Читать книгу Practical Cardiovascular Medicine - Elias B. Hanna - Страница 47

Approximately 20–40% of patients presenting with NSTEMI have CKD. Although the bleeding risk is increased in renal failure regardless of the anticoagulant used, bivalirudin (in patients undergoing PCI) and fondaparinux (outside PCI) are associated with less bleeding than UFH or enoxaparin in patients with mild or moderate renal failure.⁵⁹ When GFR is < 30 ml/min, UFH or dose-adjusted enoxaparin are approved for use; the bleeding risk is, however, higher with enoxaparin at any stage of renal failure, including GFR 30-60 ml/min, and UFH is preferred.¹³⁸ A GPI is best avoided in CKD; if used, the bolus and infusion doses of eptifibatide are reduced in half when GFR is < 50 ml/min.

CKD patients are inherently high-risk patients. Despite the high prevalence of CKD, large randomized trials that have addressed the benefit of an invasive strategy in ACS have excluded patients with advanced CKD. Subgroup analyses of these trials suggest a benefit of an invasive strategy in patients with mild CKD, and observational data suggest that patients with mild or moderate CKD (GFR 30–60 ml/min) derive a benefit from an invasive strategy, which makes sense, considering the inherently high ischemic risk of these patients.^139,140 This benefit may extend to carefully selected high-risk patients with CKD stages 4 or 5, who, nonetheless, have a higher risk of bleeding and renal and HF complications peri-PCI.¹⁴⁰