The pathophysiology and presentation of acute coronary syndrome differs in patients with CKD and ESRD than in the general population. First, the presentation of patients with CKD is subtler and often times missed or incorrectly diagnosed. Second, the pathophysiology is more aggressive with more complex, with calcification and multivessel coronary disease, thus therapies tested in the general population might not be as effective in CKD and ESRD. Lastly, patients with ESRD are often excluded from clinical trials making generalization from these trials difficult.