CKD stage
Description
GFR (ml/min per 1.73 m2)
1
Kidney damage with normal or increased GFR
≥90
2
Kidney damage with mild decreased GFR
60–89
3
Moderate decreased GFR
30–59
4
Severe decreased GFR
15–29
5
Kidney failure
<15 (or dialysis)
Fig. 4.1
Electrocardiogram (ECG) on admission
Background | Findings at the time of admission | Findings during hospital stay | |||
1. Age (years) | Points | 4. Heart rate at Admission (bpm) | Points | 7. Serum creatinine At admission (ml/min) | Points |
≤ 29 | 0 | ≤ 49.9 | 0 | 0.0–0.39 | 1 |
30–39 | 0 | 50–69.9 | 3 | 0.4–0.79 | 3 |
40–49 | 18 | 70–89.9 | 9 | 0.8–1.19 | 5 |
50–59 | 36 | 90–109.9 | 14 | 1.2–1.59 | 7 |
60–69 | 55 | 110–149.9 | 23 | 1.6–1.99 | 9 |
70–79 | 73 | 150–199.9 | 35 | 2.0–3.99 | 15 |
80–89 | 91 | ≥ 200 | 43 | ≥ 4.0 | 20 |
≥ 90 | 100 | ||||
5. SAP at admission (mmHg) | 8. Elevated enzymes or markers | 15 | |||
2. History of heart failure | 24 | ≤ 79.9 | 24 | ||
80–99.9 | 22 | 9. No percutaneous revascularization | 14 | ||
3. History of myocardial infarction | 12 | 100–119.9 | 18 | ||
120–139.9 | 14 | ||||
140–159.9 | 10 | ||||
160–199.9 | 4 | ||||
≥ 200 | 0 | ||||
6. Depressed ST–segment | 11 | ||||
Condition | Points | Total score | Stroke risk/year (%) | |
|---|---|---|---|---|
C | Congestive heart failure (or left ventricular ejection fraction ≤ 35 %) | 1 | 0 | 0 |
H | Hypertension: blood pressure consistently above 140/90 mmHg (or treated hypertension on medication) | 1 | 2 | 1.3 |
A2 | Age ≥ 75 years | 2 | 2 | 2.2 |
D | Diabetes mellitus | 1 | 3 | 3.2 |
S2 | Prior stroke or TIA or thromboembolism | 2 | 4 | 4.0 |
V | Vascular disease (e.g., peripheral artery disease, myocardial infarction, aortic plaque) | 1 | 5 | 6.7 |
A | Age 65–74 years | 1 | 6 | 9.8 |
Sc | Sex category (i.e., female sex) | 1 | 7 | 9.6 |
8 | 6.7 | |||
9 | 15.2 | |||
Points | Bleeding risk category | In-hospital bleeding rate (%) | |
|---|---|---|---|
Baseline hematocrit, % | Very low, ≤20 | 3.0 | |
<31 | 9 | Low, 21–30 | 5.5 |
31–33.9 | 7 | Moderate, 31–40 | 9.0 |
34–36.9 | 3 | High, 41–50 | 12.0 |
37–39.9 | 2 | Very high, >50 | 19.0 |
≥40 | 0 | ||
Creatinine clearance, a mL/min | |||
≤15 | 39 | ||
>15–30 | 35 | ||
>30–60 | 28 | ||
>60–90 | 17 | ||
>90–120 | 7 | ||
>120 | 0 | ||
Heart rate (bpm) | |||
≤70 | 0 | ||
71–80 | 1 | ||
81–90 | 3 | ||
91–100 | 6 | ||
101–110 | 8 | ||
111–120 | 10 | ||
≥121 | 11 | ||
Sex | |||
Male | 0 | ||
Female | 8 | ||
Signs of CHF at presentation | |||
No | 0 | ||
Yes | 7 | ||
Prior vascular disease† | |||
No | 0 | ||
Yes | 6 | ||
Diabetes mellitus | |||
No | 0 | ||
Yes | 6 | ||
Systolic pressure, mmHg | |||
≤90 | 10 | ||
91–100 | 8 | ||
101–120 | 5 | ||
121–180 | 1 | ||
181–200 | 3 | ||
≥201 | 5 |
Condition | Points | Total score | Risk of major bleeding/year (%) | |
|---|---|---|---|---|
H | Hypertension (uncontrolled blood pressure above 160/90 mmHg) | 1 | 0 | <1 |
A | Renal (dialysis, transplant, creatinine > 2.6 mg/dL or >200 μmol/L) and/or liver (cirrhosis, bilirubin > 2× normal or AST/ALT/AP > 3× normal) disease | 1 or 2 | 1–2 | 2–3 |
S | Stroke | 1 | ≥3 | 4–12 |
B | Bleeding (previous or predisposition to) | 1 | ||
L | Labile INR (unstable/high or TTR < 60 %) | 1 | ||
E | Elderly (i.e., age > 65 years) | 1 | ||
D | Drug usage predisposing to bleeding (antiplatelet agents, NSAIDs) and/or alcohol (≥8 drinks a week) | 1 or 2 |
Table 4.6
Patient’s risk profile
CHA2DS2-VASc | GRACE | HAS-BLED | CRUSADE |
|---|---|---|---|
Congestive heart failure 0 | Age | Hypertension 1 | Baseline hematocrit 3 |
Hypertension 1 | Heart rate | Abnormal liver or renal function 1 | Creatinine clearance 28 |
Age > 75 years 2 | Systolic blood pressure | Stroke 0 | Heart rate 3 |
Diabetes mellitus 1 | Creatinine | Bleeding 0 | Sex 8 |
