Clinical features, use of evidence-based therapies, and cardiovascular outcomes among patients with chronic kidney disease following non-ST-elevation acute coronary syndrome.
BACKGROUND
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.


OBJECTIVE
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 Acute 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) (Pinteraction = 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 (Pinteraction = 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.
Department of Medicine, Stanford University Medical Center, Stanford, California.
June-Wha
JW
Rhee
Stephen D
SD
Wiviott
Benjamin M
BM
Scirica
C Michael
CM
Gibson
Sabina A
SA
Murphy
Marc P
MP
Bonaca
David A
DA
Morrow
Jessica L
JL
Mega
D000083:Acetanilides / Q000627:therapeutic use*; D054058:Acute Coronary Syndrome / Q000175:diagnosis* / Q000188:drug therapy* / Q000503:physiopathology; D000368:Aged; D003404:Creatinine / Q000097:blood; D004311:Double-Blind Method; D004562:Electrocardiography; D004791:Enzyme Inhibitors / Q000627:therapeutic use*; D019317:Evidence-Based Medicine; D005260:Female; D005919:Glomerular Filtration Rate; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D010879:Piperazines / Q000627:therapeutic use*; D000069458:Ranolazine; D051436:Renal Insufficiency, Chronic / Q000150:complications*
D000083:Acetanilides; D004791:Enzyme Inhibitors; D010879:Piperazines; D000069458:Ranolazine; D003404:Creatinine