Chronic kidney disease in acute coronary syndromes

Antiplatelet strategy for patients with acute coronary syndrome and chronic kidney disease: a systematic review and meta-analysis

Background

Patients with both acute coronary syndrome (ACS) and chronic kidney disease (CKD) face heightened risks of adverse cardiovascular events and bleeding. An optimal antiplatelet strategy for this patient population is needed.

Methods

We conducted a systematic review and meta-analysis to evaluate comparative advantages of clopidogrel vs. ticagrelor in the choice of dual antiplatelet therapy (DAPT) strategies for patients with ACS combined with CKD, while also exploring the appropriate duration of DAPT in the presence of CKD. Relevant studies were retrieved from PubMed, Embase, Cochrane Library, and Web of Science. The primary outcomes were all-cause mortality, major adverse cardiovascular events (MACE), and major bleeding. Data were analyzed using RevMan 5.4.1, and STATA 14 was used to assess publication bias. This study was registered with PROSPERO (CRD42024593764).

Results

Six studies involving 9,947 patients met the inclusion criteria. Compared with clopidogrel, ticagrelor was associated with a reduced risk of MACE (RR: 0.89, 95% CI: 0.80-0.99; P = 0.04) and stroke (RR: 0.66, 95% CI: 0.45-0.96; P = 0.03) in patients receiving DAPT. No significant differences were observed in all-cause mortality, major bleeding, cardiovascular death, or acute myocardial infarction. Three studies on DAPT duration showed a consistent trend, indicating that shortening DAPT duration did not benefit patients.

Conclusions

In patients with ACS combined with CKD, ticagrelor-based DAPT has advantages over clopidogrel-based DAPT, which is associated with a lower incidence of MACE. And shortening the duration of DAPT does not improve clinical outcomes.

Anticoagulant therapy in renal insufficiency theme: Anticoagulation in complex situations

Many patients with impaired renal function have concurrent indications for anticoagulant therapy, including atrial fibrillation and venous thromboembolism. For mild chronic kidney disease, data from clinical trials and existing guidelines can be applied to clinical management. The benefits and harms of anticoagulation therapy in patients with more advanced renal impairment are nuanced, as both thrombotic and bleeding risk are increased. Until recently, data regarding anticoagulants in severe renal impairment were primarily observational, but emerging evidence includes a few small clinical trials and the emergence of novel agents hypothesized to have improved efficacy and safety in this population. In this review, we summarize existing data on anticoagulation in patients with chronic kidney disease. We suggest a framework for anticoagulation decision-making in the burgeoning worldwide population of patients with chronic kidney disease.

Characteristics of calcified nodule attributable to culprit lesion in acute coronary syndrome: A systematic review and meta-analysis

The presence of calcified nodule (CN) is a significant characteristic of atherothrombosis in acute coronary syndrome (ACS). However, its characteristics continue to be understudied. This review aimed to further investigate these characteristics. This study found that CN was a distinctive feature of an atheromatous plaque, representing 6.3% of ACS. CN was more common in NSTE-ACS than in STEMI patients (9.4% vs. 6.6%). CN was also chiefly observed in the left anterior descendant artery (48%), followed by the right coronary (40.4%) and left circumflex (14.5%) arteries. Higher prevalence of hypertension (78.8%), diabetes mellitus (50.8%), multivessel disease (71.7%), and kidney disease (26.43%) were noted in CN compared to non-CN patients. CN-associated ACS also 6-fold increased the risk of target lesion revascularization compared to those without CN.

Inorganic nitrate benefits contrast-induced nephropathy after coronary angiography for acute coronary syndromes: the NITRATE-CIN trial

BACKGROUND AND AIMS

Contrast-induced nephropathy (CIN), also known as contrast-associated acute kidney injury (CA-AKI) underlies a significant proportion of the morbidity and mortality following coronary angiographic procedures in high-risk patients and remains a significant unmet need. In pre-clinical studies inorganic nitrate, which is chemically reduced in vivo to nitric oxide, is renoprotective but this observation is yet to be translated clinically. In this study, the efficacy of inorganic nitrate in the prevention of CIN in high-risk patients presenting with acute coronary syndromes (ACS) is reported.

METHODS

NITRATE-CIN is a double-blind, randomized, single-centre, placebo-controlled trial assessing efficacy of inorganic nitrate in CIN prevention in at-risk patients presenting with ACS. Patients were randomized 1:1 to once daily potassium nitrate (12 mmol) or placebo (potassium chloride) capsules for 5 days. The primary endpoint was CIN (KDIGO criteria). Secondary outcomes included kidney function [estimated glomerular filtration rate (eGFR)] at 3 months, rates of procedural myocardial infarction, and major adverse cardiac events (MACE) at 12 months. This study is registered with ClinicalTrials.gov: NCT03627130.

