myocardial infarct size and cardiovascular outcome as determined by cardiovascular magnetic resonance. J Cardiovasc Magn Reson. 2010;12:61.

    Article  PubMed  Google Scholar 

  48. Effectiveness of intravenous thrombolytic treatment in acute myocardial infarction. Gruppo Italiano per lo Studio della Streptochinasi nell'Infarto Miocardico (GISSI). Lancet 1986;1(8478): 397-402.

  49. Randomised trial of intravenous streptokinase, oral aspirin, both, or neither among 17,187 cases of suspected acute myocardial infarction: ISIS-2. ISIS-2 (Second International Study of Infarct Survival) Collaborative Group. Lancet 1988;2(8607): 349-360.

    Google Scholar 

  50. Theroux P, Ouimet H, McCans J, et al. Aspirin, heparin, or both to treat acute unstable angina. N Engl J Med. 1988;319(17):1105–11.

    Article  PubMed  CAS  Google Scholar 

  51. Patrono C, Garcia Rodriguez LA, Landolfi R, Baigent C. Low-dose aspirin for the prevention of atherothrombosis. N Engl J Med. 2005;353(22):2373–83.

    Article  PubMed  CAS  Google Scholar 

  52. Jneid H, Anderson JL, Wright RS, et al. 2012 ACCF/AHA focused update of the guideline for the management of patients with unstable angina/Non-ST-elevation myocardial infarction (updating the 2007 guideline and replacing the 2011 focused update): a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation. 2012;126(7):875–910.

    Article  PubMed  Google Scholar 

  53. Yusuf S, Zhao F, Mehta SR, et al. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. N Engl J Med. 2001;345(7):494–502.

    Article  PubMed  CAS  Google Scholar 

  54. Wiviott SD, Braunwald E, Angiolillo DJ, et al. Greater clinical benefit of more intensive oral antiplatelet therapy with prasugrel in patients with diabetes mellitus in the trial to assess improvement in therapeutic outcomes by optimizing platelet inhibition with prasugrel-Thrombolysis in Myocardial Infarction 38. Circulation. 2008;118(16):1626–36.

    Article  PubMed  CAS  Google Scholar 

  55. James S, Angiolillo DJ, Cornel JH, et al. Ticagrelor vs. clopidogrel in patients with acute coronary syndromes and diabetes: a substudy from the PLATelet inhibition and patient Outcomes (PLATO) trial. Eur Heart J. 2010;31(24):3006–16.

    Article  PubMed  CAS  Google Scholar 

  56. James S, Budaj A, Aylward P, et al. Ticagrelor versus clopidogrel in acute coronary syndromes in relation to renal function: results from the Platelet Inhibition and Patient Outcomes (PLATO) trial. Circulation. 2010;122(11):1056–67.

    Article  PubMed  Google Scholar 

  57. Montalescot G, Silvain J. Ticagrelor in the renal dysfunction subgroup: subjugated or substantiated? Circulation. 2010;122(11):1049–52.

    Article  PubMed  Google Scholar 

  58. Samama MM, Bara L, Gerotziafas GT. Mechanisms for the antithrombotic activity in man of low molecular weight heparins (LMWHs). Haemostasis. 1994;24(2):105–17.

    PubMed  CAS  Google Scholar 

  59. Warkentin TE, Levine MN, Hirsh J, et al. Heparin-induced thrombocytopenia in patients treated with low-molecular-weight heparin or unfractionated heparin. N Engl J Med. 1995;332(20):1330–5.

    Article  PubMed  CAS  Google Scholar 

  60. Antman EM, Morrow DA, McCabe CH, et al. Enoxaparin versus unfractionated heparin with fibrinolysis for ST-elevation myocardial infarction. N Engl J Med. 2006;354(14):1477–88.

    Article  PubMed  CAS  Google Scholar 

  61. Cohen M, Demers C, Gurfinkel EP, et al. A comparison of low-molecular-weight heparin with unfractionated heparin for unstable coronary artery disease. Efficacy and Safety of Subcutaneous Enoxaparin in Non-Q-Wave Coronary Events Study Group. N Engl J Med. 1997;337(7):447–52.

