Curr Probl Cardiol. 2013 May;38(5):165-206. doi: 10.1016/j.cpcardiol.2012.12.004.
Atherosclerosis of the coronary arteries is common, extensive, and more unstable among patients with chronic renal impairment or chronic kidney disease (CKD). The initial presentation of coronary disease is often acute coronary syndrome (ACS) that tends to be more complicated and has a higher risk of death in this population. Medical treatment of ACS includes antianginal agents, antiplatelet therapy, anticoagulants, and pharmacotherapies that modify the natural history of ventricular remodeling after injury. Revascularization, primarily with percutaneous coronary intervention and stenting, is critical for optimal outcomes in those at moderate and high risk for reinfarction, the development of heart failure, and death in predialysis patients with CKD. The benefit of revascularization in ACS may not extend to those with end-stage renal disease because of competing sources of all-cause mortality. In stable patients with CKD and multivessel coronary artery disease, observational studies have found that bypass surgery is associated with a reduced mortality as compared with percutaneous coronary intervention when patients are followed for several years. This article will review the guidelines-recommended therapeutic armamentarium for the treatment of stable coronary atherosclerosis and ACS and give specific guidance on benefits, hazards, dose adjustments, and caveats concerning patients with baseline CKD.
冠状动脉粥样硬化在慢性肾功能损害或慢性肾脏病（CKD）患者中较为常见、广泛且更不稳定。冠心病的初始表现通常为急性冠状动脉综合征（ACS），在该人群中往往更为复杂，死亡风险更高。ACS 的药物治疗包括抗心绞痛药物、抗血小板治疗、抗凝药物以及可改变损伤后心室重构自然病程的药物治疗。血运重建，主要通过经皮冠状动脉介入治疗和支架置入术，对于预防中高危再梗死、心力衰竭以及 CKD 患者透析前死亡至关重要。对于终末期肾病患者，ACS 的血运重建获益可能不会扩展，因为存在多种全因死亡的竞争来源。在 CKD 合并多支血管病变的稳定患者中，观察性研究发现，当患者接受数年随访时，与经皮冠状动脉介入治疗相比，旁路手术与降低死亡率相关。本文将回顾指南推荐的稳定型冠状动脉粥样硬化和 ACS 的治疗方法，并就基线 CKD 患者的获益、危害、剂量调整和注意事项提供具体指导。
