Dear friends, as I already mentioned to you we have with us Prof. Sandeep Bansal from Delhi, a very busy cardiologist from Safdarjung Hospital. You just heard few minutes ago, he gave his viewpoint on how to manage patients coming in the emergency with STEMI with an underlying almost end-stage kidney failure. Let us listen to Sandeep Bansal, his message and the protocol, which he recommends, what we should do in a setting of CKD or a renal failure in a patient who come with STEMI. Dr. Sandeep Bansal, please give your message and protocol how to manage such patients when they come in emergency so that we can protocolize and give this instruction to all the emergencies everywhere in India. How we can manage our patients to the best of our capability in a situation like this in CKD with kidney failure.
The first thing is to be able to judge whether the patient is really in chronic kidney disease or not. Because there can be situations where a person has a very severe acute ST elevation MI and because of renal hypoperfusion, there is a rise in the creatinine and that distinction is pretty much simple. We all know that ultrasounds are available and so with the help of the kidney size and cephalopelvic differentiation, those are the two important features that we look for, we can know whether it is an acute renal failure or a chronic renal failure. So the subset that we are referring to right know is those patients who have chronic kidney disease as we talked. The second step is that based on the creatinine that we get, we need to calculate the EGFR in these patients and as we are aware, we again do not have to keep this in our minds any longer, they are available on all the smart phones, the apps can be easily downloaded. There are different methods to calculate the EGFR that are there and the most widely recommended, my nephrology friends recommend, that there is a method called an EPI method, which is again available in the app, so you calculate the EGFR. The calculation of this EGFR is extremely important one to categorize the degree of renal failure and also because that tells us whether we would be able to do procedure safely and whether a person would need renal replacement therapy in the form of dialysis in the background or not. For example, if somebody’s EGFR is 40 mL then we multiply it by a factor of 3.75 and we get the total amount of dye that can be safely given to these patients without having to resort to dialysis. On the other hand, if a patient is in absolutely end-stage renal disease where he needs a renal replacement therapy, which means EGFR of less than 15 mL/min per 1.37 m. sq area then that means these patients are going to anyway need a dialysis. So depending upon the clinical situation there can be situations where the person cannot undergo dialysis because he is so sick, so in those patients perhaps our hands are kind of tied down, we can only give you know dual antiplatelets plus we can give some blood thinners like enoxaparin, that is all that we can do. However, if the patient’s EGFR allows, we can take these patients for an angioplasty. Again it will depend upon what you find when you do an angiography. Most of us can do angiographies now with very low amount of dye. I find that most of the times we use less than 50 mL. in fact 30 to 40 mL of dye, we are able to do our angiographies all the time. So if upon that we find that in another few mL we would be able to do the angioplasty also that is the best option. World over it has now recognized that primary angioplasty is the best option. If your EGFR is reasonable, you are in a scenario where you are not able to do a primary angioplasty then giving a thrombolytic as I said is a better option. Among the thrombolytics, I would like to choose something that is fibrin specific and is less likely to cause intracranial hemorrhage, because these patients would be at a greater risk for intracranial hemorrhage, so I would like to use say tenecteplase, which is fibrin specific, it is a single shot bolus, it is rapidly acting, causes less ICH, so that would be my drug of choice. Most of the times, the dual anti platelet therapy is not a contraindication, it can be safely given. If we have thrombolysed the patient, then we also have to give enoxaparin to these patients. Again it has to modified perhaps in some patients of CKD who have really low EGFR. There are no standard guidelines as such, but I would believe that it has to be individualized from patient-to-patient. The other therapies that are concerned are ACE inhibitors and beta blockers and statins. Statins in STEMI you would treat as you normally do. You have to give initially high dose of statins and you know continue to give high dose of statins starting within the first 24 hours of ST elevation MI. ACE-inhibitors, again I firmly believe, at least my nephrology friends do believe that there is absolutely no contraindication for an ACE-inhibitor. No level of creatinine as we commonly believe it is 2 or 2.5 or 3, I find that my nephrology friends use ACE-inhibitors at any creatinine levels. The only thing is we have to be able to watch the potassium. If we are able to watch the potassium then there is no level of contraindication to using the ACE-inhibitors, however, for a general physician, for a person who is not in a multi-specialty hospital set up and is ready to tackle all the complications, perhaps in those scenarios and many a times we have patients who cannot get their potassiums done so regularly, so in those scenarios, perhaps a creatinine of 2.25 or 2.5 would be the upper limit where I would safely use an ACE-inhibitor. Beta blockers again have to be used as per the requirements of the patient. If there is tachycardia you have to use beta-blockers, but you have to start with a lower dose in these patients and build up the dose as the heart rate response comes in. Again, there are a lot of precautions that we have to do while we take these patients for angioplasty. If the patient is in heart failure, it is the most tricky situation, because you cannot give adequate fluids to these patients, otherwise most of the times, we say that you start with a saline infusion which would be started quite well prior to the procedure. Keep these patients hydrated, keep within the limits of the dye load that we can give to these patients and I guess that is the way these patients are acutely managed.
Very nice Sandeep, I think you have mentioned very clear-cut that the contraindication is not always a contraindication. We have to do individualize our patient, see what we can do best for the patient, because every individual responds in a different manner. I think the way you have mentioned, that we can give contrast to a limited number of patients, we go by the EGFR. There are some guidelines. There are some criteria and it depends on in which situation, where and who is managing the patient. Is it a multi discipline or it is a small community hospital or a small centre, I think all these limitations are very important where the facilities are, where the facilities are not. So we should be bold. We have to see what are the benefits versus hazards. Our therapy can be given and we should not be in any fear, oh this patient is of a CKD or a renal failure, I cannot do angioplasty, I cannot do angiography, I think this myth should be out. The second point you mentioned very categorically tenecteplase. I still would like to ask you, should the dose of TNK should be weight adjusted here or there is a limitation that we give less dose of TNK like we do in elderly to prevent the hemorrhagic complication, we sometime reduce to half the dose. What is your message, take home message Sandeep?
See, by and large we need to give 0.5 mg/kg of tenecteplase. That is the standard dosage. For the elderly, it has been recommended that if somebody is beyond 75 may be we could put it down to 70 in our country, if somebody is more than that then we cut down the dose by 50% because that leads to lesser incidence of ICH. As far as the renal failure patients are concerned, there are really no recommendations as such. If the patient happens to be older, the same 50% cut.
Sandeep is very bold and he is saying there is no recommendation, please create your own protocol. Give it to your patients the full dose and see who responds in what way and create your own literature, create your own data. It is the subset of patient, which we need more validation, but I think tenecteplase can easily be given. The message is very clear. The message is manage the STEMI for the sake of STEMI with comorbidity. Comorbidity has to be considered very important, but the STEMI which is a life-taker, we have to save the life in whatever best we can. And I think Sandeep gave a very nice message that it is not only tenecteplase or angioplasty or stenting, even the drugs, which are used. He was very, very bold in saying that ACE-inhibitors is no more a contraindication even if the creatinine level is high. The only thing which we should keep in mind is measuring the potassium level which is very important. In a tertiary hospital with a huge team work, nephrologist colleagues are there, cardiologists are there and everybody manage to the best of capability, but in a small hospital there are limitations we have to be a little careful. Similarly, beta-blockers and diuretics, because all these patients are hemodynamically compromised. He also gave a situation, if a patient has got CKD with STEMI and is in a state of cardiologic shock, you must take a decision purely on individual basis, but what is the objective? The objective is only one, what best I can do for my patient to get him out from this jeopardy. Thank you Sandeep. It was very nice.