RESULTS

Over 3 years, 640 patients were randomized with a median follow-up of 1.0 years, 319 received inorganic nitrate with 321 received placebo. The mean age of trial participants was 71.0 years, with 73.3% male and 75.2% Caucasian; 45.9% had diabetes, 56.0% had chronic kidney disease (eGFR <60 mL/min) and the mean Mehran score of the population was 10. Inorganic nitrate treatment significantly reduced CIN rates (9.1%) vs. placebo (30.5%, P < .001). This difference persisted after adjustment for baseline creatinine and diabetes status (odds ratio 0.21, 95% confidence interval 0.13-0.34). Secondary outcomes were improved with inorganic nitrate, with lower rates of procedural myocardial infarction (2.7% vs. 12.5%, P = .003), improved 3-month renal function (between-group change in eGFR 5.17, 95% CI 2.94-7.39) and reduced 1-year MACE (9.1% vs. 18.1%, P = .001) vs. placebo.

CONCLUSIONS

In patients at risk of renal injury undergoing coronary angiography for ACS, a short (5 day) course of once-daily inorganic nitrate reduced CIN, improved kidney outcomes at 3 months, and MACE events at 1 year compared to placebo.

Acute Kidney Injury in Acute Myocardial Infarction and Its Outcome at 3 and 6 Months

Epidemiological data on the prevalence of acute kidney injury (AKI) in acute coronary syndrome are sparse, with most studies having been conducted retrospectively. This study prospectively analyzed the incidence of AKI in patients with acute myocardial infarction (AMI) and to identify the risk factors for AKI and their renal outcome at 3 and 6 months. This was a prospective and observational study, which enrolled 120 patients presenting with their first episode of AMI to our hospital and consented to the study. Renal function tests were performed at admission, at 48 h, and at follow-up at 3 and 6 months. The majority of the patients underwent a percutaneous coronary intervention (59.2%), 21.7% received thrombolytic therapy, and 19.2% were managed conservatively. At 48 h, 11 patients had AKI. At 3 months, 8 patients had died, and renal dysfunctions were seen in 9 out of 112 patients. At 6 months, 12 patients out of 112 had renal dysfunction. There was no difference in the incidence of AKI in patients with an estimated glomerular filtration rate above and below 60 mL/min/1.73 m2. Killip Class 4 and diabetes mellitus were associated with an increased incidence of renal dysfunction in AMI patients. The type of treatment and the use of a contrast agent in the coronary intervention did not affect the development of AKI. According to this study, if indicated, a percutaneous coronary intervention should not be denied to patients for fear of developing AKI. This needs to be examined in larger randomized trials.

Early Major Adverse Cardiovascular Event in a Patient With Chronic Kidney Disease: A Case Report

Acute coronary syndrome (ACS) is common in people with chronic kidney disease (CKD) and is linked to poor short- and long-term outcomes. The diagnosis of myocardial infarction is challenging in patients with CKD as they have baseline elevated troponin levels. To date, there are no widely accepted guidelines to suggest what is a clinically significant change in troponin levels in these patients. We report a case of a patient with CKD who presented with chest pain to the emergency department (ED). His baseline troponin was high; however, the delta change was 11%. He was discharged from the ED for outpatient follow-up, but within 36 hours, he had significant ST elevation myocardial infarction (STEMI) with unstable hemodynamics and acute heart failure requiring urgent intubation and coronary revascularization. This case highlights the gap in clinical knowledge and practice in a relatively not uncommon presentation in emergency departments.

Plasma trimethylamine-N-oxide, its precursors and risk of cardiovascular events in patients with acute coronary syndrome: Mediating effects of renal function

Aims

To examine associations of the gut microbial metabolite trimethylamine-N-oxide (TMAO) and its precursors with risk of cardiovascular events in acute coronary syndrome (ACS), and determine whether these associations were mediated by renal function.

Methods

In this prospective cohort study, we included 309 patients with ACS. During a mean follow-up of 6.7 years, 131 patients developed major adverse cardiovascular events (MACE) (myocardial infarction, hospitalization for heart failure, and all-cause mortality). Plasma concentrations of TMAO, trimethylamine (TMA), choline, betaine, dimethylglycine and L-carnitine were profiled by liquid chromatography tandem mass spectrometry. Hazard ratios were estimated with multivariable Cox regression models. The mediating role of estimated glomerular filtration rate (eGFR) was tested under a counterfactual framework.

Results

After adjustment for traditional cardiovascular risk factors and medications, participants in the highest tertile vs. the lowest tertile of baseline TMAO and dimethylglycine concentrations had a higher risk of MACE [(HR: 1.83; 95% CI: 1.08, 3.09) and (HR: 2.26; 95% CI: 1.17, 3.99), respectively]. However, with regards to TMAO these associations were no longer significant, whereas for dimethylglycine, the associations were attenuated after additional adjustment for eGFR. eGFR mediated the associations of TMAO (58%) and dimethylglycine (32%) with MACE incidence. The associations between dimethylglycine and incident MACE were confirmed in an internal validation. No significant associations were found for TMA, choline, betaine and L-carnitine.

