Xử trí hội chứng vành cấp ở người có bệnh thận mạn

Management of Acute Coronary Syndrome in Chronic Kidney Disease Dafsah Arifa Juzar Indonesian Heart Association Harapan Kita, Jakarta, Indonesian • • • • • • Background Diagnostic Reperfusion Antiplatelets & Anticoagulant Betablocker RAAS inhibitor Background • The incidence of AMI is increased in this vulnerable subgroup • Atypical clinical presentation of AMI may be more frequent • ECG changes that may mimic or obscure AMI • Left ventricular hypertrophy is common • patients with renal dysfunction are more prone to adverse events • Cardiovasscular medication : antiplatelets & anticoagulation, • Cardiovascular procedures : coronary • Relative lack of evidence and potential for uncertainty in selecting medications Clinical Presentation of ACS Among CKD Patients Szummer K et al J Intern Med 2010;268:40–49 Unique pathobiology of CKD • greater luminal encroachment and • higher plaque burden • greater necrotic core and dense calcium with less fibrous tissue • modulate coronary atherosclerotic plaque composition to a less stable phenotype – Metalloproteinases are elevated – potentiates foam cell generation by enhancing macrophage entry • accelerated infarct expansion in association with enhanced inflammation and oxidative stress, Baber U, etal JACC Cardiovasc Imaging 2012;5:S53–S61 Ponda MP etal Atherosclerosis 2010;210:57–62 Naito K, Anzai, etal J Card Fail 2008; Pelisek J, etal P J Vasc Surg 2011 Prone to adverse event Gibson CM, etal Eur Heart J 2004;25:1998–2005 Age adjusted Hazard Ratio for death from any cause CV event & Hospitalization 1,200,295 ambulatory adults Go AS et al N Engl J Med 2004;351:1296–1305 Conservative (C) VS Invasive (I) protocol defined bleeding TACTIC TIMI IB Januzzi J, etal Am J Cardiol 2002 Dec 1;90(11):1246-9 Relevance CKD in ACS • underutilization of known cardio-protective therapies, • less aggressive treatment, • more frequent errors in dosing with excess toxicity from conventional therapies Diagnostic Cardiac biomarker Anticoagulant • Patients with CrCl