Clinical Decisionmaking

Concern about bleeding problems should not delay giving clot-busting drugs to heart attack patients with kidney disease

People suffering from mild to moderate kidney disease have a 2- to 4-fold risk, respectively, of dying after a heart attack than those with normal kidney function. Yet, patients with kidney disease are less likely to receive recommended clot-busting (thrombolytic) medications after a heart attack. Physicians may be reluctant to give thrombolytic medications to heart attack patients with kidney disease due to their concern about potential bleeding problems these medications might cause. According to a new study, however, heart attack patients with worse kidney function are not at greater risk for hemorrhage or other bleeding problems due to thrombolytic medication than patients with normal kidney functioning.

These findings support existing recommendations for expedient thrombolytic treatment for heart attack patients with kidney disease, conclude the researchers. Supported in part by the Agency for Healthcare Research and Quality (HS13853), they retrospectively analyzed data on all Medicare heart attack patients from 4,601 hospitals. They measured time to receipt of thrombolytic medication within 6 hours of hospital arrival and bleeding events. Nearly 14 percent of the 109,169 patients received thrombolytic therapy.

Average time to thrombolytic therapy was longer in patients with worse kidney function. For instance, average time to receipt of thrombolytic therapy for patients with normal kidney function (serum creatinine level of 1.5 mg/dL or less) was 70.8 minutes after hospital arrival, for those with moderately impaired kidney function (serum creatinine level greater than 2.0), 88.3 minutes, and for dialysis patients, 86.7 minutes. Yet, dialysis patients who received thrombolytics did not have significantly more bleeding problems than those with normal kidney function. Both groups were about twice as likely to suffer from bleeding problems as patients not given thrombolytics.

See "Delay in time to receipt of thrombolytic medication among Medicare patients with kidney disease," by Britt B. Newsome, M.D., M.P.H., M.S.P.H., David G. Warnock, M.D., Catarina I. Kiefe, M.D., Ph.D., and others in the October 2005 American Journal of Kidney Disease 46(4), pp. 595-602.

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