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Cardiac Risk In ESRD Patient
DR.BADR ALHOMAYEED.MD
NEPHROLOGY AND KIDNEY TRANSPLANT CONSULTANT
FEB/8/2014
Objectives:
Relation ship between ESRD and cardiovascular morbidity and
mortality.
Risk factors for the development of cardiovascular disease in ESRD
patient.
Different cardiovascular manifestations in ESRD patient.
Efforts to reduce cardiovascular risk in ESRD patient.
Conclusion.
Cardiac Diseases in maintenance Hemodialysis patients:
Result of the HEMO Study
Percentage of Patients
100
90
80
70
60
50
40
30
20
10
0
Any cardiac disease
Ischemic Heart disease
Congestive heart failure
Arrythmia
Other heart disease
Kidney International (2004) 65,2380-2389
Causes of Death in Incident Dialysis Patients, 2009-2011, First
180 days
USRDS 2013
Causes of Death in Prevalent Dialysis Patients, 2009-2011
USRDS 2013
Survival of Patients with Cardiovascular Diagnoses &
Procedures, by Modality, 2009–2011
USRDS 2013
Risk Factors For Cardiovascular disease in ESRD patients.
Henrich W L CJASN 2009;4:S106-S109
Congestive Heart Failure in Dialysis Patients
Congestive heart failure is a common presenting symptoms of
cardiovascular disease in dialysis population.
CHF contributes significantly to mortality and morbidity and also
worsens the quality of life in ESRD patients.
Overt left ventricular hypertrophy (LVH) is very common.
Myocardial disease can also reduce cardiac reserve, making the patient
more vulnerable to episodes of hypotension during dialysis.
Rates of a CHF diagnosis in ESRD patients
USRDS 2013
Heart failure in prevalent dialysis patients, by modality, 2011
USRDS 2013
Long-term Survival of Incident Hemodialysis Patients who are
Hospitalized for Congestive Heart Failure, Pulmonary Edema, or
Fluid Overload.
Banerjee D et al. CJASN 2007;2:1186-1190
Salt+H2o retention , AVF,
Anemia
Hypertension
LV pressure
overload
Conc. LVH




HPTH
Malnutrition
Uremic toxins
Dialysis induced
low BP
LV volume over
load
Eccentric LVH
Vascular
remodeling
Overload
cardiomyopathy
LV dilatation &
Hypertrophy
 Myocytes death
 Myocardial fibrosis
 Decrease capillary
perfusion
Diastolic
dysfunction
Systolic
dysfunction
Nephrol Dial Transplant (2000) 15 [Suppl 5]: 58–68
Cardiac fibrosis associated with increased mortality in
ESRD patients.
Henrich W L CJASN 2009;4:S106-S109
Reduction in systolic BP during hemodialysis in patients
with and without HD-induced regional wall motion
abnormalities (RWMAs).
Burton J O et al. CJASN 2009;4:914-920
Change in EF at rest and during HD over 12 mo in patients
with fixed reductions in segmental function of >60%.
Burton J O et al. CJASN 2009;4:1925-1931
The association of hemodialysis-induced RWMAs with mortality and
outcome.
Burton J O et al. CJASN 2009;4:914-920
Unadjusted survival in patients with systolic and diastolic heart
failure, by age, 2010–2011
Systolic Heart failure
Diastolic Heart Failure
USRDS 2013
Coronary artery disease in ESRD
Approximately 20% of mortality in ESRD patient can be
attributed to coronary artery disease.
Many dialysis patients have more than one of the
traditional risk factors , resulting in an even higher risk of
adverse outcomes.
Patients who have both DM and HTN have a 5-6 fold
increased risk of having heart disease compared to those
without history of either condition.
Am J Kidney Dis.2005; 45(2):316
Biochemical, Functional, and Anatomic evaluation of
Coronary Heart Disease in ESRD
Stenvinkel P et al. JASN 2003;14:1927-1939
Stable Coronary Artery Disease
Clinical manifestation:
-Frequent hypotension or chest pain on hemodialysis.
-Exercise induced chest discomfort.
-Exertional dyspnea.
-Sudden cardiac arrest.
-Sudden cardiac death.
-Arrhythmia.
Screening
- If there is a change in symptoms related to IHD or clinical status (e.g. Recurrent low BP
, CHF unresponsive to dry weight changes, or inability to achieve dry weight because of
hypotension), evaluation for CAD is recommended.
-Dialysis patients with significant reduction in LV systolic function (EF<40%) should be
evaluated for CAD.
