Presentation on theme: "Cardiac Risk In ESRD Patient"— Presentation transcript:
1Cardiac Risk In ESRD Patient Dr.Badr Alhomayeed.mdNephrology and Kidney Transplant ConsultantFeb/8/2014
2Objectives:Relation ship between ESRD and cardiovascular morbidity andmortality.Risk factors for the development of cardiovascular disease in ESRDpatient.Different cardiovascular manifestations in ESRD patient.Efforts to reduce cardiovascular risk in ESRD patient.Conclusion.
3Cardiac Diseases in maintenance Hemodialysis patients: Result of the HEMO Study Kidney International (2004) 65,
4Causes of Death in Incident Dialysis Patients, 2009-2011, First 180 days USRDS 2013
5Causes of Death in Prevalent Dialysis Patients, 2009-2011 USRDS 2013
6Survival of Patients with Cardiovascular Diagnoses & Procedures, by Modality, 2009–2011 USRDS 2013
7Risk Factors For Cardiovascular disease in ESRD patients. Henrich W L CJASN 2009;4:S106-S109
8Congestive 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.
9Rates of a CHF diagnosis in ESRD patients USRDS 2013
10Heart failure in prevalent dialysis patients, by modality, 2011 USRDS 2013
11Long-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:
13Cardiac fibrosis associated with increased mortality in ESRD patients. Henrich W L CJASN 2009;4:S106-S109
14Reduction 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:
15Change 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:
16The association of hemodialysis-induced RWMAs with mortality and outcome. Burton J O et al. CJASN 2009;4:
17Unadjusted survival in patients with systolic and diastolic heart failure, by age, 2010–2011 Systolic Heart failureDiastolic Heart FailureUSRDS 2013
18Coronary 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
19Biochemical, Functional, and Anatomic evaluation of Coronary Heart Disease in ESRD Stenvinkel P et al. JASN 2003;14:
20Stable 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.
21Screening- 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 ofhypotension), evaluation for CAD is recommended.-Dialysis patients with significant reduction in LV systolic function (EF<40%) should beevaluated for CAD.- Evaluation for heart disease should occur at initiation of dialysis and include abaseline electrocardiogram (ECG) and echocardiogram. Both of these tests provideinformation pertinent to, but not restricted to, CAD evaluation. Annual ECGs arerecommended after dialysis initiation.K/DOQI clinical practice guidlines
22Screening- If the patient has “complete” coronary revascularization (i.e., all ischemic coronaryvascular beds are bypassed), the first re-evaluation for CAD should beperformed 3 years after coronary artery bypass (CAB) surgery, then every 12months thereafter.- If the patient has “incomplete” coronary revascularization after CAB surgery(i.e., not all ischemic coronary beds are re vascularized), then evaluation forCAD should be performed annually.K/DOQI clinical practice guidlines
23Screening- CAD evaluation should also include exercise or pharmacological stressechocardiographic or nuclear imaging tests.-“Automatic” CAD evaluation with stress imaging is currently notrecommended for all dialysis patients .- Stress imaging is appropriate (at the discretion of the patient’s physician) inselected high-risk dialysis patients for risk stratification even in patients whoare 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 ofangiographic assessment. (C)K/DOQI clinical practice guidelines
24Acute Coronary Syndrome The evaluation and diagnosis of the dialysis patients with an acutecoronary syndrome is based upon the constellation of symptomsand signs, findings on electrocardiogram, and levels of cardiacbiomarkers.Dialysis patients with an acute coronary syndrome may presentwith atypical symptoms and signs.
