Acute coronary syndrome in chronic kidney disease

Red Flags

Chest pain with eGFR <30 — high mortality; troponin baseline often elevated, trend over hours rather than absolute value drives diagnosis^[1]
Acute pulmonary oedema in dialysis patient — distinguish volume overload from ACS by ECG and troponin trend; both can coexist^[2]
Atypical or absent chest pain in dialysis ACS — uraemic neuropathy and diabetes mask classical symptoms; have a low threshold for serial ECG and troponin^[1]
Bleeding risk markedly elevated with eGFR <30 — uraemic platelet dysfunction; balance antithrombotic intensity carefully^[1]

Early invasive strategy^[1]
Coronary angiography within 24–72 h for NSTE-ACS in CKD remains beneficial despite contrast risk; STEMI requires primary PCI without delay regardless of eGFR. Use renal-protective contrast strategy

Drug	Class	Adult	Paediatric	Notes
Aspirin^[1]	Antiplatelet (loading)	300 mg PO loading then 75–100 mg PO once daily	—	No renal adjustment. Continue lifelong unless contraindicated
Clopidogrel^[1]	P2Y12 inhibitor	300–600 mg loading then 75 mg once daily for 12 months	—	Preferred over ticagrelor or prasugrel in advanced CKD due to bleeding risk; no specific renal adjustment but caution if eGFR <15
Atorvastatin^[1]	HMG-CoA reductase inhibitor (high-intensity statin)	40–80 mg PO once daily	—	Initiate during admission. No dose adjustment for CKD
Enoxaparin^[1]	Low-molecular-weight heparin	1 mg/kg SC BD; reduce to 1 mg/kg SC once daily if eGFR 15–30 mL/min; AVOID if eGFR <15 (use unfractionated heparin instead)	—	UFH preferred when eGFR <15 due to predictable clearance
Metoprolol succinate^[1]	Beta-blocker	25–200 mg PO once daily, titrate to heart rate 55–60 bpm	—	No renal adjustment. Initiate within 24 h if no contraindication

Aspirin^[1]

Antiplatelet (loading)

No renal adjustment. Continue lifelong unless contraindicated

Clopidogrel^[1]

P2Y12 inhibitor

Preferred over ticagrelor or prasugrel in advanced CKD due to bleeding risk; no specific renal adjustment but caution if eGFR <15

Atorvastatin^[1]

HMG-CoA reductase inhibitor (high-intensity statin)

Initiate during admission. No dose adjustment for CKD

Enoxaparin^[1]

Low-molecular-weight heparin

Adult: 1 mg/kg SC BD; reduce to 1 mg/kg SC once daily if eGFR 15–30 mL/min; AVOID if eGFR <15 (use unfractionated heparin instead)
Paediatric: —

UFH preferred when eGFR <15 due to predictable clearance

Metoprolol succinate^[1]

Beta-blocker

No renal adjustment. Initiate within 24 h if no contraindication

Take all heart-attack medications daily even when feeling well — stopping any antiplatelet within the first year sharply raises stent-thrombosis and reinfarction risk^[1]
Watch for unusual bruising, black stools, or prolonged bleeding from cuts — kidney disease plus blood thinners means higher bleeding risk; report promptly to your clinician^[2]
If you are on dialysis, attend every session — fluid overload after a heart attack can mimic recurrent angina^[2]

STEMI or NSTE-ACS with ongoing ischaemia, haemodynamic instability, or refractory arrhythmia regardless of eGFRCath lab for primary or early PCI^[1]
Stabilised NSTE-ACS in eGFR <30 — invasive vs conservative strategy decisionCardiology and nephrology shared decision making^[1]
Dialysis-dependent patient with refractory angina on optimal medical therapyCardiology heart team for revascularisation evaluation^[1]

Diagnostic and treatment considerations for ACS in patients with CKD, where atypical presentations and renal-modified drug dosing are common.

1.2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes (CKD subgroup) and KDIGO 2024 CKD Clinical Practice Guideline (2025)
2.KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney International (2024)