How to Manage the Renal Patient with Coronary Heart Disease

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Abstract
The management of ischemic heart disease in patients with chronic kidney disease (CKD) is a special challenge for clini- cians. The recent heightened awareness of CKD as an impor- tant risk factor for cardiovascular death is a welcome devel- opment; the eventual outcome will be clinical trials targeting CKD patients for prevention and treatment of coronary heart disease and its devastating complications. The reader is urged to consult National Kidney Foundation (NKF) task forces dealing with cardiovascular disease in chronic renal failure (1,2) and, most recently, lipid management (3). At the present time, however, clinicians are often faced with a nettlesome dilemma in their approach to renal patients with ischemic heart disease; most of the evidence-based practice guidelines are based on clinical trials performed in patients without CKD. Patients with renal disease have typically been excluded from major cardiovascular treatment trials in the past; although there is no shortage of recent reviews on cardiovascular disease in renal disease (4 -10), there is most certainly a paucity of good clinical trial data in CKD patients. The application of imperfect data to clinical practice, however, is nothing new for clinicians, as this is common in medical practice. It is not my intention to offer a general review on cardio- vascular disease and renal disease, but rather to present my (admittedly idiosyncratic) approach to clinical management of coronary heart disease in renal patients distilled partly from the literature and personal experience. This paper will focus on cardiac disease in dialysis patients, but I will also attempt to frame special cardiac management issues pertaining to nondi- alysis CKD patients. Background Epidemiology and the Burden of Cardiovascular