Conclusion

These findings suggest that renal function may be a key mediator in the association of plasma TMAO with the development of cardiovascular events after ACS. The present findings also support a role of dimethylglycine in the pathogenesis of MACE, which may be mediated, at least partially, by renal function.

Challenges of long-term dual antiplatelet therapy use following acute coronary syndromes

An acute coronary syndrome (ACS) event is associated with a high risk of recurrent ACS, stroke, and death. To ameliorate the risk of subsequent events, current guidelines for ST-segment elevation myocardial infarction and non-ST-segment elevation ACS recommend long-term management strategies for secondary prevention including risk factor modification and anti-ischemic and antiplatelet therapies. Dual antiplatelet therapy (DAPT), comprising aspirin plus a P2Y₁₂ inhibitor, is a critical component of secondary prevention therapy following ACS. However, despite the importance of DAPT for secondary prevention after ACS, questions remain over the optimal duration of therapy. Clinical evidence is emerging that maintenance DAPT >12 months lowers the risk of recurrent ACS events; however, this benefit must be considered against any potential risks of prolonged DAPT such as bleeding. Several tools for bleeding risk assessment have shown promise; however, their limited accuracy and discriminative power necessitates further development. Assessment of patient ischemic risk should consider the complexity of the percutaneous coronary intervention (PCI) procedure, anatomic burden of coronary artery disease, and additional underlying risk factors. Consequently, identifying patients in whom the risk:benefit ratio favors prolonged DAPT may prove invaluable for clinicians in deciding which patients should continue or stop taking DAPT at 12 months after PCI, or consider P2Y₁₂ inhibitor monotherapy as an option. This article reviews the most recent information about the risks and benefits of DAPT continued for >12 months after ACS and provides critical guidance to assist physicians in identifying patients most likely to benefit from a secondary prevention strategy with DAPT.

Ticagrelor vs. Clopidogrel in Acute Coronary Syndrome Patients With Chronic Kidney Disease After New-Generation Drug-Eluting Stent Implantation

Background: The impact of ticagrelor-based dual antiplatelet therapy (DAPT) on acute coronary syndrome (ACS) in patients with chronic kidney disease (CKD) remains unclear. Methods: Data on a total of 1,067 ACS patients with CKD including end-stage renal disease (ESRD) who underwent new-generation drug-eluting stent implantation were extracted from a multicenter registry. This study aimed to compare outcomes of patients treated with ticagrelor- (n = 449) and those treated with clopidogrel-based (n = 618) DAPT. Outcomes of interest included major adverse cardiac and cerebrovascular events (MACCEs) and bleeding (Bleeding Academic Research Consortium grade 3 or 5) at 12 months. Propensity-score matching (346 pairs) analysis was performed. Results: The patients with ESRD showed the highest MACCE and bleeding rates (P < 0.001). There was no difference in the rate of MACCEs between the treatment groups (7.8% vs. 8.4%; hazard ratio [HR] = 0.95, 95% confidence interval [CI] = 0.56-1.61, P = 0.855); however, a trend toward an increased bleeding rate was observed in the ticagrelor-based DAPT group (6.8% vs. 3.8%, HR = 1.84, 95% CI = 0.93-3.63, P = 0.079). Among patients with CKD stage III/IV but without ESRD (277 pairs), the ticagrelor-based DAPT group showed a reduced MACCE rate (3.6% vs. 8.7%, HR = 0.41, 95% CI = 0.19-0.86, P = 0.018) and a similar bleeding rate (5.1% vs. 3.2%, HR = 1.61, 95% CI = 0.70-3.71, P = 0.267), compared with those of the clopidogrel-based DAPT group. Conclusion: The effects of ticagrelor-based DAPT on ischemic and bleeding outcomes of ACS patients with CKD varied according to CKD stage; in ACS patients with CKD without ESRD, ticagrelor-based DAPT reduced MACCE risk without increasing bleeding risks, relative to those observed with clopidogrel-based DAPT.

Prognostic impact of iron deficiency in acute coronary syndromes

BACKGROUND

Iron deficiency (IDef) is a prevalent condition in patients with heart disease and in those with heart failure (HF). Evidence has shown that this deficit is associated with worse prognosis. Data in literature are scarce on the prognostic impact of IDef in acute coronary syndromes (ACS), which is the main objective of this study.

METHODS

Observational, retrospective study which included 817 patients admitted for ACS. Two groups were defined according to the presence (n=298) or absence of IDef (n=519) on admission. The clinical event under study was the occurrence of death or severe HF in the long term. Independent predictors of prognosis were determined with logistic regression analysis.

RESULTS

Thirty-six percent of patients had IDef. There was higher mortality (p=0.004), higher incidence of HF (p=0.011) during follow-up and a higher rate of hospital readmissions (p=0.048) in this group. IDef was an independent predictor of death or severe HF in follow-up, along with anemia, left ventricular dysfunction, renal dysfunction and the absence of revascularization. IDef also enabled us to further stratify the prognosis of patients without anemia based on the occurrence of death or severe HF and those with lower Killip classes (≤2) based on the occurrence of death.

