Both the GWTG Quality Improvement Program and the North Carolina Reperfusion of Acute Myocardial Infarction in Carolina Emergency Department s initiative demonstrated that focused quality improvement efforts and programs designed to systematize care across integrated regional cen- ters can lessen disparities and improve the care of elderly patients with STEMI.23,41 Numerous studies have highlighted the fact that patients with chronic kidney disease of all stages less frequently receive guideline-recommended interventions than do patients with nor- mal renal function, despite evidence of benefit from most acute In a project that linked the US Renal Data System database with the NRMI (National Registry of Myocardial Infarction) 3, patients on dialysis had longer prehospital delays, werelessoftenrecognizedashavinganacuteMI,andlessoftenhad STelevationorLBBBoninitialECGthanpatientsnotondialysis. apy, and only 70% received aspirin on admission. The in-hospital Figure 1. Age- and sex-adjusted incidence rates of acute MI, 1999 to 2008. I bars represent 95% con- fidence intervals. MI indicates myocardial infarction; STEMI, ST-elevation myocardial infarction. Reprinted with permission from Yeh et al.14 O Gara et al 2013 ACCF/AHA STEMI Guideline e369 mortality rate was 21.3% among patients on dialysis, compared with 11.7% for patients with end-stage renal failure not on dialy- sis. At discharge, only 67% of patients on dialysis were pre- scribed aspirin, and only 57% were prescribed beta blockers. In the GRACE (Global Registry of Acute Coronary Events) regis- try, the in-hospital mortality rate was approximately 30% among patients with STEMI or LBBB MI with stage 4 or 5 chronic kidney disease. Both fibrinolysis and primary PCI were associ- ated with higher bleeding rates in patients with severely reduced Progressive renal dysfunction is a strong pre- dictor of bleeding with antithrombotic therapy, a risk that may reflect intrinsic renal dysfunction and/or failure to adjust or avoid antithrombotic medications that are dependent on renal 2.3. 