- Evaluation for heart disease should occur at initiation of dialysis and include a
baseline electrocardiogram (ECG) and echocardiogram. Both of these tests provide
information pertinent to, but not restricted to, CAD evaluation. Annual ECGs are
recommended after dialysis initiation.
K/DOQI clinical practice guidlines
Screening
- If the patient has “complete” coronary revascularization (i.e., all ischemic coronary
vascular beds are bypassed), the first re-evaluation for CAD should be
performed 3 years after coronary artery bypass (CAB) surgery, then every 12
months thereafter.
- If the patient has “incomplete” coronary revascularization after CAB surgery
(i.e., not all ischemic coronary beds are re vascularized), then evaluation for
CAD should be performed annually.
K/DOQI clinical practice guidlines
Screening
- CAD evaluation should also include exercise or pharmacological stress
echocardiographic or nuclear imaging tests.
-“Automatic” CAD evaluation with stress imaging is currently not
recommended for all dialysis patients .
- Stress imaging is appropriate (at the discretion of the patient’s physician) in
selected high-risk dialysis patients for risk stratification even in patients who
are not renal transplant candidates. (C)
-Patients who are candidates for coronary interventions and have stress teststhat are positive for ischemia should be referred for consideration of
angiographic assessment. (C) K/DOQI clinical practice guidelines
Acute Coronary Syndrome
The evaluation and diagnosis of the dialysis patients with an acute
coronary syndrome is based upon the constellation of symptoms
and signs, findings on electrocardiogram, and levels of cardiac
biomarkers.
Dialysis patients with an acute coronary syndrome may present
with atypical symptoms and signs.
Admission Variables for ESRD patient with ACS
Dialysis
(n=3049)
Variable
Non Dialysis
(n=534935)
Admission Diagnosis
P.value
< 0.0001
MI
657
(21.8)
229207 (43.8)
R/O MI
713
(23.7)
122752 (23.5)
Unstable Angina
291
(9.7)
59943 (11.9)
other
1348 (44.8)
110836 (21.2)
Systolic Blood Pressure
Mean+/- SD
143.6 +/- 39.3
143.8+/-32.3
1.0000
Median
143
142
1.0000
Mean+/- SD
75.5+/-20.7
80.7+/- 18.5
< 0.0001
Median
74
80
< 0.0001
Pulse BPM : Mean +/- SD
94.7+/- 24.1
86.7+/-24.2
< 0.0001
Pulse BMD: Median
92
84
< 0.0001
Diastolic Blood Pressure
Herzog et al Circulation September 25, 2007
Admission Variables for ESRD patient with ACS
Variables
Dialysis (n=3049)
Chest Pain
1325 (44.4)
3553442 (68.3)
< 0.0001
No CHF
1775 (58.4)
394914 (75.2)
< 0.0001
Rales, JVP distention
764 (24.1)
83433
(15.9)
< 0.0001
pulmonary oedema
461 (15.2)
40074
(7.6)
< 0.0001
Cardiogenic Shock
39
6778
(1.3)
< 0.0001
(1.3)
Non dialysis (n=534935)
P.value
ECG:
ST elevation
579 (19.1)
188099 (35.9)
< 0.0001
ST depression
840 (27.7)
151492 (28.9)
1.0000
Non specific
1338 (44.1)
187650 (35.8)
< 0.0001
Q wave
970 (5.6)
46744 (8.9)
< 0.0001
LBBB
244 (8.1)
30134 (5.8)
< 0.0001
RBBB
198
(6.5)
30485 (5.8)
1.0000
Normal
193
(6.4)
40196 (7.7)
0.3294
Other
760
(24.1)
92146 (17.6)
< 0.0001
Herzog et al Circulation September 25, 2007
Admission Variables for ESRD patient with ACS
Variables
Dialysis (n=3049)
Non dialysis (n=534935)
P.values
Myocardial Infarction type
Antero/septal
508
(16.7)
126566 (23.7)
< 0.0001
Inferior
555
(18.2)
163559
(30.6)
< 0.0001
Posterior
65
(2.1)
23060
(4.3)
< 0.0001
Lateral
293
(9.6)
66367
(12.4)
< 0.0001
Rt. Ventricle
involvement
13
(0.4)
3624
(0.7)
1.0000
Unspecified/other
1892
(62.1)
229312
( 42.9)
< 0.0001
Q wave
78
(22.1)
199602 ( 37.4)
< 0.0001
Non Q wave
2371 ( 77.8)
334793 (62.6)
< 0.0001
Herzog et al Circulation September 25, 2007
Rates of an AMI event in ESRD patients
USRDS 2013
Estimated mortality of dialysis patients after acute
myocardial infarction (MI).
