Therapeutic Management in Patients with Renal Failure who Experience an Acute Coronary Syndrome

Background and objectives: Prior reports have suggested that patients with impaired renal function receive less aggressive care after an acute coronary syndrome (ACS). The aim of this study was to determine whether this held true in a contemporary cohort, after thorough adjustment for cotreatments/comorbidities. Design, setting, participants, & measurements: Patients who were admitted for an ACS in eight participating hospitals were stratified into three groups according to estimated creatinine clearance (CrC): less than 45 ml/min, 45 to 60 ml/min, and reference >60 ml/min. Results: During hospitalization, uses of reperfusion therapy in tertiary care centers [difference between CrC <= 45 ml/min and reference group (Delta): 4%, 95% confidence interval (0): (-13%, 21%)] and systemic anticoagulation [Delta: 0%, CI (-5%, 5%)] were similar in the three groups. Coronary angiography was performed less often in patients with lower CrC [Delta: -16%, CI: (-31%, -1%)]. At discharge, nearly all patients received either an antiplatelet agent or warfarin regardless of CrC [Delta: -1%, CI: (-3%, 1%)]. Discharge use of angiotensin converting enzyme (ACE) inhibitors or angiotensin-receptor blockers was comparable [Delta: 7%, Cl: (-1%, 15%)]. beta-blockers [Delta: -9%, CI: (-17%, -1%)] and lipid-lowering drugs (LLDs) [Delta: -7%, CI: (-13%, -1%)] were used less frequently in patients with lower CrC. In multivariate analyses, decreased CrC predicted lower coronary angiography and LLD use, but not lower beta-blocker use at discharge. Conclusions: These results suggest that in patients with ACS, the extent of undertreatment due to chronic kidney disease is less than reported previously, which is partially explained by more complete adjustment for cotreatments/comorbidities. Clin J Am Soc Nephrol 5: 87-94, 2010. doi: 10.2215/CJN.04290609