1. Cardiovascular Disaster in Hemodialysis patients
Pattaraporn MD.

2. Causes of death in prevalent dialysis patients 2008-2010
41.6%
26.5%

3. Cardiovascular Disaster

4. Sudden death Unexpected natural death
Within a short time period >> 1-24 h
Due to cardiac etiology
New or more serious symptoms

5. Possible Mechanisms Responsible for SD in HD
Rapid electrolyte shifts/Hypervolemia
Myocardial interstitial fibrosis
Microvessel disease
CHF
CAD/MI
LVH/LV dysfunction
QT dispersion
Cardiac arrhythmia
cardiomyopathy
Cardiac arrest
Inflammation
Ischecmic heart disease
Sympathetic overactivity

6. Left ventricular Hypertrophy and Heart failure
Concentric LV hypertrophy
Eccentric LV hypertrophy

7. Left ventricular Hypertrophy and Heart failure
LVH is an powerful indicator of mortality in dialysis patients
Presence of LVH >>> arrhythmia
Left ventricular systolic dysfunction >> arrhythmia
Redaelli B: Lancet 1988;ii:305–309.

8. Myocardial Interstitial fibrosis and Microvessel disease
Inadequate capillary density + increased oxygen demand >> relative hypoxia >> fibrosis

9. Myocardial Interstitial fibrosis and Microvessel disease
Fibrous tissue >> high electrical resistance
Development of atrial and ventricular reentry types of arrhythmias
Risk factor for the development of arrhythmias especially during the dialysis

10. QT Dispersion
Difference between the longest and shortest QT intervals >> EKG 12 lead
Predict an increased risk of malignant arrhythmias
Normal value of QT dispersion in normal subjects was ≤40 ms
Dialysis patients with QT dispersion > 74 ms >>  ventricular arrhythmias or SD
Low K+ and low Ca2+ >> acquired long QT syndrome

12. Sympathetic overactivity
 Heart rate >> myocardial demand  supply >> cardiac hypertrophy and fibrosis
Decrease heart rate variability (reflecting autonomic dysfunction) >> increased risk for all-cause and SD in HD

14. Inflammation
Marker : C-reactive protein, inhibit the hepatic generation of albumin
Reflection of vascular injury VS actually promotes vascular injury ?
High CRP level ( >6 mg/l ) : independent , predictive marker of future myocardial infarction
Herzig, K. A. et al. J. Am. Soc. Nephrol. 12, 814–821 (2001).
Inflammation could trigger SD >> atherosclerosis or direct effect on myocardium

15. Other factors Rapid electrolyte shifts Hypervolemia Anemia
Dyslipidemia
Hypertension
Calcium/phosphate deposition

16. Prevention of Sudden Death
Avoiding low K
dialysate & rapid
electrolyte shifts
Prevention of Sudden Death
ACEI and
ARBs
Beta-blocker
Implantable defibrillators

17. Beta-blocker Reduction of Improve Heart rate variability
Cardiac hypertrophy & fibrosis
Antifibrillary activity
Ventricular arrhythmia
Reduced risk of acute MI
Improve Heart rate variability
Increase in baroreflex sensitivity

18. ACEI and ARBs Reduction of Cardiac hypertrophy & fibrosis
Fatal arrhythmia

19. Avoiding low K dialysate & rapid electrolyte shifts:
To avoid
QT dispersion
Re‐entrant arrhythmias
Premature ventricular extrasystole (VES)

20. Most effective therapy for SCD in the general population Indication
Implantable defibrillators or Implantable Cardioverter Defibrillators (ICDs)
Most effective therapy for SCD in the general population
Indication
Survival of cardiac arrest due to VT or VF
Episode of sustained VT causing severe hemodynamic compromise
Episode of sustained VT without hemodynamic compromise + EF 35%
MI + EF 35% + nonsustained VT on 24-h ECG + inducible VT on electrophysiologic testing
MI + EF 30% QRS duration  120 ms on ECG

21. Greater risk of device complications
Implantable defibrillators or Implantable Cardioverter Defibrillators (ICDs)
42% risk reduction for death in dialysis patients with ICDs implanted according to conventional guidelines
Greater risk of device complications
No statistically increase >>> infection or fistula thrombosis
Kidney Int. 2005;68:

22. Herzog CA et al. Kidney Int. 2005;68:818-825.

23. Thank You