Unstable angina / non ST elevation myocardial infarction chronic kidney disease
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Unstable angina / NSTEMI Microchapters |
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Differentiating Unstable Angina/Non-ST Elevation Myocardial Infarction from other Disorders |
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Diagnosis |
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Treatment |
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Antitplatelet Therapy |
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Additional Management Considerations for Antiplatelet and Anticoagulant Therapy |
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Risk Stratification Before Discharge for Patients With an Ischemia-Guided Strategy of NSTE-ACS |
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Unstable angina / non ST elevation myocardial infarction chronic kidney disease On the Web |
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Chronic kidney disease (CKD) constitutes a risk factor for adverse outcomes after MI. It is a coronary artery disease equivalent as well as a risk factor for progression of CAD.
Chronic Kidney Disease with UA/NSTEMI
There is limited evidence available on the management of UA/NSTEMI in this group due to their under representaion in randomized trials. Limited evidence shows that cardiovascular medications and interventional strategies can be applied safely in those with renal impairment and provide therapeutic benefits. However, use of some of the medications and some strategies can be limited in the setting of ACS in these patients:
- Bleeding complications are higher in this patient subgroup because of platelet dysfunction and dosing errors;
- Benefits of fibrinolytic therapy, antiplatelet agents, and anticoagulants can be outweighed by bleeding complications; and
- Use of renin angiotensin-aldosterone inhibitors can impose a greater risk because of the complications of hyperkalemia and worsening renal function in the CKD patient.
- Angiography carries an increased risk of contrast-induced nephropathy.
A diagnosis of renal dysfunction is critical to proper medical therapy of UA/NSTEMI. Many cardiovascular drugs used in UA/NSTEMI patients are renally cleared; their doses should be adjusted for estimated creatinine clearance. Use of the Cockroft-Gault formula to generate dose adjustments is recommended.
Recommendations
- In association with 'National Kidney Foundation', AHA advisory recommends that all patients with CAD be screened for evidence of kidney disease by estimating glomerular filtration rate, testing for microalbuminuria, and measuring the albumin-to-creatinine ratio (Class IIa, Level of Evidence: C).
- ACC/AHA guidelines[1] recommends that in patients with mild to moderate chronic kidney disease, early angiography with intent of revascularization can be reasonable however clinicians should assess the risks, benefits and alternatives for each individual patients before considering the early invasive strategy.
- A recent meta-analysis[2] showed that an early angiography in patients admitted for non-ST elevation acute coronary syndrome (with co-existing chronic renal disease), significantly reduced the risk of re-hospitalization at 1 year in comparison to conservative therapy. However the study did not show any significant difference in reduction of all cause mortality, nonfatal MI, and a composite of death or nonfatal MI.
2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes (DO NOT EDIT) [3]
Chronic Kidney Disease
| Class I |
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"1. CrCl should be estimated in patients with NSTE-ACS, and doses of renally cleared medications should be adjusted according to the pharmacokinetic data for specific medications. (Level of Evidence: B)" |
| "2. Patients undergoing coronary and LV angiography should receive adequate hydration. (Level of Evidence: C)" |
| Class IIa |
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"1. An invasive strategy is reasonable in patients with mild (stage 2) and moderate (stage 3) CKD. (Level of Evidence: B) " |
