It is prudent to omit LV angiography in patients with CKD and assess LV function with echocardiography. In an analysis from 3 ACS trial databases of 19304 patients with NSTEMI, 42% (8152 patients) had abnormal renal func- tion on the basis of serum creatinine and calculated CrCl; total mortality and mortality/MI were increased at 30 days and 180 days. CrCl was independently associated with mortality (HR: 0.81) and the risk of mortality/MI (HR: 0.93).656 The VALIANT (Valsartan in Acute Myocardial Infarction) trial included 14527 high-risk patients with AMI with LV dysfunc- tion or HF and a serum creatinine level 1.5 mg/dL.658,659 The Modification of Diet in Renal Disease equation was used, and patients were analyzed based on their estimated GFR. There was an increasing adjusted HR for both death and the compos- ite endpoint of cardiovascular death, reinfarction, HF, stroke, or resuscitation after cardiac arrest with decreasing estimated GFR. For death, with a GFR <45.0 mL per minute/1.73 m2 , the adjusted HR was 1.70 compared with patients with a GFR in whom the adjusted HR was 1.14. There are insufficient data on the benefit-to-risk ratio of an invasive strategy in patients with NSTE-ACS and advanced CKD (stages 4 and 5).652 There is also less evidence-based medical therapy and revasculariza- tion data in patients with CKD because of the risk for con- trast-induced nephropathy, increased need for dialysis, and increased mortality. Multiple studies have evaluated radio- graphic agents, including ionic versus nonionic media and isosmolar or low-osmolar agents. The strength and consistency of relationships between spe- cific isosmolar or low-osmolar agents and contrast-induced nephropathy or renal failure are insufficient for selection of low-osmolar and isosmolar media. 