Introduction:
Coronary artery disease (CAD) is prevalent in patients with chronic kidney disease (CKD) due to the associated classical cardiovascular risk factors and specific uremia related risk factors accelerating the atherosclerosis process. Studies in patients with CKD have shown higher burden of multi vessel disease, with higher plaque burden, leading to increased risk of mortality and morbidity, particularly following acute coronary syndrome (ACS). Aim of the study was to analyse the CKD specific risk factors, management, and outcome of patients with CKD who had ACS.
Methods:
A single center, retrospective observational study conducted between January 2020-December 2022. Data of patients of CKD stage 3-5 admitted under Department of Nephrology, in a tertiary care center in South India were analysed, and data of patients who had ACS were collected. Data obtained was analysed using chi square test, paired & unpaired student t tests.
Results:
Prevalence of ACS was 11.33% (116/1023). 71% patients were male with mean age of 62.53+10 years. Diabetic kidney disease (90%) was the major cause of CKD. 75% patients belonged to CKD stage 5, of which 65% patients were on maintenance hemodialysis (MHD), with mean dialysis vintage of 3.6 ± 1.56 years. Non-ST Elevation Myocardial Infarction (NSTEMI) was the most common form of ACS (70.7%). Mean ejection fraction (EF) was 42.06 ± 9.21%. 53.45% of patients underwent coronary angiogram (CAG), of which 37% patients had triple vessel disease (TVD). 66% patients had lesion in left anterior descending (LAD) artery. 79% of patients who underwent CAG, had intervention in the form of stent placement (45.16%) or bypass surgery (33.87%). Prevalence of NSTEMI was higher in CKD stage 5 on MHD as compared to STEMI (69% vs 10%, p<0.001). Mean phosphorous values were higher in patients of CKD stage 5 non-dialysis (ND) group as compared to CKD stage 5 on MHD group (6.44+2.2 vs 4.7+1.9, p<0.001), while it was opposite in parathyroid hormone (PTH) levels (568+288 vs 399+140, p-0.05). Albumin levels were higher in CKD stages 3&4 compared to CKD stage 5(MHD&ND) (3.39+0.61 vs 3.06+0.56, p-0.009). Patients of CKD stage 5 (MHD&ND) had higher presentation with cardiogenic shock as compared to CKD stage 3&4 (55% vs 27.5%, p-0.01). Of the 59 patients not on MHD, 63% required to undergo renal replacement therapy (RRT) as a complication of ACS (p-0.004), of which 43% underwent CAG. Mortality was 21.55% amongst patients who had ACS, with 84% patients belonging to CKD stage 5 vs 16% to CKD stages 3&4(p<0.001). Mortality was higher in patients of CKD stage 5 on MHD as compared to CKD 3-5ND (64% vs 36%, p– 0.05). Mean phosphorous and low-density lipoprotein (LDL) levels were higher in mortality group as compared to survivor group (6.4 +2.5 vs 5.3+1.7, p – 0.24; 129+31 vs 109+33, p-0.03).
Conclusions:
ACS has higher mortality in patients with CKD, especially in patients on MHD. Hyperparathyroidism, hyperphosphatemia, hypoalbuminemia and elevated levels of LDL play a significant role in atherosclerosis leading to ACS. Majority of the patients present with atypical symptoms and NSTEMI with TVD and low EF, leading to increased incidence of cardiogenic shock contributing to mortality and morbidity. Hence, there is a need for aggressive workup and treatment of ischemia for better quality of life and outcome.
I have no potential conflict of interest to disclose.
I did not use generative AI and AI-assisted technologies in the writing process.