Acute coronary syndrome in ESRD patients

Abstract

CASE PRESENTATION A 55-year-old male with end-stage renal disease (ESRD) secondary to diabetic nephropathy on hemodialysis for 2 years via a tunneled catheter line was admitted to the Brigham & Women’s Hospital with chest pain. The chest pain was localized to the midline, radiated to the left arm, and was present at rest with no diaphoresis. His cardiac enzymes were elevated (troponin-I of 11.46 ng/ml and creatinine kinase-MB of 30.7 ng/ml) and his electrocardiogram (EKG) showed nonspecific ST–T wave changes that were unchanged from previous EKG 6 months earlier. He had a history of coronary artery disease (CAD) status post coronary artery bypass graft (CABG) 10 months earlier, type 1 diabetes mellitus since the age of 6 years, and peripheral neuropathy, blindness secondary to proliferative retinopathy, gastroparesis, neurogenic bladder, peripheral vascular disease (above-knee amputation of right limb), hypertension, and hypercholesterolemia. He had a failed living-related renal transplant because of recurrent diabetic nephropathy and chronic allograft nephropathy after 15 years. He had no history of stroke. His medications included aspirin, metoprolol, simvastatin, gemfibrozil, insulin, calcium acetate, sevelamer, epoeitin alfa, methadone, and hydromorphone hydrochloride. There was no significant family history of cardiovascular or renal disease. On physical examination, he was alert and afebrile, with a blood pressure of 135/60 mmHg, heart rate of 70 beats per minute, respiratory rate of 14 breaths per minute, with an oxygen saturation of 100% on room air and jugular venous pressure of 7 cm. His tunneled catheter site on the right side of the neck was clean, with no tenderness or erythema. Cardiac examination revealed distant heart sounds with no murmurs. The rest of the examination was unremarkable. CLINICAL DIAGNOSIS A clinical diagnosis of acute coronary syndrome (ACS) (a non-ST-elevation myocardial infarction (MI)) was made.