ACS in the setting of noncardiac surgery is associated with increased mortality. Several risk scores have been developed to determine the probability of mortality.646 648 A meta-analysis of the prognostic value of troponin and CK-MB after noncar- diac surgery that included 14 studies enrolling 3318 patients demonstrated that elevated troponin after surgery was an independent predictor of mortality both in the hospital and at Markedly elevated troponins are associ- ated with increased mortality compared with minimal troponin elevation, even though the latter still indicates a postoperative In patients with UA in whom the risks of bleed- ing with antiplatelet therapy outweigh the benefits, GDMT with beta blockers, nitrates, and ACE inhibitors should be optimized to achieve symptom control. In patients with a rela- tive or absolute contraindication to antiplatelet or anticoagu- lant therapy, coronary angiography may be helpful to identify anatomy requiring revascularization after recovery from the noncardiac surgery. 7.6. CKD: Recommendations Class I 1. CrCl should be estimated in patients with NSTE- ACS, and doses of renally cleared medications should be adjusted according to the pharmacokinetic data for specific medications.649,650 (Level of Evidence: B) 2. Patients undergoing coronary and LV angiogra- phy should receive adequate hydration. (Level of Evidence: C) Class IIa 1. An invasive strategy is reasonable in patients with mild (stage 2) and moderate (stage 3) CKD.649 652 (Level of Evidence: B) CKD is a major risk factor for poor outcomes in patients with Patients with impaired renal function have additional adverse baseline characteristics, including older age, a history of prior HF, and peripheral arterial disease. It is prudent to omit LV angiography in patients with CKD and assess LV function with echocardiography. 