CONCLUSION

IDef was an independent predictor of death or severe HF in patients admitted with ACS and enabled additional stratification for those without anemia on admission and in those with Killip classes ≤2.

High-Sensitivity Troponin for Suspected Acute Coronary Syndrome in Patients With Chronic Kidney Disease Versus Patients Without Chronic Kidney Disease

BACKGROUND

Heart disease is the leading cause of death in the United States. Patients with acute coronary syndrome (ACS) who have chronic kidney disease (CKD) have a twofold increase in mortality compared to patients with normal kidney function. Patients with CKD tend to have elevated baseline high-sensitivity cardiac troponin-T (hs-cTnT) levels. We studied patients with or without CKD to find out if a higher baseline hs-cTnT influenced the change in hs-cTnT (delta) when ruling in or ruling out ACS.

METHODS

Eighty-nine patients were included in this study (29 with CKD; 60 without CKD). Delta hs-cTnT was dichotomized based on those who had delta of ≥ 5, or < 5. We calculated the positive predictive values, negative predictive values, sensitivities and specificities. Shapiro-Wilk test and independent t-test were used for the continuous variables. Mann-Whitney U test was used to examine the variables between the two groups. Chi-square test was used to compare the categorical variables between the two groups.

RESULTS

The mean ages of patients with CKD and without CKD were 61.2 and 58.9 years, respectively (P = 0.508). We found that although there were differences in the sensitivities, specificities, positive predictive values and negative predictive values of delta hs-cTnT > 5 for ACS between the patients with CKD and without CKD, the differences were not statistically significant. Subgroup analysis showed that in patients with CKD, the positive predictive values and sensitivities of delta hs-cTnT > 5 for CAD requiring percutaneous coronary intervention (PCI) and stent were significantly higher compared to the patients without CKD (82.4% vs. 27.3%, and 82.4% vs. 40.0%, respectively) (P < 0.05).

CONCLUSIONS

In calculating delta hs-cTnT to rule in or rule out ACS, the presence of CKD does not influence the delta. Patients with CKD and a delta hs-cTnT > 5 have significantly higher risk of undergoing PCI.

Prognostic impact of iron deficiency in acute coronary syndromes

BACKGROUND

Iron deficiency (IDef) is a prevalent condition in patients with heart disease and in those with heart failure (HF). Evidence has shown that this deficit is associated with a worse prognosis. There is only a small amount of data in the literature regarding the prognostic impact of IDef in acute coronary syndromes (ACS), which is the main objective of this study.

METHODS

Observational, retrospective study which included 817 patients admitted for ACS. Two groups were defined according to the presence (n = 298) or absence of IDeF (n = 519) on admission. The clinical event under study was the occurrence of death or severe HF in long term. Independent predictors of prognosis were determined with logistic regression analysis.

RESULTS

36% of patients had IDef. These patients had a higher mortality rate (p = 0.004), higher incidence of HF (p = 0.011) during follow-up and a higher rate of hospital readmissions (p = 0.048). IDef was an independent predictor of death or severe HF in follow-up, along with anemia, left ventricular dysfunction, renal dysfunction and the absence of revascularization. Besides, IDef also enabled us to further stratify the prognosis of patients without anemia based on the occurrence of death or severe HF and those with lower Killip classes (≤2) based on the occurrence of death.

CONCLUSION

IDef was an independent predictor of death or severe HF in patients admitted with ACS and enabled additional stratification for those without anemia on admission and in those with Killip classes ≤2.

P2Y12 Antiplatelet Choice for Patients with Chronic Kidney Disease and Acute Coronary Syndrome: A Systematic Review and Meta-Analysis

This study aims to evaluate potentially appropriate antiplatelet therapy in patients with chronic kidney disease. A systematic analysis was conducted to identify the clinical outcomes of available antiplatelet therapy regimens with enhanced platelet inhibition activity (intervention of 5 regimens) over the standard dose of clopidogrel-based dual antiplatelet therapy in patients with renal insufficiency. An electronic keyword search was performed on Pubmed, Embase, and Cochrane Library per PRISMA guidelines. We performed a prespecified net clinical benefit analysis (a composite of the rates of all-cause or cardiac-related death, myocardial infarction, major adverse cardiac outcomes, and minor and major bleeding), and included 12 studies. The intervention substantially lowered the incidence of all-cause mortality (RR 0.67; p = 0.003), major adverse cardiac outcomes (RR 0.79; p < 0.00001), and myocardial infarction (RR 0.28; p = 0.00007) without major bleeding (RR 1.14; p = 0.33) in patients with renal insufficiency, but no significant differences were noticed with cardiac-related mortality and stent thrombosis. The subgroup analysis revealed substantially elevated bleeding risk in patients with severe renal insufficiency or on hemodialysis (RR 1.68; p = 0.002). Our study confirmed that the intervention considerably enhances clinical outcomes in patients with renal insufficiency, however, a standard dose of clopidogrel-based antiplatelet therapy is favorable in patients with severe renal insufficiency.

