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Choice of Beta Blocker. Objectives  Gain an appreciation and understanding of the management of Left Ventricular Hypertrophy in hemodialysis patients.

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Presentation on theme: "Choice of Beta Blocker. Objectives  Gain an appreciation and understanding of the management of Left Ventricular Hypertrophy in hemodialysis patients."— Presentation transcript:

1 Choice of Beta Blocker

2 Objectives  Gain an appreciation and understanding of the management of Left Ventricular Hypertrophy in hemodialysis patients  Review the evidence supporting selection of a beta-blocker in hemodialysis patients

3 Mr. TC  58 yoa male admitted on 4 Dec  ID ht: 172 cm wt: 52 kg BMI: 17.6  CC: cough/SOB, leg swelling  HPI: was in Victoria visiting son, progressively weak over 2 days  Previous admission – NRGH Oct 2011 for LLL pneumonia - ICU

4 Mr. TC  PMH: DM, diabetic retinopathy, hypertension, dyslipidemia, chronic kidney disease - diabetic nephroslcerosis with protinuria, hypokalemia  Surgeries: Bilateral cataract extractions, left finger amputation – saw injury  Allergies: none  Compliance: supported by daughter who helps to organize medications in dosette. No issues

5 Mr. TC  Social History:  Lives at home with spouse and 5 children  Chauffeur  Born in China and emigrated to Canada at age 16  Non smoker, non drinker  No illicit drug use

6 Medications PTA ConditionMedication Hypertensionramipril 5 mg daily amlodipine 2.5 mg daily CKDepoeitin 4000 Units twice weekly ferrous gluconate 300 mg TID furosemide 20 mg QAM and 40 mg lunch calcium carbonate 1250 mg TID AC Ranitidine 150 mg daily

7 Medications PTA ConditionMedication DiabetesInsulin glargine 6 units HS aspart via sliding scale HyperlipidemiaRosuvastatin 10 mg HS

8 New Diagnoses  Severe CAD – CABG x 3 15 Dec  Acute renal insufficiency – start HD 18 Dec for volume control  Recurrent bradycardia – code blue X 3  DDDR pacemaker  Left Ventricular Hypertrophy  EF 40% prior to CABG, improved to 50% by 28 Dec

9 Discharge Medications – 12 Dec ConditionMedication Hypertensionramipril 5 mg daily ERSDacetaminophen mg Q6H prn epoeitin 6000 Units three times/week ferrous gluconate 125 mg IV Q 2 weeks calcium carbonate 500 mg TID AC pantoprazole 40 mg daily replavite 1 tablet daily dousate sodium 100 mg BID lactulose ml BID PRN sennosides 1-2 tabs daily PRN furosemide 80 mg BID

10 Discharge Medications ConditionMedication Diabetesinsulin regular 30 %/NPH 70% 10 units QAM and 12 units QPM Hyperlipidemiarosuvastatin 10 mg HS Post CABGASA 81 mg daily metoprolol 25 mg BID

11 Labs 11 Jan  Hg 72 HCT 0.22 MCV 89 Retic 60  Iron 7 Fe Sat 0.18 Ferritin 764  Na 133, K 5.1 Cl 103 CO2 24  Scr 208, EGFR 29 70% Urea Reduction  TSH 2.65 Alb 31  Ca 2.17 PO PTH 6.9

12 DRPs  Patient is at risk of morbidity and mortality due to left ventricular hypertrophy (LVH)  Patient is anemic and at risk of morbidity and worsening LVH  Patient is hyperphosphatemic and at risk of mineral bone disease

13 Primary Goals of Therapy  Health Care Team  Reduce morbidity and mortality associated with dialysis and cardiovascular disease  Regress left ventricular hypertrophy  Achieve targets for diabetes control  Patient  Wishes to be off dialysis  Return to work

14 Left Ventricular Hypertrophy  Occurs in up to 80 % of dialysis patients  Major risk factor for mortality  2/3 die from heart failure or sudden death  Worsening LVH  Strong predictor of sudden death and arrhythmias  Associated prolonged QT interval and dispersion  Major risk factors  Increasing age, hypertension, volume overload and anemia

15 LVH Management  Control blood pressure  Conerstone is volume control  Antihypertensive medications  Correct anemia  Maintenance of calcium and phosphate mineral balance  Vascular calcification

16 Antihypertensive medications

17 PICO  Patient: Post CABG dialysis patient with left ventricular hypertrophy  Intervention: metoprolol  Comparator: other beta blockers  Outcome: mortality, regression of left ventricular hypertrophy

18 Literature Search  Search terms  Dialysis or hemodialysis, beta blockers  Databases  Medline, IPA, CDSR, ACP Journal Club  Limits  Humans, English  Results  2 RCTs – 1 retrospective cohort study

