The American Journal of Medicine
Volume 119, Issue 3 , Pages 248-254, March 2006

Chronic Kidney Disease in Patients with Non–ST-Segment Elevation Acute Coronary Syndromes

  • Jin H. Han, MD

      Affiliations

    • Department of Emergency Medicine, University of Cincinnati School of Medicine, Cincinnati, Ohio
    • Corresponding Author InformationRequests for reprints should be addressed to Jin H. Han, MD, Vanderbilt University Medical Center, Department of Emergency Medicine, 703 Oxford House, Nashville, TN 37232.
    • ,
  • Abhinav Chandra, MD

      Affiliations

    • Department of Emergency Medicine, Duke University Medical Center, Durham, NC
    • ,
  • Jyotsna Mulgund, MS

      Affiliations

    • Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
    • ,
  • Matthew T. Roe, MD, MHS

      Affiliations

    • Division of Cardiology, Duke University Medical Center, Durham, NC
    • Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
    • ,
  • Eric D. Peterson, MD, MPH

      Affiliations

    • Division of Cardiology, Duke University Medical Center, Durham, NC
    • Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
    • ,
  • Lynda A. Szczech, MD

      Affiliations

    • Division of Nephrology, Duke University Medical Center, Durham, NC
    • Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
    • ,
  • Uptal Patel, MD

      Affiliations

    • Division of Nephrology, Duke University Medical Center, Durham, NC
    • Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
    • ,
  • E. Magnus Ohman, MD

      Affiliations

    • University of North Carolina School of Medicine, Chapel Hill, NC
    • ,
  • Christopher J. Lindsell, PhD

      Affiliations

    • Institute of Health Policy and Health Services Research, University of Cincinnati School of Medicine, Cincinnati, Ohio
    • ,
  • W. Brian Gibler, MD

      Affiliations

    • Department of Emergency Medicine, University of Cincinnati School of Medicine, Cincinnati, Ohio

Received 1 January 2005; received in revised form 22 August 2005; accepted 22 August 2005.

Abstract 

Purpose

Chronic kidney disease has been linked to high mortality rates in patients with ST-segment elevation myocardial infarction but has not been well described for patients with non–ST-segment elevation acute coronary syndromes. We examined the treatment and outcomes of patients with both non–ST-segment elevation acute coronary syndromes and moderate to severe chronic kidney disease.

Subjects and Methods

We evaluated 45343 patients with non–ST-segment elevation acute coronary syndromes enrolled in the CRUSADE Quality Improvement Initiative and compared treatments and outcomes in patients with and without moderate to severe chronic kidney disease.

Results

Patients presenting with moderate to severe chronic kidney disease (n = 6560) were older, more often diabetic, and more likely to present with signs of congestive heart failure. Adherence to Class IA/IB guidelines recommendations was lower in patients with moderate to severe chronic kidney disease, who were significantly less likely to be treated with medications, undergo invasive cardiac procedures, and be given discharge counseling. Moderate to severe chronic kidney disease was associated with a 50% increased risk of mortality and a 70% increased likelihood of transfusion. Despite having a higher risk of adverse outcomes, patients with moderate to severe chronic kidney disease were treated less aggressively than patients with normal renal function.

Conclusions

These findings suggest that, in patients with moderate to severe chronic kidney disease, safety concerns about adverse outcomes and the absence of trial data for this population may limit the use of guidelines-recommended therapies and interventions for non–ST-segment elevation acute coronary syndromes. The decreased use of discharge counseling in patients with moderate to severe chronic kidney disease and non–ST-segment elevation acute coronary syndromes may represent therapeutic nihilism.

Keywords:  Chronic kidney disease , Acute coronary syndromes , Quality improvement , Guidelines

 

 CRUSADE is funded by Millennium Pharmaceuticals, Inc., Cambridge, MA, and Schering Corporation, Kenilworth, NJ. Bristol-Myers Squibb (Plainsboro, NJ)/Sanofi Pharmaceuticals (New York, NY) Partnership provides additional funding support.

PII: S0002-9343(06)00003-9

doi:10.1016/j.amjmed.2005.08.057

The American Journal of Medicine
Volume 119, Issue 3 , Pages 248-254, March 2006

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