title: Impact of chronic kidney disease on early (30-day) and late (1-year) outcomes of patients with acute coronary syndromes treated with alternative antithrombotic treatment strategies: an ACUITY (Acute Catheterization and Urgent Intervention Triage strategY) substudy.
abstract: OBJECTIVE
  In this substudy of the ACUITY (Acute Catheterization and Urgent Intervention Triage strategY) trial, we investigated the relationship between chronic kidney disease (CKD) and clinical outcomes, and compared the safety and efficacy of bivalirudin monotherapy versus heparin plus a glycoprotein IIb/IIIa inhibitor (GPI).
  
  
  BACKGROUND
  CKD is an important predictor of prognosis in the general population. The outcomes of patients with CKD and acute coronary syndromes (ACS) have not been well studied.
  
  
  METHODS
  In the ACUITY study, 13,819 patients with moderate- and high-risk ACS undergoing an early, invasive strategy were randomly assigned to 1 of 3 antithrombin regimens: a heparin plus a GPI, bivalirudin plus a GPI, or bivalirudin monotherapy. CKD (creatinine clearance <60 ml/min) was present in 2,469 (19.1%) of 12,939 randomized patients with baseline creatinine clearance data.
  
  
  RESULTS
  Patients with CKD had worse 30-day and 1-year clinical outcomes than those with normal renal function. There were no significant differences between bivalirudin monotherapy and heparin plus a GPI in rates of 30-day composite ischemia (11.1% vs. 9.4%, p = 0.27) and net clinical adverse outcomes (16.1% vs. 16.9%, p = 0.65). There was remarkably less major bleeding (6.2% vs. 9.8%, p = 0.008) at 30 days, but no significant difference in 1-year composite ischemia (22.0% vs. 18.9%, p = 0.10) or mortality (7.1% vs. 7.3%, p = 0.96).
  
  
  CONCLUSIONS
  In patients with ACS, CKD is associated with higher 30-day and 1-year adverse event rates. Compared with heparin plus a GPI, the use of bivalirudin monotherapy in patients with CKD results in nonstatistically different ischemic outcomes, but significantly less 30-day major bleeding.
authors.affiliation: Columbia University Medical Center and Cardiovascular Research Foundation, New York, New York 10032, USA. rmehran@crf.org
authors.forename: Roxana
authors.initials: R
authors.lastname: Mehran
authors.forename: Eugenia
authors.initials: E
authors.lastname: Nikolsky
authors.forename: Alexandra J
authors.initials: AJ
authors.lastname: Lansky
authors.forename: Ajay J
authors.initials: AJ
authors.lastname: Kirtane
authors.forename: Young-Hak
authors.initials: YH
authors.lastname: Kim
authors.forename: Frederick
authors.initials: F
authors.lastname: Feit
authors.forename: Steven
authors.initials: S
authors.lastname: Manoukian
authors.forename: Jeffrey W
authors.initials: JW
authors.lastname: Moses
authors.forename: Ramin
authors.initials: R
authors.lastname: Ebrahimi
authors.forename: E Magnus
authors.initials: EM
authors.lastname: Ohman
authors.forename: Harvey D
authors.initials: HD
authors.lastname: White
authors.forename: Stuart J
authors.initials: SJ
authors.lastname: Pocock
authors.forename: George D
authors.initials: GD
authors.lastname: Dangas
authors.forename: Gregg W
authors.initials: GW
authors.lastname: Stone
mesh_terms: D054058:Acute Coronary Syndrome / Q000188:drug therapy* / Q000401:mortality; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015906:Angioplasty, Balloon, Coronary / Q000009:adverse effects / Q000401:mortality; D015415:Biomarkers / Q000097:blood; D002908:Chronic Disease; D001026:Coronary Artery Bypass / Q000009:adverse effects / Q000401:mortality; D003404:Creatinine / Q000097:blood; D004359:Drug Therapy, Combination; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D006470:Hemorrhage / Q000139:chemically induced; D006493:Heparin / Q000009:adverse effects / Q000627:therapeutic use*; D006629:Hirudins / Q000009:adverse effects; D006801:Humans; D007674:Kidney Diseases / Q000150:complications* / Q000401:mortality; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000209:etiology; D017202:Myocardial Ischemia / Q000209:etiology; D016017:Odds Ratio; D010446:Peptide Fragments / Q000009:adverse effects / Q000627:therapeutic use*; D010975:Platelet Aggregation Inhibitors / Q000009:adverse effects / Q000627:therapeutic use*; D019039:Platelet Glycoprotein GPIIb-IIIa Complex / Q000037:antagonists & inhibitors*; D011446:Prospective Studies; D011994:Recombinant Proteins / Q000009:adverse effects / Q000627:therapeutic use; D018570:Risk Assessment; D013997:Time Factors; D016896:Treatment Outcome; D014218:Triage
chemical_list: D015415:Biomarkers; D005343:Fibrinolytic Agents; D006629:Hirudins; D010446:Peptide Fragments; D010975:Platelet Aggregation Inhibitors; D019039:Platelet Glycoprotein GPIIb-IIIa Complex; D011994:Recombinant Proteins; D006493:Heparin; D003404:Creatinine; C074619:bivalirudin