Ticagrelor in the Renal Dysfunction Subgroup: Subjugated or Substantiated?

Chronic kidney disease (CKD) is a serious condition associated with premature mortality, decreased quality of life, and increased health-care expenditures. The most recent data from the National Health and Nutrition Examination Survey estimated that the prevalence of CKD in the US population was 16.8% and had increased by 15.9% in comparison with that of the previous decade.1 These numbers are expected to rapidly increase with the aging of the population and furthermore with the epidemic of diabetes mellitus, a condition associated with a three-fold increase of the prevalence of CKD.2,3Article see p 1056 CKD prevalence is twice as high in patients with cardiovascular disease, and recent registry data using the contemporary Modification of Diet in Renal Disease equation have reported a prevalence of moderate or severe CKD of 30.5% in ST elevation myocardial infarction4 and 42.9% in non-ST elevation myocardial infarction. This figure is much higher than what is usually reported in controlled trials where patients with CKD are often excluded, but similar to what has been observed in other registries.5 Figure. Hazard ratio for efficacy (95% confidence interval) evaluated as the composite end point of cardiovascular death, myocardial infarction, or stroke, in the Clopidogrel in Unstable Angina to Prevent Recurrent Events (CURE), Clopidogrel for Reduction of Events During Observation (CREDO), TRial to assess Improvement in Therapeutic Outcomes by optimizing platelet inhibitioN with prasugre (TRITON) and PLATO trials according to renal function calculated with the Cockroft-Gault equation when not specified or the Modification of Diet in Renal Disease equation when indicated so. * indicates a significant relative risk reduction with the study criteria or a significant probability value for interaction between subgroups. NA indicates not available.Renal dysfunction is a powerful independent predictor of thrombotic and bleeding complications and, subsequently, of mortality. Worse clinical outcomes …