What is the management approach for a patient with coronary artery disease (CAD) and chronic kidney disease (CKD)?

Management of Coronary Artery Disease with Chronic Kidney Disease

The management of patients with both coronary artery disease (CAD) and chronic kidney disease (CKD) requires aggressive risk factor control, appropriate medical therapy with statins and antiplatelet agents, and a conservative approach to revascularization except in cases of acute coronary syndromes or significant symptoms despite optimal medical therapy.

Risk Assessment and Monitoring

• Annual clinical follow-up is recommended to assess symptoms, functional status, medication adherence, and monitoring for complications 1
• Validated CAD-specific patient-reported health status measures may help quantify symptom burden 1
• Estimate 10-year cardiovascular risk using validated risk tools 1
• Assess kidney function by eGFR in all patients with CAD 1

Medical Therapy

Lipid Management

• Statin therapy is strongly recommended for all patients with CAD and CKD:
  • For adults with CKD and eGFR <60 ml/min per 1.73 m² (G3a-G5): statin or statin/ezetimibe combination 1
  • For adults aged ≥50 years with CKD and eGFR ≥60 ml/min per 1.73 m² (G1-G2): statin therapy 1
  • For adults aged 18-49 years with CKD and CAD: statin therapy 1
  • Target LDL-C <1.4 mmol/L (<55 mg/dL) and ≥50% reduction from baseline 2
  • Consider PCSK9 inhibitors if LDL goals not achieved with maximum tolerated statin plus ezetimibe 1, 2

Antiplatelet Therapy

• Low-dose aspirin (75-100 mg daily) is recommended for secondary prevention 1, 2
• Consider P2Y12 inhibitors (e.g., clopidogrel) when there is aspirin intolerance 1
• For patients with acute coronary syndrome, dual antiplatelet therapy with aspirin and a P2Y12 inhibitor is indicated 3

Blood Pressure Management

• Target BP: 120-130 mmHg systolic if tolerated, but not <120 mmHg 1
• Target diastolic BP: <80 mmHg, but not <70 mmHg 1
• ACE inhibitors are recommended for patients with CAD and CKD, particularly those with diabetes 1
• Initial antihypertensive treatment should include a RAS blocker with a calcium channel blocker or thiazide/thiazide-like diuretic 1
• Use low- or iso-osmolar contrast media at lowest possible volume during invasive procedures 1

Diabetes Management

• Risk factor control (BP, LDL-C, and HbA1c) to targets is recommended 1
• SGLT2 inhibitors (empagliflozin, canagliflozin, or dapagliflozin) are recommended for patients with diabetes and CVD 1
• GLP-1 receptor agonists (liraglutide or semaglutide) are recommended for patients with diabetes and CVD 1
• Screen all patients for diabetes and monitor blood glucose levels frequently in those with known diabetes 1
• Avoid hypoglycemia 1

Revascularization Strategy

• In stable ischemic heart disease with CKD, an initial conservative approach using intensive medical therapy is an appropriate alternative to an initial invasive strategy 1
• Consider invasive strategy for patients with:
  • Acute or unstable coronary disease
  • Unacceptable levels of angina despite medical therapy
  • Left ventricular systolic dysfunction attributable to ischemia
  • Left main disease 1
• When revascularization is indicated in highly symptomatic patients, the least invasive procedure is recommended 1
• Special considerations for CKD patients undergoing invasive procedures:
  • Higher risk of contrast-induced nephropathy
  • Higher procedural complications
  • Higher restenosis rates even with drug-eluting stents 4

Lifestyle Modifications

• Diet emphasizing vegetables, fruits, legumes, nuts, whole grains, and lean protein 1
• Reduce saturated fat (<6% of total calories) 1
• Minimize sodium (<2,300 mg/d; optimally 1,500 mg/d) 1
• Limit refined carbohydrates and sugar-sweetened beverages 1
• Avoid trans fat completely 1
• Consider a plant-based "Mediterranean-style" diet in addition to lipid-modifying therapy 1
• Regular physical activity appropriate to patient's functional capacity 2
• Smoking cessation 2
• Weight management 2
• Multidisciplinary exercise-based cardiac rehabilitation 1

Common Pitfalls and Considerations

• Dietary supplements (omega-3 fatty acids, vitamins C, D, E, beta-carotene, and calcium) are not beneficial for reducing acute CVD events 1
• Medication dosages may need adjustment based on renal function 1
• CKD patients often present with atypical symptoms or silent ischemia, requiring higher clinical suspicion 1
• Non-invasive stress testing shows reduced accuracy in patients with CKD 1
• Avoid combining ACE inhibitors and ARBs 2
• Be cautious with contrast agents in advanced CKD to prevent further deterioration 1

Special Considerations for Older Patients

• Apply the same diagnostic and interventional strategies as for younger patients 1
• Adapt antithrombotic agent dosages and secondary prevention measures to renal function and specific contraindications 1
• Annual influenza vaccination is recommended, especially for older patients 1