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Cardiovascular Disaster in Hemodialysis patients Pattaraporn MD.

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Presentation on theme: "Cardiovascular Disaster in Hemodialysis patients Pattaraporn MD."— Presentation transcript:

1 Cardiovascular Disaster in Hemodialysis patients Pattaraporn MD.

2 Causes of death in prevalent dialysis patients % 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 Cardiac arrest QT dispersion Cardiac arrhythmia cardiomyopathy Ischecmic heart disease Myocardial interstitial fibrosis Microvessel disease CHF CAD/MI LVH/LV dysfunction Myocardial interstitial fibrosis Microvessel disease CHF CAD/MI LVH/LV dysfunction Rapid electrolyte shifts/Hypervolemia Inflammation 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 Ca 2+ >> acquired long QT syndrome

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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

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14 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 Inflammation

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

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

17 Beta-blocker Reduction of – 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 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 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: Implantable defibrillators or Implantable Cardioverter Defibrillators (ICDs)

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

23 Thank You


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