Previous stroke/TIA 0 | Congestive heart failure | Labile INR 0 | Signs of congestive heart failure 0 |
Vascular disease 1 | Cardiac arrest on admission | Elderly > 65 years 1 | Prior vascular disease 0 |
Age 65–75 0 | ST segment deviation | Drugs or alcohol 0 | Diabetes mellitus 6 |
Sex (female gender) 1 | Elevated cardiac enzymes | Systolic blood pressure 3 | |
Total score | |||
6 = high risk | 145 = high risk | 3 = high risk | 51 = very high risk |
4.2 Periprocedural Issues
There are a number of considerations on timing of CORO/PCI, vascular access site, and management of antithrombotic therapy in a patient undergoing CORO/PCI on aggressive antithrombotic therapy, including OAC and concomitant administration of antiplatelet agents, because of the increased risk of bleeding and/or vascular complications.
The current European Society of Cardiology (ESC) guidelines on the management of non-ST-elevation acute coronary syndromes (NSTE-ACS) [2] recommend early angiography within 24 h after admission in patients with at least one of the following high-risk criteria (Table 4.7): a) rise or fall in cardiac troponin, compatible with myocardial infarction (MI), b) dynamic ST- or T-wave changes (symptomatic or silent), and c) GRACE score > 140.
Very high–risk criteria (within 2 h when at least one is present) |
Hemodynamic instability or cardiogenic shock |
Recurrent or ongoing chest pain refractory to medical treatment |
Life-threatening arrhythmias or cardiac arrest |
Mechanical complications of myocardial infarction |
Acute heart failure |
Recurrent dynamic ST- or T-wave changes, particularly with intermittent ST-elevation |
High–risk criteria (within 24 h when at least one is present) |
Rise or fall in cardiac troponin compatible with myocardial infarction |
Dynamic ST- or T-wave changes (symptomatic or silent) |
GRACE score >140 |
Intermediate–risk criteria (within 72 h when at least one is present) |
Diabetes mellitus |
Renal insufficiency (eGFR < 60 ml/min/1.73 m2) |
LVEF <40 % or congestive heart failure |
Early postinfarction angina |
Prior PCI |
Prior CABG |
GRACE risk score >109 and <140 |
Low–risk criteria |
Any characteristics not mentioned above |
Regarding periprocedural anticoagulation, it should be noted that rivaroxaban (and all other NOACs on average) has a half-life of 5–9 h and 7–13 h in elderly patients (Table 4.8) [4]. Whereas mild impairment of renal function is not expected to substantially prolong the elimination of (and the exposure to) rivaroxaban (and other NOACs), moderate renal impairment (i.e., creatinine clearance 30-50 ml/min) has been shown to prolong half-life (Table 4.8). In this latter situation, the recommended dose of rivaroxaban is 15 mg once daily. Periprocedural recommendations on the management of rivaroxaban should therefore be considered the same for both the settings above (Table 4.9) [5]. Also, such consideration likely applies to other NOACs, including the other factor Xa inhibitors apixaban and edoxaban, as well as the thrombin inhibitor dabigatran. Controversial, but apparently limited, is the value of laboratory tests to determine the level of anticoagulation in patients treated with NOACs [4]. A specific anti-Xa level can be determined for factor Xa inhibitors, whereas specific tests may be used for the thrombin inhibitor, but the clinical consequence for the given patient (i.e., that for adjusting the dose of an intravenous anticoagulant during PCI) is currently undefined. So far, no strong correlations have been shown between the anti-Xa level and the risk for embolic, ischemic, or bleeding complications [5].
Table 4.8
Main pharmacological properties of warfarin and non-vitamin K antagonist oral anticoagulants
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