Cardioprotective Drugs and Acute Coronary Syndrome in Patients on the Waiting List for Renal Transplantation

Abstract

Background: The incidence of Acute Coronary Syndrome (ACS) in patients (pts) with advanced CKD is close to 30/1000 pts-year (Kidney Int 2002; 62: 1799). The effect of cardioprotective medications on the incidence of ACS on the waiting-list pts is poorly understood. Objective : to assess the incidence and risk factors for ACS in a cohort of 1522 hemodialysis pts on the waiting list for renal transplantation prospectively treated with aspirin, b-blockers, statins and renin-angiotensin inhibitors irrespectively of risk strati fi cation starting on inception and maintained before and after transplantation. Results: 83 pts (57±8 yo, 65% males, 65% Caucasians, 53% diabetics and 49% with associated CV disease) developed ACS (5.4/1000 pts-year): myocardial infarction (MI) = 53 (66%) and unstable angina (UA) = 28 (34%). The median time for the occurrence of ACS was 52 months. Compared to pts who did not develop CV events, ACS pts were older and had more angina, diabetes, associated CV disease, higher serum total-cholesterol, LV mass index and abnormal myocardial scan. The sole independent predictor of ACS was an altered myocardial scan (p=0.0009, 95% CI 0.21-0.80, HR 0.50). 35 out of 53 pts with MI (66%) died during hospitalization; UA was not associated with in-hospital deaths. Mortality was higher in pts with ACS compared to controls (55% versus 20%, p=0.0001, HR 0.28, 95% CI 0.20- 0.39). 8 pts with ACS underwent renal transplantation. There were 2 deaths caused by MI 1.6 and 12 months after operation. In the control group (n= 360) there were 4 MI-related deaths. Overall post-transplant mortality was comparable in ACS and in controls (p=0.29). Conclusions: the incidence of ACS appears to be reduced in this cohort prospectively treated with cardioprotective medications. Risk factors do not differ from those in the general population. Myocardial scan is useful to detect pts at higher risk of ACS. The incidence of ACS was not increased by renal transplantation in pts with previous ACS. The in-hospital mortality by MI is very high.