What is the latest management approach for acute coronary syndrome (ACS) in patients with chronic kidney disease (CKD)?

Latest Management Approach for Acute Coronary Syndrome in Patients with Chronic Kidney Disease

Apply the same diagnostic and therapeutic strategies in patients with CKD as for those with normal renal function, with careful attention to anticoagulant dose adjustments and bleeding risk, while maintaining an invasive approach when clinically indicated. 1

Diagnostic Approach

Troponin Interpretation

• High-sensitivity cardiac troponin (hs-cTn) assays maintain excellent diagnostic and prognostic accuracy in CKD patients, though baseline elevations are common due to chronic cardiac injury 1
• A threshold of <5 ng/L effectively rules out myocardial injury even in renal dysfunction 2
• Patients with troponin concentrations >99th percentile have a two-fold greater risk of cardiac events at 1 year, regardless of final diagnosis 1
• Assess absolute changes in cardiac troponin (increase and/or decrease) to differentiate acute MI from chronic cardiac injury 1

Renal Function Assessment

• Assess kidney function by estimated glomerular filtration rate (eGFR) in all ACS patients at presentation 1
• Pay special attention to elderly patients, women, and those with low body weight, as they are at higher risk for unrecognized renal impairment 2
• Monitor renal function for 2-3 days after coronary angiography or PCI in patients with baseline renal impairment 2

Invasive Strategy Decision-Making

When to Pursue Invasive Management

• Coronary angiography and revascularization remain recommended after careful risk-benefit assessment, even in advanced CKD 2
• The benefit of invasive strategy declines with greater reductions in renal function: no mortality benefit is seen in patients with eGFR <15 mL/min/1.73m² or those on dialysis 1
• For patients with eGFR ≥15 mL/min/1.73m², invasive strategy reduces 1-year mortality compared to conservative management 1

Revascularization Modality Selection

• CABG should be considered over PCI in patients with multivessel CAD whose surgical risk profile is acceptable and life expectancy is >1 year 1
• This recommendation is particularly important in CKD patients, as observational data suggest CABG provides superior long-term outcomes compared to PCI in multivessel disease 3
• Radial access is strongly preferred over femoral access to reduce bleeding complications 1

Contrast-Induced Nephropathy Prevention

Contrast Selection and Volume

• Use low- or iso-osmolar contrast media at the lowest possible volume (<4 mL/kg or <100 mL total) 1, 2
• This is a Class I, Level A recommendation from the European Society of Cardiology 1

Hydration Protocols

• Pre- and post-hydration with isotonic saline should be administered if expected contrast volume is >100 mL 1
• Standard protocol: isotonic saline 12 hours before and 24 hours after angiography 2
• Tailored hydration regimens may be considered as an alternative to standard protocols 1

Anticoagulation Management

Anticoagulant Selection by eGFR

• For eGFR <30 mL/min/1.73m²: Switch all anticoagulation to unfractionated heparin (UFH) infusion adjusted to aPTT 2
• UFH requires no dose adjustment and provides predictable monitoring through aPTT 2
• Fondaparinux is contraindicated when eGFR <20 mL/min/1.73m² and should only be used when eGFR ≥20 mL/min/1.73m² 2
• Enoxaparin and bivalirudin require dose adjustments at eGFR <30 mL/min/1.73m², but UFH remains preferred due to superior monitoring capability 2

Critical Safety Considerations

• Bleeding risk is substantially elevated in patients with severe CKD due to reduced drug clearance and uremic platelet dysfunction 2
• Monitor closely for bleeding complications, as renal insufficiency is an independent risk factor for in-hospital bleeding 2
• CKD is both a major criterion for high bleeding risk (eGFR <30 mL/min/1.73m²) and a minor criterion (eGFR 30-59 mL/min/1.73m²) in the 2025 ACC/AHA guidelines 1

Antiplatelet Therapy

Dual Antiplatelet Therapy (DAPT)

• Administer the same first-line antiplatelet treatment as patients with normal kidney function 1, 2
• Oral antiplatelet agents (aspirin and P2Y12 inhibitors) do not require dose adjustment for renal function 1, 2
• However, for patients with stage 5 CKD (eGFR <15 mL/min/1.73m²), there are insufficient safety and efficacy data for P2Y12 receptor inhibitors 1

Bleeding Risk Mitigation

• Proton pump inhibitors (PPIs) are recommended in patients with ACS at elevated bleeding risk treated with DAPT 1
• PPIs markedly decrease gastrointestinal bleeding risk without increasing ischemic events, even when used with clopidogrel 1
• The antiplatelet effects of ticagrelor and prasugrel are not modified by concomitant PPI use 1

DAPT De-escalation Considerations

• De-escalation from ticagrelor or prasugrel to clopidogrel may be considered in high bleeding risk patients 1
• This can be guided by platelet function assays or genotyping for CYP2C19 polymorphisms 1
• Clinical trials have shown either noninferiority or reductions in minor bleeding with guided de-escalation 1

Medical Therapy Optimization

Statins and Lipid Management

• High-dose statins are indicated for secondary prevention, irrespective of contrast-induced nephropathy risk 1
• Statins are recommended in all patients with chronic coronary syndromes and CKD 1
• Risk factor control (blood pressure, LDL-C) to target values is recommended 1

Renin-Angiotensin System Inhibitors

• ACE inhibitors or ARBs should be used with adjusted dosing regimens to prevent side effects 2
• Treatment with ACE inhibitors is recommended in CCS patients with diabetes for event prevention 1

Beta-Blockers

• Beta-blockers should be used with adjusted dosing regimens based on renal function 2
• Special attention must be paid to potential dose adjustments of renally excreted drugs 1

Special Populations and Considerations

Severe CKD (eGFR <15 mL/min/1.73m²) and Dialysis Patients

• The mortality benefit of invasive strategy is lost in this population 1
• Treatment decisions should weigh the lack of proven mortality benefit against symptom relief and quality of life considerations 1
• Insufficient safety data exist for P2Y12 inhibitors in stage 5 CKD 1

Multivessel Disease

• CABG provides superior long-term survival compared to PCI in CKD patients with multivessel disease when surgical risk is acceptable 1, 3
• Life expectancy >1 year is a key consideration for CABG selection 1

Common Pitfalls to Avoid

Undertreatment Due to Perceived Risk

• Despite higher bleeding risk, CKD patients are often undertreated with proven therapies 4, 5, 6
• These patients have much to gain from conventional revascularization strategies used in the general population 5
• Percutaneous coronary revascularization has been associated with superior long-term survival in CKD patients with ACS 7

Inappropriate Anticoagulant Selection

• Avoid fondaparinux when eGFR <20 mL/min/1.73m² 2
• Do not use enoxaparin or bivalirudin without appropriate dose adjustment when eGFR <30 mL/min/1.73m² 2
• UFH is the safest choice for severe renal impairment due to predictable monitoring 2

Inadequate Contrast Nephropathy Prevention

• Failure to use low- or iso-osmolar contrast at minimal volumes is a missed opportunity for renal protection 1, 2
• Inadequate hydration protocols increase risk of further renal deterioration 1, 2

Overlooking Bleeding Risk Stratification

• CKD itself (eGFR <60 mL/min/1.73m²) is a bleeding risk criterion that should trigger consideration of PPI therapy and careful anticoagulant selection 1, 2
• The presence of at least 1 major or 2 minor bleeding risk criteria identifies patients requiring intensified bleeding prevention strategies 1