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) (DO NOT EDIT)[4]
Chronic Kidney Disease (DO NOT EDIT)[4]
| Class I |
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"1. Creatinine clearance should be estimated in UA/NSTEMI patients and the doses of renally cleared medications should be adjusted according to the pharmacokinetic data for specific medications.[5][6] (Level of Evidence: B)" |
| "2. Patients undergoing cardiac catheterization with receipt of contrast media should receive adequate preparatory hydration.[7][8] (Level of Evidence: B)" |
| "3. Calculation of the contrast volume to creatinine clearance ratio is useful to predict the maximum volume of contrast media that can be given without significantly increasing the risk of contrast-associated nephropathy.[9][10] (Level of Evidence: B)" |
| Class IIa |
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"1. An invasive strategy is reasonable in patients with mild (stage 2) and moderate (stage 3) CKD.[5][6][2][11] (Level of Evidence: B) (There is insufficient data on benefit/risk of invasive strategy in UA/NSTEMI patients with advanced CKD [stages 4, 5])" |
References
- ↑ Wright RS, Anderson JL, Adams CD, Bridges CR, Casey DE, Ettinger SM, Fesmire FM, Ganiats TG, Jneid H, Lincoff AM, Peterson ED, Philippides GJ, Theroux P, Wenger NK, Zidar JP (2011). "2011 ACCF/AHA Focused Update of the Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction (Updating the 2007 Guideline): A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". Circulation. doi:10.1161/CIR.0b013e31820f2f3e. PMID 21444889. Retrieved 2011-03-31. Unknown parameter
|month=ignored (help) - ↑ 2.0 2.1 Charytan DM, Wallentin L, Lagerqvist B, Spacek R, De Winter RJ, Stern NM, Braunwald E, Cannon CP, Choudhry NK (2009). "Early angiography in patients with chronic kidney disease: a collaborative systematic review". Clinical Journal of the American Society of Nephrology : CJASN. 4 (6): 1032–43. doi:10.2215/CJN.05551008. PMID 19423566. Retrieved 2011-04-03. Unknown parameter
|month=ignored (help) - ↑ Ezra A. Amsterdam, MD, FACC; Nanette K. Wenger, MD et al.2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. JACC. September 2014 (ahead of print)
- ↑ 4.0 4.1 2012 Writing Committee Members. Jneid H, Anderson JL, Wright RS, Adams CD, Bridges CR; et al. (2012). "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. 126 (7): 875–910. doi:10.1161/CIR.0b013e318256f1e0. PMID 22800849.
- ↑ 5.0 5.1 Wright RS, Reeder GS, Herzog CA, Albright RC, Williams BA, Dvorak DL; et al. (2002). "Acute myocardial infarction and renal dysfunction: a high-risk combination". Ann Intern Med. 137 (7): 563–70. PMID 12353943.
- ↑ 6.0 6.1 Shlipak MG, Heidenreich PA, Noguchi H, Chertow GM, Browner WS, McClellan MB (2002). "Association of renal insufficiency with treatment and outcomes after myocardial infarction in elderly patients". Ann Intern Med. 137 (7): 555–62. PMID 12353942.
- ↑ Solomon R, Werner C, Mann D, D'Elia J, Silva P (1994). "Effects of saline, mannitol, and furosemide to prevent acute decreases in renal function induced by radiocontrast agents". N Engl J Med. 331 (21): 1416–20. doi:10.1056/NEJM199411243312104. PMID 7969280.
- ↑ Erley CM (1999). "Does hydration prevent radiocontrast-induced acute renal failure?". Nephrol Dial Transplant. 14 (5): 1064–6. PMID 10344335.
- ↑ Laskey WK, Jenkins C, Selzer F, Marroquin OC, Wilensky RL, Glaser R; et al. (2007). "Volume-to-creatinine clearance ratio: a pharmacokinetically based risk factor for prediction of early creatinine increase after percutaneous coronary intervention". J Am Coll Cardiol. 50 (7): 584–90. doi:10.1016/j.jacc.2007.03.058. PMID 17692741.
- ↑ Freeman RV, O'Donnell M, Share D, Meengs WL, Kline-Rogers E, Clark VL; et al. (2002). "Nephropathy requiring dialysis after percutaneous coronary intervention and the critical role of an adjusted contrast dose". Am J Cardiol. 90 (10): 1068–73. PMID 12423705.
- ↑ Szummer K, Lundman P, Jacobson SH, Schön S, Lindbäck J, Stenestrand U; et al. (2009). "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. 120 (10): 851–8. doi:10.1161/CIRCULATIONAHA.108.838169. PMID 19704097.