Clinical Features, Use of Evidence-Based Therapies, and Cardiovascular Outcomes Among Patients With Chronic Kidney Disease Following Non-ST-Elevation Acute Coronary Syndrome

June-Wha Rhee, Stephen D. Wiviott, Benjamin M. Scirica, C. Michael Gibson, Sabina A. Murphy, Marc P. Bonaca, David A. Morrow, Jessica L. Mega
2014 Clinical Cardiology  
Chronic kidney disease (CKD) is associated with an increased risk of cardiovascular events following acute coronary syndrome (ACS). The underlying pathobiology and optimal treatments for this population continue to be evaluated. Hypothesis: Patients with CKD will receive fewer evidence-based therapies and experience high rates of adverse cardiovascular events in both the short-and long term. Methods: The MERLIN-TIMI 36 (Metabolic Efficiency With Ranolazine for Less Ischemia in Non-ST-Elevation
more » ... cute Coronary Syndromes-Thrombolysis in Myocardial Infarction 36) trial randomized non-ST-elevation ACS patients to ranolazine or placebo, with no exclusion for renal dysfunction (except dialysis). We conducted a prespecified analysis among 6543 patients based on the degree of CKD. Results: Patients with worse renal function were older with more comorbidities (P < 0.0001 for each). They were less likely to receive evidence-based cardiovascular medicines (P < 0.04 for each). Rates of an early invasive management strategy varied based on renal function; however, among patients with the highest TIMI risk scores, the rates of an early invasive management strategy were similar regardless of glomerular filtration rate (GFR) (P interaction = 0.005). Lower GFR was associated with increased rates of cardiovascular disease or myocardial infarction in the short and long term, even after adjustment (GFR <30 vs ≥90 mL/min/1.73 m 2 ; hazard ratio [HR]: 3.24 [95% confidence interval {CI}: 1.26-8.38] through 7 days and HR: 2.12 [95% CI: 1.33-3.39] through 1 year). The effect of ranolazine vs placebo on clinical outcomes was similar among those with and without CKD (P interaction = not significant). Conclusions: Following ACS, patients with renal dysfunction had more cardiovascular risk factors but were less likely to receive evidence-based medical therapies. A strong graded, independent relationship between the degree of CKD and poor clinical outcomes was observed over time. Continued efforts to optimize ACS treatment strategies in patients with CKD are warranted. Abbreviations: ACE-I, angiotensin-converting enzyme inhibitor; ARB, angiotensin II receptor blocker; BMI, body mass index; CABG, coronary artery bypass graft; GFR, glomerular filtration rate (mL/min/1.73 m 2 ); IQR, interquartile range; LM, left main; MI, myocardial infarction; LMWH, low-molecular weight heparin; NSTEMI, non-ST-elevation myocardial infarction; PCI, primary coronary intervention; UA, unstable angina; UFH, unfractionated heparin. Clin. Cardiol. 37, 6, 350-356 (2014) 353 J.-W. Rhee et al: CKD and outcomes after ACS Published online in Wiley Online Library (
doi:10.1002/clc.22253 pmid:24481910 fatcat:u4zl2qso75bqpa3ytmooqbfj6e