Impact of renal function on patients with acute coronary syndromes: 15,593 patient-years study

Introduction

Coexistence of chronic kidney disease (CKD) in the case of acute coronary syndromes (ACS) significantly worsens the outcomes.

Aim

The aim of our study was to assess renal function impact on mortality among patients with ACS.

Materials and methods

The study was based on records of 21,985 patients hospitalized in the Medical University of Bialystok in 2009–2015. Inclusion criteria were ACS. Exclusion criteria were: death within 24 h of admission, eGFR <15 ml/min/1.73 m², hemodialysis. Mean observation time was 2296 days.

Results

Criteria were met by 2213 patients. CKD occurred in 24.1% (N = 533) and more often affected those with NSTEMI (26.2 (337) vs. 21.2 (196), p = .006). STEMI patients had higher incidence of post-contrast acute kidney injury (PC-AKI) (5 (46) vs. 4.1 (53), p < .001). During the study, 705 people died (31.9%), more often with NSTEMI (33.2% (428) vs. 29.95% (277), p < .001). However, from a group of patients suffering from PC-AKI 57.6% died. The risk of PC-AKI increased with creatinine concentration (RR: 2.990, 95%CI: 1.567–5.721, p < .001), occurrence of diabetes mellitus (RR: 2.143, 95%CI: 1.029–4.463, p = .042), atrial fibrillation (RR: 2.289, 95%CI: 1.056–4.959, p = .036). Risk of death was greater with an increase in postprocedural creatinine concentration (RR: 2.254, 95%CI: 1.481–3.424, p < .001).

Conclusion

PC-AKI is a major complication in patients with ACS, occurs more frequently in STEMI and may be a prognostic marker of long-term mortality in patients undergoing percutaneous coronary intervention (PCI). More attention should be given to the prevention and diagnosis of PC-AKI but necessary PCI should not be withheld in fear of PC-AKI.

Differential Impact of the Renal Resistive Index on Future Cardiovascular Events in Hospitalized Atherosclerotic Cardiovascular Patients According to Left Ventricular Ejection Fraction - The Jichi Vascular Hemodynamics in Hospitalized Cardiovascular Patients (J-VAS) Study

BACKGROUND

Determinants of poor outcome in atherosclerotic cardiovascular disease (ASCVD) according to left ventricular ejection fraction (LVEF) are unclear. The renal resistive index (RRI) correlates well with atherosclerotic vascular damage, which, in turn, is correlated with cardiovascular outcomes. This study investigated whether high RRI is associated with poor cardiovascular outcomes in ASCVD patients classified by LVEF.

METHODS AND RESULTS

Records of 1,598 acute coronary syndromes (ACS) and acute decompensated heart failure (ADHF) patients, categorized into preserved (p), mid-range (mr), and reduced (r) ejection fraction (EF) groups (EF ≥50% [n=1,130], 40-50% [n=223], and <40% [n=245], respectively), were analyzed retrospectively. The primary endpoint was any cardiovascular-related event: fatal and non-fatal ACS, ADHF, stroke, and sudden cardiac death. Over 1.9-years follow-up (3,030 person-years), 233 events occurred: 122, 37, and 74 in the pEF, mrEF, and rEF groups, respectively. Adjusted Cox regression analysis revealed RRI ≥0.8 was associated with the primary endpoint in the pEF group (hazard ratio [HR] 1.67; 95% confidence interval [CI] 1.09-2.56), but not in the mrEF or rEF groups. The primary endpoint risk of pEF patients with an RRI ≥0.8 was comparable to that of mrEF patients using the pEF+RRI <0.8 group as the reference (HR 1.89 [95% CI 1.26-2.83] and 1.77 [95% CI 1.19-2.63], respectively).

CONCLUSIONS

RRI was associated with the risk of cardiovascular events in ASCVD patients with pEF.

Acute Coronary Syndromes in Chronic Kidney Disease: Clinical and Therapeutic Characteristics

