Emergency evaluation of chest pain in patients with advanced kidney disease

Background: Increased rates of myocardial infarction, heart failure, arrhythmias, and death occur in patients with chronic kidney disease. We sought to evaluate the processes of care and outcomes in patients with chronic kidney disease presenting to an emergency department with chest discomfort. Methods: We enrolled 817 consecutive patients who under-went evaluation for a possible acute myocardial infarction in a prospective study of cardiac biomarkers. Renal dysfunction did not exclude patients from this study, and baseline renal function and 30-day outcomes were available,in 808. Patients were stratified by corrected creatinine clearance rate into quartiles, with those undergoing dialysis (n=51) as a fifth comparison group. Results: Those patients with advanced renal dysfunction (corrected creatinine clearance rate, <47.0 mL/min [<0.8 mL/s] per 72 kg) or who underwent dialysis had higher rates of diabetes, hypertension, and prior coronary disease. More than 99% of all patients were admitted to a chest pain observation unit or to the hospital. Rates of stress testing were lower as renal dysfunction worsened. Rates of revascularization, however, were similar for all groups. The most frequent in-hospital complication was the development of heart failure, which occurred in 36.5% of those with a corrected creatinine clearance rate of less than 47.0 mL/min per 72 kg. At 30 days, this group had the highest rates of cumulative myocardial infarction, development of heart failure, and death (40.2%). Conclusion: Chronic kidney disease is a marker for inhospital and 30-day outcomes in patients presenting to the emergency department with chest discomfort.