Herzog C A JASN 2003;14:2556-2572
Cause Specific Mortality of Dialysis patients after
Coronary Revascularization
Herzog C A et al. Nephrol. Dial. Transplant. 2008;23:2629-2633
Sudden Cardiac Death In ESRD
Sudden Cardiac Death (SCD) is the single most common cause of
death in dialysis patients.
It accounts for 20-30% of all deaths.
Over all incidence of SCD in this population is greater than coronary
events.
The risk of SCD persist after coronary revascularization.
Rate of Sudden Cardiac Death in Prevalent ESRD patient
by Modality
USRDS 2013
Distribution of deaths according to day of the week for
hemodialysis patients
Percentage of deaths
20
15
10
5
0
Sunday
Monday
Tuesday
cardiac arrest
Wedenesday
all cardiac
Thursday
Friday
Saturday
control
Bleyer et al, kidney International 1999.55:1553-1559
Probability of Sudden Cardiac Death in Incident ESRD
patient by modality
USRDS 2103
Risk Factors for Sudden Cardiac Death among ESRD
Dialysis Patient
Herzog et al. Seminars in Dialysis, 2008
Prevention of sudden death in dialysis patients.
Reduction of
‐ Cardiac hypertrophy &
fibrosis
‐ Fatal arrhythmia
‐ Heart rate variability
Avoiding low K
dialysate & rapid
electrolyte shifts:
Prevention of sudden
death
ACEI and ARBs
To avoid
‐ Cardiac arrest and
‐ Life‐threatening ventricular
tachycardia
External
& implantable
defibrillator
To avoid:
‐ QT dispersion
‐ Réentrant arrhythmias
‐ Premature VES
Beta blockers
Reduction of
‐ Cardiac hypertrophy &
fibrosis
‐ Antifibrillary activity
‐ Ventricular arrhythmia
‐ Heart rate variability
‐ Increase in baroreflex
sensitivity
‐ Reduced risk of acute MI
Blood Purif 2010;30:135–145
Atrial Fibrillation
End stage renal disease patients are more at risk for atrial
fibrillation than the general population.
AF is more prevalent in end-stage renal disease patients compared
to age-matched individuals with normal renal function .
Hemodialysis is associated with higher risk for AF compared to
peritoneal dialysis.
Left ventricular hypertrophy and electrolyte shift are strong
predisposing factors for development of AF.
Incidence of Atrial Fibrillation in Patient with ESRD
Zimmerman D et al. Nephrol. Dial. Transplant. 2012;27:3816-3822
Prevalence of Atrial Fibrillation in Patient with ESRD
Zimmerman D et al. Nephrol. Dial. Transplant. 2012;27:3816-3822
Mortality in patients with ESRD with and without
atrial fibrillation.
Zimmerman D et al. Nephrol. Dial. Transplant. 2012;27:3816-3822
Anticoagulation
Bleeding
Thrombosis
Stroke in patients with ESRD with and without
atrial fibrillation.
Zimmerman D et al. Nephrol. Dial. Transplant. 2012;27:3816-3822
Valvular Heart disease
Valvular heart disease is common in patients on
maintenance dialysis.
Valvular and annular thickening and calcification of the
heart valves with subsequent development of regurgitation
and/or stenosis of the affected one.
Aortic and mitral valve are commonly affected.
Predisposing Factors:
1-Secondary hyperparathyrodisim
8-Infective endocarditis
2-HTN
9-Mitral valve prolapse
3-DM
10-High cardiac out put state
4-LVH
11-Anemia
5-Malnutrition/ inflammatory complex 12-Arteriovenous fistula
6-Uremia
7-Hypertrophic cardiomyopathy
13-Hyperlipidemia
Pericardial disease
Patients with end-stage renal disease may develop pericarditis and
pericardial effusions, and less commonly, chronic constrictive
pericarditis.
Two forms of pericarditis in renal failure have been described
including uremic and dialysis-associated.
Uremic pericarditis results from inflammation of the visceral and
parietal membranes of the pericardial sac.
 At least two factors may contribute to dialysis associated
pericarditis: inadequate dialysis and/or fluid overload .
Alpert et al Am J Med Sci. 2003;325(4):228
Conclusion:
End stage renal disease is a situation with a cardiovascular
risk profile of almost unique severity.
ESRD patient is at high cardiac risk precipitated by both
traditional and non traditional risk factors.
Different cardiac manifestations with various degree of
severity and presentations are unique to ESRD patient on
dialysis.
Sudden cardiac death is the single most common cause of
death in ESRD patient.