Chronic kidney disease in patients with non-ST-segment elevation acute coronary syndromes

PURPOSE: Chronic kidney disease has been linked to high mortality rates in patients with ST-segment elevation myocardial infarction but has not been well described for patients with non-ST-segment elevation acute coronary syndromes. We examined the treatment and outcomes of patients with both non-ST-segment elevation acute coronary syndromes and moderate to severe chronic kidney disease. SUBJECTS AND METHODS: We evaluated 45343 patients with non-ST-segment elevation acute coronary syndromes enrolled in the CRUSADE Quality Improvement Initiative and compared treatments and outcomes in patients with and without moderate to severe chronic kidney disease. RESULTS: Patients presenting with moderate to severe chronic kidney disease (n = 6560) were older, more often diabetic, and more likely to present with signs of congestive heart failure. Adherence to Class IA/IB guidelines recommendations was lower in patients with moderate to severe chronic kidney disease, who were significantly less likely to be treated with medications, undergo invasive cardiac procedures, and be given discharge counseling. Moderate to severe chronic kidney disease was associated with a 50% increased risk of mortality and a 70% increased likelihood of transfusion. Despite having a higher risk of adverse outcomes, patients with moderate to severe chronic kidney disease were treated less aggressively than patients with normal renal function. CONCLUSIONS: These findings suggest that, in patients with moderate to severe chronic kidney disease, safety concerns about adverse outcomes and the absence of trial data for this population may limit the use of guidelines-recommended therapies and interventions for non-ST-segment elevation acute coronary syndromes. The decreased use of discharge counseling in patients with moderate to severe chronic kidney disease and non-ST-segment elevation acute coronary syndromes may represent therapeutic nihilism. (c) 2006 Elsevier Inc. All rights reserved.