Management of acute coronary syndrome in patients with chronic kidney disease: if we don't risk anything, we risk even more.

The utilization of coronary angiography and percutaneous coronary intervention in the routine care for patients with acute coronary syndromes (ACS) has resulted in significant improvement in their prognosis. Consequently, recommendations on the use of these management strategies are reflected in the ACC/AHA guidelines for the management of patients with unstable angina and myocardial infarction. However, among other causes, the 'phobia' of nephrotoxicity of iodinated contrast media (ICM) in chronic kidney disease (CKD) patients and its claimed adverse effect on short-term and long-term survival has led to a worryingly low use of ICM-based diagnostic and therapeutic interventions in patients with CKD. We argue that the fear of iodinated contrast media-induced acute kidney injury (ICI-AKI) is not a valid reason to avoid ICM-based investigations/interventions in CKD patients with ACS; the risks of myocardial infarction and death greatly outweigh the risk of ICI-AKI in most of these patients and hence they should always be considered for myocardial revascularization.