25Admission Variables for ESRD patient with ACS P.valueNon Dialysis(n=534935)Dialysis(n=3049)Variable<Admission Diagnosis(43.8)(21.8)MI(23.5)(23.7)R/O MI(11.9)(9.7)Unstable Angina(21.2)(44.8)otherSystolic Blood Pressure1.0000143.8+/-32.3/- 39.3Mean+/- SD142143MedianDiastolic Blood Pressure80.7+/- 18.575.5+/-20.7807486.7+/-24.294.7+/- 24.1Pulse BPM : Mean +/- SD8492Pulse BMD: MedianHerzog et al Circulation September 25, 2007
26Admission Variables for ESRD patient with ACS P.valueNon dialysis (n=534935)Dialysis (n=3049)Variables<(68.3)1325 (44.4)Chest Pain(75.2)1775 (58.4)No CHF(15.9)(24.1)Rales, JVP distention(7.6)(15.2)pulmonary oedema(1.3)(1.3)Cardiogenic ShockECG:(35.9)(19.1)ST elevation1.0000(28.9)(27.7)ST depression(35.8)(44.1)Non specific(8.9)(5.6)Q wave(5.8)(8.1)LBBB(5.8)(6.5)RBBB0.3294(7.7)(6.4)Normal(17.6)(24.1)OtherHerzog et al Circulation September 25, 2007
27Admission Variables for ESRD patient with ACS P.valuesNon dialysis (n=534935)Dialysis (n=3049)VariablesMyocardial Infarction type<(23.7)(16.7)Antero/septal(30.6)(18.2)Inferior(4.3)(2.1)Posterior(12.4)(9.6)Lateral1.0000(0.7)(0.4)Rt. Ventricleinvolvement( 42.9)(62.1)Unspecified/other( 37.4)(22.1)Q wave(62.6)( 77.8)Non Q waveHerzog et al Circulation September 25, 2007
28Rates of an AMI event in ESRD patients USRDS 2013
29Estimated mortality of dialysis patients after acute myocardial infarction (MI). Herzog C A JASN 2003;14:
30Cause Specific Mortality of Dialysis patients after Coronary Revascularization Herzog C A et al. Nephrol. Dial. Transplant. 2008;23:
31Sudden 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.
32Rate of Sudden Cardiac Death in Prevalent ESRD patient by Modality USRDS 2013
33Distribution of deaths according to day of the week for hemodialysis patients Bleyer et al, kidney International :
34Probability of Sudden Cardiac Death in Incident ESRD patient by modality USRDS 2103
35Risk Factors for Sudden Cardiac Death among ESRD Dialysis Patient Herzog et al. Seminars in Dialysis, 2008
36Prevention of sudden death in dialysis patients. Reduction of ‐ Cardiac hypertrophy & fibrosis‐ Fatal arrhythmia‐ Heart rate variabilityAvoiding low K dialysate & rapid electrolyte shifts:To avoid:‐ QT dispersion ‐ Réentrant arrhythmias ‐ Premature VESBeta blockersPrevention of sudden deathACEI and ARBsReduction of ‐ Cardiac hypertrophy & fibrosis ‐ Antifibrillary activity‐ Ventricular arrhythmia‐ Heart rate variability ‐ Increase in baroreflex sensitivity‐ Reduced risk of acute MITo avoid‐ Cardiac arrest and ‐ Life‐threatening ventricular tachycardiaExternal & implantable defibrillatorBlood Purif 2010;30:135–145
37Atrial FibrillationEnd 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.
38Incidence of Atrial Fibrillation in Patient with ESRD Zimmerman D et al. Nephrol. Dial. Transplant. 2012;27:
39Prevalence of Atrial Fibrillation in Patient with ESRD Zimmerman D et al. Nephrol. Dial. Transplant. 2012;27:
40Mortality in patients with ESRD with and without atrial fibrillation. Zimmerman D et al. Nephrol. Dial. Transplant. 2012;27:
44Valvular 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.
45Predisposing Factors: 8-Infective endocarditis1-Secondary hyperparathyrodisim9-Mitral valve prolapse2-HTN10-High cardiac out put state3-DM11-Anemia4-LVH12-Arteriovenous fistula5-Malnutrition/ inflammatory complex13-Hyperlipidemia6-Uremia7-Hypertrophic cardiomyopathy
46Pericardial diseasePatients 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
47Conclusion: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.