This handout is for nstemi in dialysis/eskd — troponin delta (not absolute) drives diagnosis; renally-reconciled therapy. Your care team identified this based on: chest pain or anginal equivalent (dyspnoea, fatigue, intradialytic hypotension) in a maintenance-dialysis / advanced-ckd patient — nstemi with troponin-interpretation challenge.
Other reasons your team may use this plan: troponin above the 99th-percentile url in an eskd patient — must establish whether this is a chronic stable baseline or an acute rise/fall; significant serial troponin change (rise and/or fall, e.g. ≥20% from an elevated baseline or beyond assay biological variation) in a dialysis patient with ischaemic context — acute mi signature; recurrent intradialytic hypotension with chest pain / st-t changes — peri-dialytic demand ischaemia vs type 1 nstemi.
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| aspirin | 162-325 mg load then 81 mg PO daily | PO | daily | 2023 ESC ACS — foundational antiplatelet; benefit maintained in CKD/ESKD though under-prescribed |
| ticagrelor | 180 mg load then 90 mg PO BID | PO | BID | 2023 ESC ACS — not renally dose-adjusted; PLATO renal subgroup showed preserved benefit; balance against high ESKD bleeding risk |
| clopidogrel | 300-600 mg load then 75 mg PO daily | PO | daily | No renal dose change; acceptable alternative when ticagrelor unsuitable; lower bleeding signal in very-high-risk ESKD |
| heparin (unfractionated) | weight-based IV per ACS protocol, aPTT/anti-Xa titrated | IV | continuous, monitored | 2023 ESC ACS — UFH preferred in dialysis: titratable, not renally cleared, predictable peri-procedural management around dialysis |
| enoxaparin (renally reduced) | 1 mg/kg SC ONCE daily (renal reduction) with anti-Xa monitoring if used | SC | daily | Renally cleared — accumulates in ESKD; if used at all, reduce to once-daily with anti-Xa monitoring; UFH generally preferred |
| atorvastatin | 80 mg PO daily (high-intensity) | PO | daily | High-intensity statin for ACS; note dialysis-initiation statin trials (4D/AURORA) were neutral for primary prevention but ACS secondary prevention still indicated |
| metoprolol | 12.5-25 mg PO BID, cautious uptitration | PO | BID | Post-MI benefit; cautious dosing given intradialytic-hypotension and dialysability considerations (metoprolol partially dialysed) |
| AVOID fondaparinux in severe renal failure | AVOID if CrCl <20-30 / dialysis | N/A | N/A | 2023 ESC ACS / label — fondaparinux is renally cleared and contraindicated in severe renal impairment/dialysis (accumulation, bleeding) |
| AVOID reflexive enoxaparin treatment-dose without renal reduction | AVOID standard BID treatment dosing in ESKD | N/A | N/A | Accumulation → major bleeding; if LMWH used, reduce dose + anti-Xa monitor; UFH preferred |
| Coronary angiography ± PCI with radial access + dialysis timing | Timely invasive strategy for confirmed type 1 NSTEMI; radial access; coordinate dialysis pre/post; protect residual renal function if not anuric | N/A | per risk stratification | ESKD patients are systematically under-revascularised yet derive benefit; do not withhold on ESKD alone (2023 ESC ACS); ISCHEMIA-CKD informs STABLE disease, not ACS |
Plan: ESKD NSTEMI antithrombotic + anti-ischaemic therapy — UFH preferred for ACS anticoagulation in dialysis; renally reconcile all agents; do not withhold an invasive strategy on ESKD alone (4th UDMI; 2023 ESC ACS; ISCHEMIA-CKD)
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
Establish/record a new post-event baseline troponin for future interpretation; secondary prevention (statin, antiplatelet duration balanced against high bleeding risk, BP/volume control via dialysis prescription, anaemia management); cardiology–nephrology shared care; transplant-evaluation cardiac clearance if a candidate; document the assay used and the individualised delta threshold
Guideline: 4th Universal Definition of MI (2018) + 2023 ESC ACS Guideline + 2025 ACC/AHA ACS framework + ISCHEMIA-CKD + KDIGO/KDOQI CV-in-CKD