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Prescribe statins in all patients with CKD, say researchers

GPs should treat patients with chronic kidney disease as if they have a 'coronary risk equivalent' and routinely treat them with statins, say researchers.

Their study found that patients with CKD had a greater risk of a first myocardial infarction than those with diabetes.

Researchers in the US and Canada retrospectively investigated the coronary heart disease risk of 1,268,029 patients in outpatients clinics for measurement of serum creatinine and followed them for over four years.

They split these patients into groups based on their medical history and analysed their incidence of admission to hospital for a myocardial infarction.

Those with CKD – defined as an eGFR lower than 60 mL/min per 1.73m2 – without CVD had an incidence rate of a first myocardial infarction of 6.9 per 1,000 person years. This compared with an incidence in those with a previous myocardial infarction of 18.5 per 1,000 person years.

The incidence of a first myocardial infarction was significantly higher in those with CKD compared with those with diabetes, with an incidence of 5.4 per 1,000 person years respectively.

When a more stringent criterion to define CKD was used – an eGFR of lower than 45 mL/min per 1.73 m2 – the incidence of myocardial infarction exceeded 10 per 1,000 person years.

In all patients with CKD, regardless of diabetes status, there was an incidence of myocardial infarction of 8.0 per 1,000 person years.

The myocardial infarctions also appeared more serious in those with CKD. The proportion of participants who had died within 30 days of admission for a myocardial infarction was significantly higher, with a rate of 14% in CKD compared to 8% in those with diabetes.

 This value was also higher than patients with a history of myocardial infarction, where 10% of participants died within the 30-day period.

Study leader Dr Marcello Tonelli, associate professor of medicine at the University of Alberta, Canada, said their results showed guidelines needed to change.

He said: ‘Inclusion of people with CKD in the highest risk group for coronary heart disease would imply that most people in this population should receive lipid-lowering treatment, and findings from previous studies suggest that most would meet this criterion and would thus be candidates for statin treatment.'

Dr Ivan Benett, a GPSI in cardiology in Manchester, said the conclusions from the authors seemed ‘reasonable' and should be considered for inclusion in guidelines.

‘By extrapolating from other studies it seems reasonable to suggest these patients should be considered for statin therapy as well as the usual primary prevention advice on lifestyle and BP management.'

‘Those with eGFR less than 45 ml/min and significant proteinuria should be considered for simvastatin 40mg daily as part of a primary prevention strategy for that individual.'

‘This evidence should be considered in any review of primary prevention guidelines.'

 

Lancet, available online 19 June 2012

 

UNADJUSTED INCIDENCE RATES OF MI (PER 1,000 PERSON YEARS)

PATIENT GROUP

INCIDENCE RATE

History of MI

18.5

CKD (without history of MI or diabetes)

6.9

Diabetes (without CKD)

5.4

CKD (with or without diabetes)

8.0


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