Background and Objectives: This study evaluated the clinical characteristics of the acute coronary syndromes (ACS) in chronic kidney disease (CKD) patients and established prognostic values of the biomarkers and echocardiography. Materials and Methods: 273 patients admitted to the cardiology department of the Clinical County Emergency Hospital of Oradea, Romania, with ACS diagnosis were studied. Two study groups were formed according to the presence of CKD (137 patients with ACS + CKD and 136 with ACS without CKD). Kidney Disease: Improving Global Outcomes (KDIGO) threshold was used to assess the stages of CKD. Results: Data regarding the medical history, laboratory findings, biomarkers, echocardiography, and coronary angiography were analysed for both groups. ACS parameters were represented by ST-segment elevation myocardial infarction (STEMI), which revealed a greater incidence in subjects without CKD (43.88%); non-ST-segment elevation myocardial infarction (NSTEMI), characteristic for the CKD group (28.47%, with statistically significance p = 0.04); unstable angina and myocardial infarction with nonobstructive coronary arteries (MINOCA). Diabetes mellitus, chronic heart failure, previous stroke, and chronic coronary syndrome were more prevalent in the ACS + CKD group (56.93%, p < 0.01; 41.61%, p < 0.01; 18.25%, p < 0.01; 45.26%, p < 0.01). N-terminal pro b-type natriuretic peptide (NT-proBNP) was statistically higher (p < 0.01) in patients with CKD; Killip class 3 was evidenced more frequently in the same group (p < 0.01). Single-vessel coronary artery disease (CAD) was statistically more frequent in the ACS without CKD group (29.41%, p < 0.01) and three-vessel CAD or left main coronary artery disease (LMCA) were found more often in the ACS + CKD group (27.01%, 14.6%). Conclusions: Extension of the CAD in CKD subjects revealed an increased prevalence of the proximal CAD, and the involvement of various coronary arteries is characteristic in these patients. Biomarkers and echocardiographic elements can outline the evolution and outcomes of ACS in CKD patients.

An Atypical Clinical Manifestation of a Hump-Nosed Pit Viper Envenomation

Envenomations by hump-nosed pit vipers (HNVs) are frequent in Sri Lanka and in South India. Until recently, HNV was considered a moderately venomous snake. Here, we report a case of a previously healthy female developing all the known serious complications, plus some previously unreported complications following a HNV envenomation. She had muscarinic symptoms like profuse sweating and salivation within a couple of minutes and a seizure several minutes after envenomation. Her acute kidney injury (AKI) was swift onset and progressed to end-stage renal failure at three months. She had mild parotid swelling, crepitations in her lungs, and edema of the bitten leg. She had evidence of microangiopathic hemolytic anemia and hemolytic uremic syndrome as well. She developed local tissue necrosis, a non-ST-elevation myocardial infarction (non-STEMI), and anterior ischemic optic neuropathy (AION) following the envenomation. We believe the best explanation for her swift onset complication is intravascular injection of venom. We believe ischemia due to thrombotic microangiopathy has contributed to local tissue necrosis. Those ischemia and kidney failure have contributed to non-STEMI and AION. We illustrate the issue of the sluggish progress made by medicine in understanding the complications of envenomation by using HNV as an example.

Consensus Document ANMCO/ANCE/ARCA/GICR-IACPR/GISE/SICOA: Long-term Antiplatelet Therapy in Patients with Coronary Artery Disease

Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 receptor inhibitor is the cornerstone of pharmacologic management of patients with acute coronary syndrome (ACS) and/or those receiving coronary stents. Long-term (>1 year) DAPT may further reduce the risk of stent thrombosis after a percutaneous coronary intervention (PCI) and may decrease the occurrence of non-stent-related ischaemic events in patients with ACS. Nevertheless, compared with aspirin alone, extended use of aspirin plus a P2Y12 receptor inhibitor may increase the risk of bleeding events that have been strongly linked to adverse outcomes including recurrent ischaemia, repeat hospitalisation and death. In the past years, multiple randomised trials have been published comparing the duration of DAPT after PCI and in ACS patients, investigating either a shorter or prolonged DAPT regimen. Although the current European Society of Cardiology guidelines provide a backup to individualised treatment, it appears to be difficult to identify the ideal patient profile which could safely reduce or prolong the DAPT duration in daily clinical practice. The aim of this consensus document is to review contemporary literature on optimal DAPT duration, and to guide clinicians in tailoring antiplatelet strategies in patients undergoing PCI or presenting with ACS.

Disparities in the Estimation of Glomerular Filtration Rate According to Cockcroft-Gault, Modification of Diet in Renal Disease-4, and Chronic Kidney Disease Epidemiology Collaboration Equations and Relation With Outcomes in Patients With Acute Coronary Syndrome

BACKGROUND

A simple method to assess renal function is the estimated glomerular filtration rate, and it shows prognostic implications. However, it remains unknown which equation should be used in patients with acute coronary syndrome. We compared the ability and correlation of the Cockcroft-Gault, Modification of Diet in Renal Disease-4 (MDRD-4), and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations and their predictive performance for major adverse cardiovascular events, all-cause mortality, and major bleeding in a cohort of patients with acute coronary syndrome.

