Key result
Clopidogrel in advanced CKD post-ACS is linked to frequent bleeding, ischemia, and ~33% 12-month mortality.
Why the study?
Patients with advanced CKD have high ischemic and bleeding risks after ACS but are underrepresented in trials, leaving real-world antiplatelet prescribing and outcome data limited.
In patients with advanced CKD or ESRD following ACS, real-world dual antiplatelet therapy is predominantly clopidogrel-based and is associated with high 12-month rates of mortality, recurrent ischemia, and bleeding.
Clinicians largely avoid ticagrelor in advanced CKD post-ACS; leaves open optimal P2Y12 strategy pending dedicated RCTs.
Background: Patients with advanced chronic kidney disease (CKD) experience disproportionately high ischemic and bleeding risks following acute coronary syndrome (ACS), yet remain markedly underrepresented in randomized trials of antiplatelet therapy. Consequently, real-world data describing antiplatelet prescribing patterns and clinical outcomes in this population are limited. Objectives: To describe real-world antiplatelet use and 12-month clinical outcomes in patients with advanced CKD and end-stage renal disease (ESRD) following ACS. Methods: We conducted a single-center, retrospective cohort study including adults with advanced CKD (stage 4–5) or dialysis-dependent ESRD hospitalized with ACS and discharged on dual antiplatelet therapy. Baseline characteristics, revascularization strategies, and clinical outcomes were collected. Outcomes of interest included all-cause mortality, recurrent ischemic events (recurrent myocardial infarction, stroke or transient ischemic attack, or repeat revascularization), and bleeding events defined by Thrombolysis in Myocardial Infarction (TIMI) criteria over 12 months. All analyses were descriptive in nature. Results: A total of 222 patients were included; clopidogrel was prescribed in 96.0% of patients and ticagrelor in 4.0%. The cohort was elderly, highly comorbid, and predominantly dialysis-dependent. At 12 months, all-cause mortality occurred in approximately one-third of patients, recurrent ischemic events were frequent, and bleeding complications were common. Most bleeding events occurred in dialysis-dependent individuals. Outcomes among ticagrelor-treated patients are reported descriptively only due to the very small sample size. Conclusions: In this real-world cohort of patients with advanced CKD and ESRD following ACS, a substantial burden of mortality, recurrent ischemic events, and bleeding complications was observed, underscoring the narrow therapeutic window in this high-risk population. These findings are descriptive and hypothesis-generating, supporting the need for individualized antiplatelet strategies and prospective studies specifically enrolling patients with advanced CKD.
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Alfehaid et al. (2026) studied this question. Advanced CKD patients following ACS were predominantly prescribed clopidogrel (96.0%) and experienced frequent bleeding, recurrent ischemia, and approximately 33% all-cause mortality at 12 months.
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