    Article  PubMed  CAS  Google Scholar 

  62. Morrow DA, Antman EM, Murphy SA, et al. Effect of enoxaparin versus unfractionated heparin in diabetic patients with ST-elevation myocardial infarction in the Enoxaparin and Thrombolysis Reperfusion for Acute Myocardial Infarction Treatment-Thrombolysis In Myocardial Infarction study 25 (ExTRACT-TIMI 25) trial. Am Heart J. 2007;154(6):1078–84. 1084 e1071.

    Article  PubMed  CAS  Google Scholar 

  63. Fox KA, Antman EM, Montalescot G, et al. The impact of renal dysfunction on outcomes in the ExTRACT-TIMI 25 trial. J Am Coll Cardiol. 2007;49(23):2249–55.

    Article  PubMed  CAS  Google Scholar 

  64. Weitz JI, Hirsh J. New anticoagulant drugs. Chest. 2001;119(1 Suppl):95S–107S.

    Article  PubMed  CAS  Google Scholar 

  65. Yusuf S, Mehta SR, Chrolavicius S, et al. Comparison of fondaparinux and enoxaparin in acute coronary syndromes. N Engl J Med. 2006;354(14):1464–76.

    Article  PubMed  CAS  Google Scholar 

  66. Fox KA, Bassand JP, Mehta SR, et al. Influence of renal function on the efficacy and safety of fondaparinux relative to enoxaparin in non ST-segment elevation acute coronary syndromes. Ann Intern Med. 2007;147(5):304–10.

    Article  PubMed  Google Scholar 

  67. Hirsh J, Raschke R. Heparin and low-molecular-weight heparin: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004;126(3 Suppl):188S–203S.

    Article  PubMed  CAS  Google Scholar 

  68. Weitz JI, Bates SM. Acute coronary syndromes: a focus on thrombin. J Invasive Cardiol. 2002;14(Suppl B):2B–7B.

    PubMed  Google Scholar 

  69. Stone GW, McLaurin BT, Cox DA, et al. Bivalirudin for patients with acute coronary syndromes. N Engl J Med. 2006;355(21):2203–16.

    Article  PubMed  CAS  Google Scholar 

  70. Witzenbichler B, Mehran R, Guagliumi G, et al. Impact of diabetes mellitus on the safety and effectiveness of bivalirudin in patients with acute myocardial infarction undergoing primary angioplasty: analysis from the HORIZONS-AMI (Harmonizing Outcomes with RevasculariZatiON and Stents in Acute Myocardial Infarction) trial. JACC Cardiovasc Interv. 2011;4(7):760–8.

    Article  PubMed  Google Scholar 

  71. Fox KA, Clayton TC, Damman P, et al. Long-term outcome of a routine versus selective invasive strategy in patients with non-ST-segment elevation acute coronary syndrome a meta-analysis of individual patient data. J Am Coll Cardiol. 2010;55(22):2435–45.

    Article  PubMed  Google Scholar 

  72. • O'Donoghue ML, Vaidya A, Afsal R, et al. An invasive or conservative strategy in patients with diabetes mellitus and non-ST-segment elevation acute coronary syndromes: a collaborative meta-analysis of randomized trials. J Am Coll Cardiol. 2012;60(2):106–11. This pooled analysis evaluates the benefits of an early invasive versus conservative management approach in diabetic patients with acute coronary syndromes.

    Article  PubMed  Google Scholar 

  73. Charytan DM, Wallentin L, Lagerqvist B, et al. Early angiography in patients with chronic kidney disease: a collaborative systematic review. Clin J Am Soc Nephrol. 2009;4(6):1032–43.

    Article  PubMed  Google Scholar 

  74. Szummer K, Lundman P, Jacobson SH, et al. Influence of renal function on the effects of early revascularization in non-ST-elevation myocardial infarction: data from the Swedish Web-System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies (SWEDEHEART). Circulation. 2009;120(10):851–8.

    Article  PubMed  CAS  Google Scholar 

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Usman Baber and Uschi Auguste declare that they have no conflict of interest.

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  1. The Zena and Michael A. Wiener Cardiovascular Institute, The Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY, 10029-6574, USA

    Usman Baber & Uschi Auguste

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This article is part of the Topical Collection on Management of Acute Coronary Syndromes

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Baber, U., Auguste, U. Patients with Chronic Kidney Disease/Diabetes Mellitus: The High-Risk Profile in Acute Coronary Syndrome. Curr Cardiol Rep 15, 386 (2013). https://doi.org/10.1007/s11886-013-0386-y

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