METHODS AND RESULTS

Multicenter prospective registry involving 1699 consecutive patients with acute coronary syndrome from 3 tertiary institutions. At entry, renal function was assessed using the Cockcroft-Gault, MDRD-4, and CKD-EPI-creatinine equations. During 12 months of follow-up, we recorded all major adverse cardiovascular events (composite of cardiovascular death, nonfatal myocardial infarction, and nonfatal ischemic stroke), bleeding events (Bleeding Academic Research Consortium classification), and all-cause mortality. Receiver operating characteristic curve comparisons demonstrated that Cockcroft-Gault equation had higher predictive ability compared with MDRD-4 equation for major adverse cardiovascular events (0.651 versus 0.616; P=0.023), major bleeding (0.600 versus 0.551; P=0.005), and all-cause mortality (0.754 versus 0.717; P=0.033), as well as higher predictive ability compared with CKD-EPI equation for major bleeding (0.600 versus 0.564; P=0.018). Integrated discrimination improvement and net reclassification improvement analyses showed superior discrimination and reclassification of Cockcroft-Gault equation. Decision curve analyses graphically demonstrated higher net benefit and clinical usefulness of the Cockcroft-Gault equation in comparison with MDRD-4 and CKD-EPI equations.

CONCLUSIONS

In patients with acute coronary syndrome, the Cockcroft-Gault equation presented superior predictive ability for major adverse cardiovascular events, major bleeding, and all-cause mortality compared with MDRD-4 equation, and superior predictive ability for major bleeding compared with CKD-EPI equation. The Cockcroft-Gault equation also showed higher net benefit and clinical usefulness.

Percutaneous Coronary Intervention Versus Optimal Medical Therapy for Stable Angina in Advanced CKD: A Decision Analysis

BACKGROUND

Percutaneous coronary intervention (PCI) use is low in the setting of stable symptomatic angina in individuals with advanced chronic kidney disease (CKD) despite high cardiovascular risk in this population, and PCI is frequently deferred out of concern for precipitating dialysis therapy. Whether this is appropriate is uncertain, and patient-centered data comparing the relative risks and benefits of continued medical therapy versus PCI in patients with advanced CKD and stable angina are scarce.

STUDY DESIGN

Decision analysis.

SETTING & POPULATION

Hypothetical cohort of individuals with advanced CKD (stages 4-5 with estimated glomerular filtration rates ≤ 20mL/min/1.73m2) and stable angina.

MODEL, PERSPECTIVE, & TIMELINE

A Markov model with a Monte Carlo simulation through 12 cycles, that is, 3 years of 3-month intervals, with 10,000 microsimulations predicted mean quality-adjusted life-years.

INTERVENTION

PCI first, medical management, or dialysis (hemodialysis [HD]) followed by PCI.

OUTCOMES

Outcomes modeled were progression to HD therapy (for those not assigned to the preemptive HD strategy), catheter infection, and death.

RESULTS

Our analysis showed mean quality-adjusted life-years of 1.103 ± 0.69 for PCI first, 1.088±0.70 for medical management, and 0.670±0.58 for HD followed by PCI. Probabilistic sensitivity analysis found PCI as the preferred strategy > 60% of the time.

LIMITATIONS

Values for probabilities and utilities were estimated and/or derived from multiple sources that were not uniform in their populations in terms of age, comorbid condition burden, and degree of kidney failure, and several simplifying assumptions were made.

CONCLUSIONS

Our analysis demonstrates that quality-adjusted life expectancy is similar for the PCI first and medical management strategies in patients with advanced CKD with stable angina and that the decision depends on patient preferences other than those incorporated in our model. Both strategies are superior to preemptive dialysis.

Prevalence and Significance of Unrecognized Renal Dysfunction in Patients with Acute Coronary Syndrome

BACKGROUND

Unrecognized renal insufficiency, defined as estimated glomerular filtration rate <60 mL/min/1.73 m(2) in the presence of normal serum creatinine, is common among patients with acute coronary syndrome. We aimed to determine the prevalence and clinical significance of unrecognized renal insufficiency in a large unselected population of patients with acute coronary syndrome.

METHODS

The study population consisted of patients with acute coronary syndrome included in the Acute Coronary Syndrome Israeli biennial Surveys during 2000-2013. The estimated glomerular filtration rate was calculated using the simplified Modification of Diet in Renal Disease formula. Patients were stratified into 3 groups: 1) normal renal function (estimated glomerular filtration rates ≥60 mL/min/1/73 m(2)); 2) unrecognized renal insufficiency (estimated glomerular filtration rates <60 mL/min/1/73 m(2) with serum creatinine ≤1.2 mg/dL); and 3) recognized renal insufficiency (estimated glomerular filtration rates <60 mL/min/1/73 m(2) with serum creatinine ≥1.2 mg/dL). The primary endpoint was all-cause mortality at 1 year.

RESULTS

Included in the study were 12,830 acute coronary syndrome patients. Unrecognized renal insufficiency was present in 2536 (19.8%). Patients with unrecognized renal insufficiency were older and more frequently females. All-cause mortality rates at 1 year were highest among patients with recognized renal insufficiency, followed by patients with unrecognized renal insufficiency, with the lowest mortality rates observed in patients with normal renal function (19.4%, 9.9%, and 3.3%, respectively, P <.0001). Despite their increased risk, patients with renal insufficiency were less frequently referred for coronary angiography and were less commonly treated with guideline-based cardiovascular medications.

