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Management of
Acute Coronary Syndrome in
Chronic Kidney Disease
Dafsah Arifa Juzar
Indonesian Heart Association
Harapan Kita, Jakarta, Indonesian


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Background
Diagnostic
Reperfusion
Antiplatelets & Anticoagulant
Betablocker
RAAS inhibitor


Background
• The incidence of AMI is increased in this vulnerable subgroup
• Atypical clinical presentation of AMI may be more frequent
• ECG changes that may mimic or obscure AMI
• Left ventricular hypertrophy is common

• patients with renal dysfunction are more prone to adverse events
• Cardiovasscular medication : antiplatelets & anticoagulation,

• Cardiovascular procedures : coronary
• Relative lack of evidence and potential for uncertainty in selecting
medications


Clinical Presentation of ACS Among
CKD Patients

Szummer K et al. J Intern Med. 2010;268:40–49.


Unique pathobiology of CKD
• greater luminal encroachment and
• higher plaque burden
• greater necrotic core and dense calcium with less
fibrous tissue
• modulate coronary atherosclerotic plaque
composition to a less stable phenotype
– Metalloproteinases are elevated
– potentiates foam cell generation by enhancing
macrophage entry

• accelerated infarct expansion in association with
enhanced inflammation and oxidative stress,
Baber U, etal. . JACC Cardiovasc Imaging. 2012;5:S53–S61.
Ponda MP etal. . Atherosclerosis. 2010;210:57–62.
Naito K, Anzai, etal.. J Card Fail. 2008;
Pelisek J, etal. P. J Vasc Surg. 2011

Prone to adverse event

Gibson CM, etal. Eur Heart J. 2004;25:1998–2005.


Age adjusted Hazard Ratio for death from any
cause CV event & Hospitalization
1,200,295 ambulatory adults

Go AS et al. N Engl J Med. 2004;351:1296–1305


Conservative (C) VS Invasive (I)
protocol defined bleeding TACTIC TIMI IB

Januzzi J, etal. Am J Cardiol. 2002 Dec 1;90(11):1246-9.


Relevance CKD in ACS
• underutilization of known cardio-protective
therapies,
• less aggressive treatment,
• more frequent errors in dosing with excess
toxicity from conventional therapies


Diagnostic
Cardiac biomarker

Cardiac Biomarker in CKD
NPV 0hr/1hr algorithm

Stratification by Troponin

EGFR < 60 98,8%
EGFR > 60 99,2%

Mueller C, etal. Ann Emerg Med. 2016;68:76-87
Gibson CM, etal. Eur Heart J. 2004;25:1998–2005
.


Reperfusion Strategy


Crude rates and adjusted odds ratios for death
by CKD stages stages.

Caroline S. Fox et al. Circulation. 2010;121:357-365


Early PCI in AMI

Huang HD et al International journal of cardiology. 2013;168:3741-6


Incidence of adverse outcome & 6 mo
death stratified by renal function

GFR > 60 ml/mnt/1.73m2
GFR 30-59 ml/mnt/1.73m2

GFR < 30 ml/mnt/1.73m2

Medi C, J Am Coll Cardiol Intv. 2009;2(1):26-33.


STEMI reperfusion vs. non reperfusion
by renal function
GRACE registry data

Medi C, J Am Coll Cardiol Intv. 2009;2(1):26-33.


Incidence of Stroke and major bleeding

Medi C, J Am Coll Cardiol Intv. 2009;2(1):26-33.


PCI
Early revascularization
• associated with reduced
mortality in ACS patients
with CKD, including those
with severe CKD or
receiving dialysis

PCI – Risk of contrast

Huang HD et al.. 2013;168:3741-6


*Plans should be made in case CI-AKI occurs
and dialysis is required.
**IV isotonic crystalloid 3 ml/kg/h for 1 h
before.
Initial LVEDP-guided crystalloid:
<13 mmHg
: 5 ml/kg/h x 4h
13 to 18mmHg
: 3 ml/kg/h x 4h
>18 mm Hg
: 1.5 ml/kg/h x 4h

Renal damage markers: IGFBP-7*TIMP2
(NephroCheck), NGAL, L-FABP.


Pharmacotherapy for ACS
Among Patients With CKD


Aspirin
• There is no increased bleeding risk with
aspirin therapy among patients receiving
hemodialysis

• The available data suggest that aspirin
therapy is safe and effective in ACS patients

with CKD and should be used in these patients
to reduce the risk of death and vascular
events
Ethier J. et al. Aspirin prescription and outcomes in hemodialysis patients: the Dialysis Outcomes and
Practice Patterns Study (DOPPS). Am J Kidney Dis. 2007;50:602–611


Clopidogrel vs Placebo

The GUSTO severe bleeding is nonsignificantly higher with clopidogrel than placebo

Dasgupta A et al.


Ticagrelor vs Clopidogrel
Creatinine Clearance vs Major Bleeding

Creatinine Clearance vs Primary Outcome

James S 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;122:1056–1067


Prasugrel vs Clopidogrel

Wiviott SD et al. TRITON-TIMI 38 Investigators. Prasugrel versus clopidogrel in patients with acute
coronary syndromes. N Engl J Med. 2007;357:2001–2015


The glycoprotein (GP) IIb/IIIa receptor

antagonists
• The use of GP IIb/IIIa receptor antagonists in CKD patients with
ACS indicate a reduction in ischemic events but overall increase
in the risk of bleeding events
Melloni C et al. Safety and efficacy of adjusted-dose eptifibatide in patients with acute coronary syndromes
and reduced renal function. Am Heart J.2011;162:884–892

• Eptifibatide and tirofiban can be considered as a treatment
strategy in CKD patients presenting with ACS within follow
dosing recommendations