Guidelines for the treatment of acute coronary syndromes in patients with chronic kidney disease
Scope of this guidance
Many drugs are contraindicated or need dose adjustment when patients have impaired renal function. This guideline provides additional guidance to the NHS Lothian ACS protocol for patients with renal impairment. Immediate management of acute coronary syndromes and decisions as to whether interventional management is required should be taken with the cardiology team, as for other patients.
Medications for immediate management of ACS in CKD:
1) Guidelines for usage of second antiplatelet: Risk of bleeding increases and the benefit derived from dual antiplatelets decreases as degree of renal impairment worsens. It is unclear what the optimum time course for dual antiplatelets is, especially in those with CKD. It is possible for many patients the risk of continuing the medication for longer than 3 months outweigh the benefits. The decision as to whether to continue beyond 3 months should be made on an individual patient’s risk of bleeding.
2) Guidelines for anticoagulant therapy: Fondaparinux is not licensed below an eGFR of 20. Bleeding risk also increases with anticoagulants as degree of renal impairment worsens. Where patients are at high risk of bleeding, it may be preferable to avoid anticoagulants. For those patients who are not at high risk of bleeding we recommend using dalteparin when eGFR is below 20. The dose of dalteparin is calculated based on weight as per the table below and factor Xa level monitoring should be performed.
The medication should be continued for 8 days, until PCI or until discharge (whichever occurs sooner). Where factor Xa levels are out-with the target range the result should be discussed with the haematology registrar on call for advice on dose adjustment.
3) Guidelines for starting ACEi: Creatinine and potassium levels should always be checked after starting the medication. Particular caution should be exercised in patients with eGFR below 20. They are especially prone to hyperkalaemia and have little leeway for deterioration of renal function. It is, therefore, generally not advisable to commence ACEi therapy where eGFR <20.
Where patients were on an ACEi prior to the ACS the medication should be reintroduced after being withheld over the period they were unwell or underwent any contrast based investigations.
Further management of ACS in CKD patients:
Dialysis patients: Haemodialysis may be destabilising for the cardiac muscle following a myocardial infarction. Accordingly all haemodialysis patients who have had a confirmed infarct should have their first dialysis after the event performed with cardiac monitoring in situ. Once the cardiology team are satisfied no further immediate interventions or investigations are required, please contact the renal registrar on call to arrange for a monitored dialysis in renal HDU.
Ensure you know:
1) what days the patient usually has dialysis
2) the current serum potassium
Guideline written by Matthew Sayer & Elizabeth Hird (March 2020)