CONCLUSIONS

Acute coronary syndrome patients with unrecognized renal insufficiency should be considered as a high-risk population. The question of whether this group would benefit from a more aggressive therapeutic approach should still be evaluated.

Understanding and Managing Atrial Fibrillation in Patients with Kidney Disease

Chronic kidney disease (CKD) is on the rise due to the increased rate of related comorbidities such as diabetes and hypertension. Patients with CKD are at higher risk of cardiovascular events and atrial fibrillation is more common in this patient population. It is estimated that the prevalence of chronic atrial fibrillation in patients with CKD is two to three times higher than general population. Furthermore, patients with CKD are less likely to stay in sinus rhythm. Atrial fibrillation presents a major burden in this population due to difficult treatment decisions in the setting of a lack of evidence from randomized clinical trials. Patients with CKD have higher risk of stroke with more than half having a CHADS2 score ≥ 2. Anticoagulation have been shown to significantly decrease embolic stroke risk, however bleeding complications such as hemorrhagic stroke is twofold higher with warfarin. Although newer novel anticoagulation drugs have shown promise with lower intracranial hemorrhage risk in comparison to warfarin, lack clinical trial data in CKD and the unavailability of an antidote remains an issue. In this review, we discuss the treatment options available including anticoagulation and the evidence behind them in patients with chronic kidney disease suffering from atrial fibrillation.

Adding flexible temporal constraints to identify chronic comorbid conditions in ambulatory claims data

Chronic comorbid conditions are important predictors of primary care outcomes, provide context for clinical decisions, and are potential complications of diseases and treatments. Comorbidity indices and multimorbidity categorization strategies based on administrative claims data enumerate diagnostic codes in easily modifiable lists, but usually have inflexible temporal requirements, such as requiring two claims greater than 30 days apart, or three claims in three quarters. Table structures and claims data search algorithms were developed to support flexible temporal constraints. Tables of disease categories allow subgroups with different numbers of events, different times between similar claims, variable periods of interest, and specified diagnostic code substitutability. The strategy was tested on five years of private insurance claims from 2.2 million working age adults. The contrast between rarely recorded, high prevalence diagnoses (smoking and obesity) and frequently recorded but not necessarily chronic diagnoses (musculoskeletal complaints) demonstrated the advantage of flexible temporal criteria.

Elevated Homocysteine and the Risk of Contrast-Induced Nephropathy

Contrast-induced nephropathy (CIN) is a common complication in patients with impaired kidney function undergoing coronary angiography/angioplasty. We evaluated whether elevated homocysteine (known to be associated with free radical generation and oxidative stress) increases the risk of CIN. Patients (n = 876) with creatinine clearance <60 mL/min undergoing coronary angiography or percutaneous coronary intervention (PCI) were divided into tertiles of homocysteine levels. Contrast-induced nephropathy was defined as ≥0.5 mg/dL or ≥25% creatinine increase 24 to 48 hours post-PCI. A significant relationship was observed between homocysteine levels and the risk of CIN ( P = .033), confirmed after correction for baseline confounding factors, adjusted odds ratio, OR (95% confidence interval, [CI]) = 1.68 (1.09-2.59), P = .019. This association was also significant applying the new definition of contrast-induced acute kidney injury (11.9% in group 1, 10.4% in group 2, and 22.8% in group 3; P < .001), adjusted OR (95% CI) = 1.96 (1.3-2.95), P = .001. Future studies are needed to confirm our findings and to define the role of homocysteine in CIN.

Treatment of non-ST-elevation myocardial infarction and ST-elevation myocardial infarction in patients with chronic kidney disease

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).

Management of atrial fibrillation in chronic kidney disease: double trouble

Chronic kidney disease (CKD) has a very well-established link with cardiovascular disease. Below stage 3 CKD (glomerular filtration rate <60 mL/min), there is a progressive increase in both total mortality and cardiovascular-specific mortality as kidney function declines; indeed, it is more likely for a patient with CKD stage 3 to die of cardiovascular disease than to progress to CKD stage 4 and beyond. Arrhythmia is particularly common in patients with CKD. Depending on the study and measurement used, the prevalence of patients with CKD with chronic atrial fibrillation (AF) is quoted at 7% to 18%, rising to 12% to 25% for those older than 70 years. These rates are up to 2 to 3 times higher than in the general population. Of all patients with AF, 10% to 15% will have CKD. However, not all standard rate and rhythm methods are suitable for this population and those that are tend to be less effective. Meanwhile, anticoagulation has long been a thorny subject, with much conflicting evidence around the balance between bleeding and stroke risk. To help clarify this, we first highlight the challenges of performing evidence-based medicine in the patient with renal disease, and then review recent and emerging research to suggest an approach to the management of patients with renal disease who have AF. We also review the potential role of the different new oral anticoagulant drugs in CKD.