Olayinka Afolabi-Brown1; Eugenia Nikolsky1; Alexandra J Lansky1; Roxana Mehran1; Martin Fahy1; Brent T McLaurin2; David A Cox3; Frederick Feit4; Antonio Colombo5; Adriano Caixeta6; Gregg W Stone6
1 Cardiovascular Rsch， New York， NY
2 AnMed Health， Anderson， SC
3 Mid Carolina Cardiology， Charlotte， NC
4 New York Univ Sch of Medicine， New York， NY
5 Ospedale San Raphael， Milan， Italy
6 Cardiovascular Rsch， New York， NY
    Objectives: We evaluated outcomes of moderate- to high-risk patients (pts) with acute coronary syndromes (ACS) and chronic kidney disease (CKD) receiving alternative antithrombotic therapy in the ACUITY trial.
Background: Knowledge of safety and efficacy of different antithrombotic medications is important considering the choice of therapy in pts with ACS having CKD.
    Methods: In the ACUITY trial， 2468(19.1%) pts had CKD (baseline creatinine clearance <60 ml/min) and 10，472 (80.9%) pts had preserved renal function. Pts were randomized to receive 1 of 3 antithrombotic regimens including heparin + glycoprotein IIb/IIIa inhibitors (H + GPI)， bivalirudin (Biv) plus a GPI， or Biv alone. Type of GPI (abciximab or a small-molecule GPI [eptifibatide and tirofiban]) was at operator’s discretion. Dosages were adjusted for renal function. Patients treated with Biv + a GPI were excluded from this analysis.
    Results: 30-day outcomes are presented in the table. Regardless of antithrombotic regimen， CKD was associated with remarkable increase in ischemic events， and more than 2-fold increase in rates of major bleeding. In pts with CKD， there were no significant differences in rates of major bleeding among those who received H +a small-molecule GPIs vs abciximab (p=0.7). In pts with CKD， Biv monotherapy compared to H +a small-molecule GPIs resulted in remarkably lower rates of major bleeding (p=0.003) without increase in rates of ischemic events. Bivalirudin monotherapy resulted in non significantly lower rates of bleeding than H+abciximab (p=0.3).
    Conclusions: CKD is associated with higher rates of 30-day ischemic events and major bleeding. Rates of major bleeding did not differ significantly between small-molecule GPIs and abciximab when used in conjunction with heparin in pts with ACS and baseline CKD. In pts with or without CKD， bivalirudin monotherapy resulted in the lowest rates of hemorrhagic events without increasing risk of ischemic complications.