Cardiovascular Disease in Chronic Kidney Disease

Abstract

Cardiovascular disease (CVD) remains the leading cause of death in both developed and developing countries. With more than 92 million Americans with at least one type of CVD, cardiovascular causes explain up to one-third deaths in the US population . Recurrent events in CVD survivors are also common, and it is estimated that 300,000 will have a repeated myocardial infarction, while 635,000 subjects will experience a heart attack for the first time. In addition to CVD, chronic kidney disease (CKD) is major public health problem. Affecting over 14% of the US population, including 17% of adults with stable coronary artery disease, CKD constitutes another non-communicable epidemic of the present century. CVD and CKD are strongly associated; the former affects up to two thirds of subjects with CKD over 66 years old, and the latter imposes a higher incidence of CVD and a worse prognosis after a cardiovascular (CV) event, including a greater risk of CV mortality and non-fatal recurrences. Given the increased risk of CVD with CKD, risk stratification tools, including biomarkers, are useful in determining which patients have the greatest risk of developing a CV event. Beyond creatinine-based estimates of eGFR, newer renal markers, such as cystatin-C and the fibroblast growth factor 23, have gained recognition as predictors of CVD. Here we present a biomarker analysis from the Stabilization of pLaques usIng Darapladib-Thrombolysis in Myocardial Infarction (SOLID) - Thrombolysis in Myocardial Infarction (TIMI) 52 trial evaluating the prognostic utility of cystatin-C in patients after acute coronary syndrome (ACS) (Project 1). In addition to an increased risk of ischemic events, patients with CKD possess an elevated risk of bleeding. This notion has led to underutilization of evidence based antiplatelet therapy at the expense of an increased ischemic risk. We therefore examined the net clinical outcome of more potent platelet inhibition with vorapaxar in patients with impaired renal function to gain insights into tolerability of antiplatelet therapy in patients with renal disease in the Thrombin Receptor Antagonist in Secondary Prevention of Atherothrombotic Ischemic Events (TRA2°P) - Thrombolysis in Myocardial Infarction (TIMI) 50 trial (Project 2).