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,

4. Causes of Death in Incident Dialysis Patients, 2009-2011, First 180 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 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.

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:

12. Salt+H2o retention , AVF, Anemia
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 in ESRD patients.
Henrich W L CJASN 2009;4:S106-S109

14. Reduction 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:

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:

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

17. Unadjusted survival in patients with systolic and diastolic heart failure, 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:

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
P.value
Non 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)
other
Systolic Blood Pressure
1.0000
143.8+/-32.3
/- 39.3
Mean+/- SD
142
143
Median
Diastolic Blood Pressure
80.7+/- 18.5
75.5+/-20.7 80 74
86.7+/-24.2
94.7+/- 24.1
Pulse BPM : Mean +/- SD 84 92
Pulse BMD: Median
Herzog et al Circulation September 25, 2007

26. Admission Variables for ESRD patient with ACS
P.value
Non 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 Shock
ECG:
(35.9)
(19.1)
ST elevation
1.0000
(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)
RBBB
0.3294
(7.7)
(6.4)
Normal
(17.6)
(24.1)
Other
Herzog et al Circulation September 25, 2007

27. Admission Variables for ESRD patient with ACS
P.values
Non dialysis (n=534935)
Dialysis (n=3049)
Variables
Myocardial Infarction type
<
(23.7)
(16.7)
Antero/septal
(30.6)
(18.2)
Inferior
(4.3)
(2.1)
Posterior
(12.4)
(9.6)
Lateral
1.0000
(0.7)
(0.4)
Rt. Ventricle
involvement
( 42.9)
(62.1)
Unspecified/other
( 37.4)
(22.1)
Q wave
(62.6)
( 77.8)
Non Q wave
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 acute myocardial infarction (MI).
Herzog C A JASN 2003;14:

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

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 :

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:

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

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

41. Anticoagulation
Bleeding
Thrombosis

42. Stroke in patients with ESRD with and without atrial fibrillation.
Zimmerman D et al. Nephrol. Dial. Transplant. 2012;27:

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:
8-Infective endocarditis
1-Secondary hyperparathyrodisim
9-Mitral valve prolapse
2-HTN
10-High cardiac out put state
3-DM
11-Anemia
4-LVH
12-Arteriovenous fistula
5-Malnutrition/ inflammatory complex
13-Hyperlipidemia
6-Uremia
7-Hypertrophic cardiomyopathy

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.