March 05, 2015
By Reuters Staff
NEW YORK (Reuters Health) - Patients with acute coronary syndrome (ACS) and chronic kidney disease (CKD) benefit from the same evidence-based medications used routinely in their peers without kidney disease, although some adjustments are needed to provide the greatest benefit while limiting the chance for harm, the American Heart Association (AHA) says in a scientific statement.
These include careful assessment of renal function and use of a validated equation to appropriately adjust the dose of medications; avoiding medications that are contraindicated in patients with stage 4 and 5 CKD; and avoiding or limiting the use of "emerging" medications that have not been formally studied in the CKD population, the AHA says.
Patients who present with ACS often have CKD, which has been linked to worse outcomes, Dr. Jeffrey Washam, of the Duke Heart Center in Durham, North Carolina, and colleagues note in the statement, published online February 23 in Circulation.
"Despite the increased risk for adverse outcomes, CKD patients presenting with ACS are less likely to receive evidence-based therapies, including medications," they point out. "In addition, patients with CKD have been under represented in randomized controlled trials of ACS pharmacotherapy."
As a result, there is a relative lack of evidence and "potential for uncertainty" in selecting medications in this high-risk population.
The new statement provides a comprehensive review of available studies and provides recommendations for pharmacotherapy by medication class for ACS patients with CKD.
Based on the existing evidence, the AHA provides the following recommendations for patients with CKD who present with ACS:
*Consider using fibrinolytic therapy for ST-segement-elevation MI (STEMI) patients presenting within 12 hours of symptom onset when primary percutaneous coronary intervention (PCI) is not available; know that rates of intracerebral hemorrhage (ICH) were higher in CKD patients receiving fibrinolytics than in non-CKD patients.
*Consider oral P2Y12 inhibitors. Data from controlled trials of newer agents (prasugrel and ticagrelor) suggest these agents should be considered in CKD patients not requiring dialysis.
*Consider using glycoprotein IIb/IIIa receptor antagonist therapy, within the context of labeled dosing modifications and exclusions for each agent; note that the data also suggest an increased rate of bleeding in patients with CKD.
*Consider using anticoagulant therapy; note that the data support consideration for fondaparinux and bivalirudin as strategies with lower rates of bleeding in patients with stage 3 and 4 CKD (relatively few patients with stage 4 CKD were included in the randomized trials evaluating these agents). Relevant labeled dosing modifications and contraindications should be considered for each agent.
*Consider beta-blocker therapy in patients who do not have a contraindication.
*Consider angiotensin-converting enzyme (ACE) inhibitor or angiotensin-receptor blocker (ARB) therapy in CKD patients with ACS and left ventricular (LV) dysfunction. Closely monitor potassium and serum creatinine (SCr).
*Based on "limited data" consider aldosterone blocker therapy in patients with post-myocardial infarction LV dysfunction (with either diabetes mellitus or heart failure signs or symptoms) and baseline SCr 2.5 mg/dL and serum potassium <5.0 mmol/L. Serum potassium should be monitored closely.
*Consider statin therapy.
The AHA says, "moving forward, inclusion and better representation of patients with CKD in randomized clinical trials will be necessary to accurately assess the risks and benefits of medications in this population."
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