19 . Cice, G., Ferrara, L., Di Benedetto, a, Russo, P. E., Marinelli, G., Pavese, F., & Iacono, a. (2001). Dilated cardiomyopathy in dialysis patients--beneficial effects of carvedilol: a double-blind, placebo-controlled trial. Journal of the American College of Cardiology, 37(2),

20 Cice 2001  P: N=114, hemodialysis with symptomatic heart failure (NYHA II-III), EF<0.35  I: carvedilol highest tolerated dose to 25 mg BID  C: placebo  O: changes in LV end-systolic and end-diastolic volumes, LVEF and heart failure symptoms after 12 months

21 Results CarvedilolMetoprolol Basal12 monthsBasal12 months LVEDV ml/m ± 994 ± 497 ± 898 ± 6P<0.05 LVESV ml/m 2 74 ± 862 ± 872 ± 972 ± 8P<0.05 LVEF %26 ± 836 ± 1126 ± 8 P<0.05

22 Limitations  small numbers, short duration  open label  no intention to treat  excluded recent MI or CABG in past 3 months

23 Cice, G., Ferrara, L., D’Andrea, A., D’Isa, S., Di Benedetto, A., Cittadini, A., Russo, P. E., et al. (2003). Carvedilol increases two-year survival in dialysis patients with dilated cardiomyopathy. Journal of the American College of Cardiology, 41(9),

24 Cice 2003  P: as per 2001 study - continuation  I: carvedilol highest tolerated dose to 25 mg BID  C: placebo  O: primary - as per 2001,  secondary - all-cause mortality, all-cause hospital admission, cardiovascular mortality, acute non- fatal MI and composite

25 Results CarvedilolMetoprolol Basal12 months 24 months Basal12 months 24 months LVEDV ml/m ± 994 ± 494 ± 597 ± 898 ± 6100 ± 5P<0.05 LVESV ml/m 2 74 ± 862 ± 864 ± 672 ± 972 ± 874 ± 3P<0.05 LVEF %26 ± 836 ± 1137 ± 1026 ± 8 24 ± 10P<0.05

26 Results

27 Limitations  small numbers, short duration  open label  No intention to treat  Excluded recent MI or CABG in past 3 months

28 Abbott, K. C., Trespalacios, F. C., Agodoa, L. Y., Taylor, A. J., & Bakris, G. L. (2004). β-Blocker Use in Long-term Dialysis Patients: Association With Hospitalized Heart Failure and Mortality. Archives of internal medicine, 164(22), Am Med Assoc.

29 Abbott 2004  P: N=2550, peritoneal and hemodialsysis from, DMMS Wave 2, with and without LVH  I/C: risk associations of medication classes used to outcome  Chart review – medications at start of study  Beta blockers analyzed with subdivision  Cardioselective vs non-cardioselective  O: admission for HF, cardiovascular related death, or death from any cause  Medicare claims over 4 years

30 Demographics

31 Results

32

33 Limitations  Retrospective cohort analysis  Hypothesis generating  small numbers, underpowered  Did not follow medication changes  Did not report on outcome of death alone  Carvedilol not included in study  FDA approved 1997

34 Recommendation  recommend continue metoprolol  follow up echo in 3 months to assess LVD

35 Monitoring Plan WhatWhoWhen Blood pressureRNOngoing Anemia – by AMPRN, Pharmacistmonthly Signs/Sx heart failureRN, MD, PharmacistOngoing Metoprolol adverse effects (dizziness, headache, depression, puritis, diaahea, bradycardia, cold extremities) RN, MD, PharmacistOngoing

36

37 References 1. Up to Date 2. Kidney Disease Outcomes Quality Initiative (KDOQI) Guidelines, 2002 The National Kidney Foundation 3. Cice, G., Ferrara, L., Di Benedetto, a, Russo, P. E., Marinelli, G., Pavese, F., & Iacono, a. (2001). Dilated cardiomyopathy in dialysis patients--beneficial effects of carvedilol: a double-blind, placebo-controlled trial. Journal of the American College of Cardiology, 37(2), Cice, G., Ferrara, L., D’Andrea, A., D’Isa, S., Di Benedetto, A., Cittadini, A., Russo, P. E., et al. (2003). Carvedilol increases two-year survivalin dialysis patients with dilated cardiomyopathy. Journal of the American College of Cardiology, 41(9), Abbott, K. C., Trespalacios, F. C., Agodoa, L. Y., Taylor, A. J., & Bakris, G. L. (2004). Β-Blocker Use in Long-term Dialysis Patients: Association With Hospitalized Heart Failure and Mortality. Archives of internal medicine, 164(22), Am Med Assoc.


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