Underuse of ACS Therapy in CKD

A recent paper in AJKD by Patel et al describes a curious but well-documented phenomenon: the finding that patients with CKD who are hospitalized with acute coronary syndrome (ACS) are less likely to receive therapies known to be beneficial for its treatment. This is ironic in the sense that, as we all know from prior experience, the subset of ACS patients with CKD tend to do very poorly as a whole from a cardiovascular standpoint, and one would imagine that this is a population in whom aggressive therapy could be very effective in reducing mortality.

This paper begins to explore some of the reasons for this underuse, which includes a decreased use of aspirin, Plavix, GP2b/3a inhibitors, and heparin in the acute setting as well as decreased prescriptions for statins or ACE-inhibitors, in patients with lower GFRs diagnosed with an NSTEMI. Only beta-blockers were found to be prescribed at relatively constant rates independent of baseline renal function.

Some the reasons for this are understandable. For example, GP2b/3a inhibitors have a higher risk of bleeding in patients with reduced GFR: the risk of major bleeding has been found to be about 1.5 times higher in patients a GFR between 30-60 mL/min and about 2.5 times higher in patients with a GFR less than 30 mL/min.