Diabetes and Chronic Kidney Disease: Complicating ACS Diagnosis and Treatment

Diagnosis and treatment of acute coronary syndrome in patients who also have diabetes or chronic kidney disease are challenging for a number of reasons, explains a recently published review article.

Many patients who present with acute coronary syndrome (ACS) have comorbid chronic kidney disease (CKD) or diabetes mellitus (DM) and, consequently, are at elevated risk for morbidity and mortality. This topic is covered by a review article published online on July 11, 2013, in Current Cardiology Report as part of its topical collection on management of acute coronary syndromes (ACS).

Among patients who have non-ST segment elevation myocardial infarction (NSTEMI) ACS, the review explains, up to 43% also have CKD and up to 27% also have DM. The comprehensive review points out a number of important facts: CKD and DM, which are both prothrombotic, inflammatory conditions, influence clinical symptoms, electrical findings, and biomarker data required for accurate diagnosis of ACS. CKD and DM patients are more likely to have dyspnea and are less likely to have chest pain than other patients. Many have arrhythmias, conduction defects, and overt bundle branch block, which muddles electrocardiogram readings. CKD and DM patients may also present with serum biomarkers of myocardial necrosis, even without symptoms. These patients tend to be sicker and have hemodynamic instability.

CKD and DM patients are more likely to be older, female, and hypertensive compared with other ACS patients. Pre-existing vascular morbidity, including stroke or lower extremity peripheral arterial disease, is very common in these populations.

CKD and DM patients are often subject to the risk-treatment paradox; that is, clinicians withhold potentially beneficial therapies in high-risk patients, fearing adverse outcomes from the treatment itself. CKD and DM patients are less likely to receive prescriptions for evidence-based discharge medications, including aspirin, clopidogrel, beta-blockers, and statins. They are also less likely to receive adequate discharge counseling.

CKD and DM accelerate atherosclerosis and thrombosis. Like all ACS patients, those with CKD and DM need dual inhibition of the coagulation cascade and platelet aggregation. Clinicians should manage them with contemporary pharmacotherapy and treatment strategies to the greatest extent possible. The review authors look at current treatments, compare invasive and conservative approaches to treatment, and address the greatest concerns—difficulty diagnosing and propensity to undertreat ACS—in patients with CKD and DM.

Ms. Wick is a visiting professor at the University of Connecticut School of Pharmacy and a freelance writer from Virginia.