ABSTRACT
ST-segment elevation myocardial infarction Treatment of STEMI in patients with CKD is particularly problematic.Traditionally, patients with advanced renal insufficiency and ESRD receiving dialysis have not been included in randomized STEMI trials evaluating either medical or interventional therapies.Thus, only scarce data deriving from limited observational studies are available and, to date, no optimal treatment strategy has been defined for this subgroup of patients.This critical deficiency has been addressed by Berger et al,33
who compared the patterns of care and the effect of standard AMI therapy on 30-day mortality between 1025 ESRD patients on chronic dialysis (either peritoneal dialysis or hemodialysis) and 145 740 non-ESRD patients.They confirmed that aspirin, beta-blockers, and ACE-inhibitors were less likely to be used in patients on dialysis, even among those considered ‘ideal candidates’ for these medications, than in patients not receiving dialysis (Figure 5.6). Nevertheless, the authors observed
Figure 5.6 Aspirin, beta-blockers, and angiotensin-converting enzyme (ACE) inhibitors are less likely to be provided to patients with endstage renal disease (ESRD) than to those without ESRD. In an analysis of patients considered ideal for the individual therapies, the overall administration rates were higher, but patients with ESRD still remained less likely to receive the therapy than those without ESRD.The P value for each comparison between ESRD and non-ESRD patients was < 0.001. (From Berger et al.33)
a similar absolute reduction in short-term mortality with aspirin, beta-blocker, and ACE inhibitor therapy when comparing the dialysis and non-dialysis groups.Aspirin was associated with a 20.7% absolute reduction in mortality in dialysis patients, and a 22.8% reduction in non-dialysis patients. Beta-blocker therapy was associated with a 13.6% absolute reduction in mortality in both the dialysis and non-dialysis patients.The ACE inhibitor use was associated with a 16.1% absolute reduction in 30-day mortality in dialysis patients and a 5.4% reduction in non-dialysis patients. The reasons for this ‘therapeutic nihilism’ in dialysis patients and in patients with advanced renal insufficiency suffering from a STEMI are not clear. Concern about further impairment of renal function and toxic side-effects due to reduced drug clearance are potential explanations. Furthermore, patients with renal insufficiency have more comorbidity and, as a consequence, more contraindications to these medications.
