Cardiac Risk In ESRD Patient

1. Cardiac Risk In ESRD Patient Dr.Badr Alhomayeed.md Nephrology and Kidney Transplant Consultant Feb/8/2014

2. 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.

3. Cardiac Diseases in maintenance Hemodialysis patients: Result of the HEMO Study Kidney International (2004) 65,2380-2389

4. Causes of Death in Incident Dialysis Patients, 2009-2011, First180 days USRDS 2013

5. Causes of Death in Prevalent Dialysis Patients, 2009-2011 USRDS 2013

6. Survival of Patients with Cardiovascular Diagnoses & Procedures, by Modality, 2009–2011 USRDS 2013

7. Risk Factors For Cardiovascular disease in ESRD patients. Henrich W L CJASN 2009;4:S106-S109

8. 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 lifein 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.

9. Rates of a CHF diagnosis in ESRD patients USRDS 2013

10. Heart failure in prevalent dialysis patients, by modality, 2011 USRDS 2013

11. 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

12. Hypertension Salt+H2o retention , AVF, Anemia LV pressure overload LV volume over load Eccentric LVH Vascular remodeling Conc. LVH Overload cardiomyopathy • HPTH • Malnutrition • Uremic toxins • Dialysis induced low BP LV dilatation & Hypertrophy • Myocytes death • Myocardial fibrosis • Decrease capillary perfusion Diastolic dysfunction Systolic dysfunction Nephrol Dial Transplant (2000) 15 [Suppl 5]: 58–68

13. Cardiac fibrosis associated with increased mortality inESRD patients. Henrich W L CJASN 2009;4:S106-S109

14. Reduction in systolic BP during hemodialysisin patientswith and without HD-induced regional wall motionabnormalities (RWMAs). Burton J O et al. CJASN 2009;4:914-920

15. 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

16. The association of hemodialysis-induced RWMAs with mortality and outcome. Burton J O et al. CJASN 2009;4:914-920

17. Unadjusted survival in patients with systolic and diastolic heartfailure, by age, 2010–2011 Systolic Heart failure Diastolic Heart Failure USRDS 2013

18. 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

19. Biochemical, Functional, and Anatomic evaluation of Coronary Heart Disease in ESRD Stenvinkel P et al. JASN 2003;14:1927-1939

20. 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.

21. 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

22. 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

23. 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 tests that are positive for ischemia should be referred for consideration of • angiographic assessment. (C) K/DOQI clinical practice guidelines

24. 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.

25. Admission Variables for ESRD patient with ACS Herzog et al Circulation September 25, 2007

26. Admission Variables for ESRD patient with ACS Herzog et al Circulation September 25, 2007

27. Admission Variables for ESRD patient with ACS Herzog et al Circulation September 25, 2007

28. Rates of an AMI event in ESRD patients USRDS 2013

29. Estimated mortality of dialysis patients after acutemyocardial infarction (MI). Herzog C A JASN 2003;14:2556-2572

30. Cause Specific Mortality of Dialysis patients after Coronary Revascularization Herzog C A et al. Nephrol. Dial. Transplant. 2008;23:2629-2633

31. 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.

32. Rate of Sudden Cardiac Death in Prevalent ESRD patient by Modality USRDS 2013

33. Distribution of deaths according to day of the week for hemodialysis patients Bleyer et al, kidney International 1999.55:1553-1559

34. Probability of Sudden Cardiac Death in Incident ESRD patient by modality USRDS 2103

35. Risk Factors for Sudden Cardiac Death among ESRD Dialysis Patient Herzog et al. Seminars in Dialysis, 2008

36. Prevention of sudden death in dialysis patients. Reduction of  ‐ Cardiac hypertrophy &  fibrosis ‐ Fatal arrhythmia ‐ Heart rate variability Avoiding low K  dialysate & rapid   electrolyte shifts: To avoid: ‐ QT dispersion   ‐ Réentrant arrhythmias   ‐ Premature VES Beta blockers Prevention  of  sudden  death ACEI and ARBs Reduction of   ‐ Cardiac hypertrophy & fibrosis       ‐ Antifibrillary activity ‐ Ventricular arrhythmia ‐ Heart rate variability   ‐ Increase in baroreflex      sensitivity ‐ Reduced risk of acute MI To avoid ‐ Cardiac arrest and      ‐ Life‐threatening ventricular tachycardia External &  implantable defibrillator Blood Purif 2010;30:135–145

37. 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.

38. Incidence of Atrial Fibrillation in Patient with ESRD Zimmerman D et al. Nephrol. Dial. Transplant. 2012;27:3816-3822

39. Prevalence of Atrial Fibrillation in Patient with ESRD Zimmerman D et al. Nephrol. Dial. Transplant. 2012;27:3816-3822

40. Mortality in patients with ESRD with and without atrial fibrillation. Zimmerman D et al. Nephrol. Dial. Transplant. 2012;27:3816-3822

41. Anticoagulation Bleeding Thrombosis

42. Stroke in patients with ESRD with and withoutatrial fibrillation. Zimmerman D et al. Nephrol. Dial. Transplant. 2012;27:3816-3822

44. 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.

45. Predisposing Factors:

46. 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

47. 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.