Unstable angina / non ST elevation myocardial infarction chronic kidney disease: Difference between revisions
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Esther Lee (talk | contribs) (/* ACC / AHA Guidelines (DO NOT EDIT) {{cite journal |author=Wright RS, Anderson JL, Adams CD, Bridges CR, Casey DE, Ettinger SM, Fesmire FM, Ganiats TG, Jneid H, Lincoff AM, Peterson ED, Philippides GJ, Theroux P, Wenger NK, Zidar JP |title=2011 ...) |
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==ACC / AHA Guidelines (DO NOT EDIT) <ref name="pmid21444889">{{cite journal |author=Wright RS, Anderson JL, Adams CD, Bridges CR, Casey DE, Ettinger SM, Fesmire FM, Ganiats TG, Jneid H, Lincoff AM, Peterson ED, Philippides GJ, Theroux P, Wenger NK, Zidar JP |title=2011 ACCF/AHA Focused Update of the Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction (Updating the 2007 Guideline): A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines |journal=[[Circulation]] |volume= |issue= |pages= |year=2011 |month=March |pmid=21444889 |doi=10.1161/CIR.0b013e31820f2f3e |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=21444889 |accessdate=2011-03-31}}</ref>== | ==ACC / AHA Guidelines (DO NOT EDIT) <ref name="pmid21444889">{{cite journal |author=Wright RS, Anderson JL, Adams CD, Bridges CR, Casey DE, Ettinger SM, Fesmire FM, Ganiats TG, Jneid H, Lincoff AM, Peterson ED, Philippides GJ, Theroux P, Wenger NK, Zidar JP |title=2011 ACCF/AHA Focused Update of the Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction (Updating the 2007 Guideline): A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines |journal=[[Circulation]] |volume= |issue= |pages= |year=2011 |month=March |pmid=21444889 |doi=10.1161/CIR.0b013e31820f2f3e |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=21444889 |accessdate=2011-03-31}}</ref>== | ||
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===Class I=== | ===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]=== | ||
'''1.''' [[Creatinine clearance]] should be estimated in [[UA]] / [[NSTEMI]] patients and the doses of renally cleared medications should be adjusted | '''1.''' [[Creatinine clearance]] should be estimated in [[UA]] / [[NSTEMI]] patients and the doses of renally cleared medications should be adjusted | ||
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'''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)'' | '''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=== | ===[[ACC AHA guidelines classification scheme#Classification of Recommendations|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].)}} | '''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].)}} | ||
Revision as of 16:55, 1 October 2012
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Unstable angina / NSTEMI Microchapters |
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Differentiating Unstable Angina/Non-ST Elevation Myocardial Infarction from other Disorders |
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Special Groups |
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Diagnosis |
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Laboratory Findings |
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Treatment |
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Antitplatelet Therapy |
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Additional Management Considerations for Antiplatelet and Anticoagulant Therapy |
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Risk Stratification Before Discharge for Patients With an Ischemia-Guided Strategy of NSTE-ACS |
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Mechanical Reperfusion |
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Discharge Care |
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Case Studies |
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [2]
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 [1] 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 [2] 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) [1]
| “ |
Class I1. 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 II1. 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].) |
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See Also
Sources
- The ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction [3]
- The 2009 ACC/AHA Focused update on the guidelines for STEMI and PCI[4]
- 2011 ACCF/AHA Focused Update of the Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction[1]
References
- ↑ 1.0 1.1 1.2 Wright RS, Anderson JL, Adams CD, Bridges CR, Casey DE, Ettinger SM, Fesmire FM, Ganiats TG, Jneid H, Lincoff AM, Peterson ED, Philippides GJ, Theroux P, Wenger NK, Zidar JP (2011). "2011 ACCF/AHA Focused Update of the Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction (Updating the 2007 Guideline): A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". Circulation. doi:10.1161/CIR.0b013e31820f2f3e. PMID 21444889. Retrieved 2011-03-31. Unknown parameter
|month=ignored (help) - ↑ Charytan DM, Wallentin L, Lagerqvist B, Spacek R, De Winter RJ, Stern NM, Braunwald E, Cannon CP, Choudhry NK (2009). "Early angiography in patients with chronic kidney disease: a collaborative systematic review". Clinical Journal of the American Society of Nephrology : CJASN. 4 (6): 1032–43. doi:10.2215/CJN.05551008. PMID 19423566. Retrieved 2011-04-03. Unknown parameter
|month=ignored (help) - ↑ Anderson JL, Adams CD, Antman EM; et al. (2007). "ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine". JACC. 50 (7): e1–e157. PMID 17692738. Text "doi:10.1016/j.jacc.2007.02.013 " ignored (help); Unknown parameter
|month=ignored (help) - ↑ [1]