Unstable angina / non ST elevation myocardial infarction chronic kidney disease

Overview of Chronic Kidney Disease in UA / NSTEMI

 * 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.
 * There is limited evidence available on the management of UA/NSTEMI in this group due to their underrepresentaion in randomized trials. But 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 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 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 1year 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.

==ACC / AHA Guidelines (DO NOT EDIT) == {{cquote|

Class I
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. (Level of Evidence: B)

2. Patients undergoing cardiac catheterization with receipt of contrast media should receive adequate preparatory hydration. (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. (Level of Evidence: B)

Class II
1. An invasive strategy is reasonable in patients with mild (stage II) and moderate (stage III) chronic kidney disease. (Level of Evidence: B) (There are insufficient data on benefit/risk of invasive strategy in UA / NSTEMI patients with advanced chronic kidney disease [stages IV, V].)}}