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Arrhythmias in chronic kidney disease samir rafla


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Arrhythmias in chronic kidney disease samir rafla

  1. 1. Arrhythmias in Chronic Kidney DiseaseProf. Samir Morcos Rafla FACC, FESC Alexandria Univ.
  2. 2. Arrhythmias in chronic kidney diseaseHeart 2011;97:766-773Chronic kidney disease (CKD) is definedas evidence of kidney damage or aglomerular filtration rate (GFR) ≤60 ). ml/min/1.73 m2 (table 1The most common causes of CKD arehypertension and diabetes mellitus. Themany causes of CKD are associated with. different varying prognoses
  3. 3. The life expectancy of a 25-year-olddialysis patient is 12 years, compared with32 years for an age equivalent transplantrecipient and 52 years for a 25-year-old inthe general population. Even patients with CKD stage 5 will onlyhave a 20–25% chance of surviving longenough to require dialysis. The greatestcause of death in CKD is prematurecardiovascular disease. 3
  4. 4. Both cardiac and renal systems appear tobe completely interdependent, furtheremphasizing the concept of the‘cardiorenal syndrome’. This is highlightedwhen considering arrhythmias in patientswith impaired renal function. 4
  5. 5. The arrhythmia burden of the patient withCKD is high, with the single greatestcontributor to mortality in end stage renaldisease (ESRD) being sudden cardiacdeath (SCD). 5
  6. 6. Ventricular arrhythmias and sudden death in patients with chronic kidney disease. J Ren Care. 2010 May;36 Suppl 1:54-60.One in four dialysis patients will die suddenly. Most donot fall into the high-risk categories that are associatedwith sudden death in the general population. The causeof sudden death in the dialysis population is unknown. Itmay be related to factors associated with chronic kidneydisease (CKD) itself, for example, inflammation, vascularstiffness, left ventricular hypertrophy, coronary arterydisease, electrolyte/fluid abnormalities or autonomicdysfunction. 6
  7. 7. Studies of patients with implantable cardioverterdefibrillators have shown that patients with CKDare more likely to use their devices for ventriculararrhythmias but in spite of this still have a highassociated mortality.Minimising risk of SCD is by good control of basicparameters such as fluid balance, electrolytesand blood pressure, along with carefulassessment of all patients for evidence ofcoronary artery disease and heart failure is themainstay of management of the CKD patient. 7
  8. 8. With regards to drug therapy, the followingkey points are noted:• Beta-blockers are advised, but sotalolshould be avoided.• Drugs which are not affected by renalmetabolism may still have an altereddistribution or binding in CKD.• All drug treatment must be closelymonitored and possible interactions soughtthoroughly 8
  9. 9. Chronic Kidney Disease and Mortality inImplantable Cardioverter-Defibrillator Recipients Cardiology Research and Practice. Volume 2010Incidence of sudden cardiac death (SCD) in end-stage renal disease (ESRD) remains high.Limited data is available about whetherimplantable cardioverter-defibrillators (ICDs) canprevent arrhythmic death in patients with chronickidney disease (CKD). The purpose of thisretrospective study was to determine the impactof CKD on all-cause and sudden cardiac death inICD recipients. 9
  10. 10. 441 pts were evaluated who underwent ICDimplantation. Mortality rate was higher in patientswith eGFR < 6 0 mL/min and those with ESRD onhemodialysis (43%, and 54%, resp.) than inpatients with eGFR ≥ 6 0 mL/min(23%; 𝑃 < . 0 0 0 5).The SCD rate was also higher in the patients withESRD (50%) than in CKD patients not on dialysis(10.2%; 𝑃 < . 0 0 0 5). Mortality rate for single-chamber ICDs was 56.8% in comparison withdual-chamber ICDs (38.1%) and for biventricularICDs (5.0%) (𝑃 < . 0 0 0 5). 10
  11. 11. The enrolled subjects had ICD implantation based onthe following criteria. (1) Nonsustained VT in patientswith coronary artery disease (CAD), previous myocardialinfarction (MI), left ventricular (LV) dysfunction, andEF <35% who had induced sustained monomorphic VTthat was nonsuppressible with anti-arrhythmic drug.(2) EF ≤30% in patients with a history of MI (MADIT II) .(3) VF or sustained VT with syncope, or sustained VTwith an LVEF <40% and severe symptoms (syncope,near syncope, CHF, angina) suggestive of hemodynamiccompromise. (4) Syncope of unknown origin in CADpatients, and severe LV dysfunction who had induciblesustained monomorphic VT with hemodynamiccompromise at EP study. 11
  12. 12. Potassium level changes – arrhythmia contributing factor in chronic kidney disease patients Rom J Morphol Embryol 2011, 52(3 Suppl):1047–1050The aim of the study was to determine in whichdegree the serum potassium changes areimplicated in arrhythmias development in CKDpatients.Methods: ECG , Holter 12
  13. 13. Results: we noticed, in our predialysis group, animportant correlation betweenhyper-/hypokalemia and arrhythmiasappearance,more frequent during hypokalemia episodes(OR=4.04, respectively OR=7.5). The same. situation was observed in chronic dialysis groupConclusions: Hypokalemia is a stronger riskfactor than hyperkalemia, but all together, any minimal changes in serum potassium levels. could determine arrhythmia in CKD patients 13
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  18. 18. Knowledge Gap 18
  19. 19. Excessive bleeding has been noted in ptsadministered warfarin in therapeuticdoses. The clinical dilemma is that strokerisk increases with declining kidneyfunction, but bleeding risk increases.during warfarin anticoagulation 19
  20. 20. Risk of arrhythmic and nonarrhythmic death in patients with heart failure and chronic kidney disease American Heart Journal Volume 161, Issue 1 , Pages 204- 209.e1, January 2011Among 6,378 patients without an ICD (age 60 ±10, LVEF 27 ± 6, male 86%), there were 421arrhythmic and 1188 nonarrhythmic deaths overa median follow-up of 34 months.Worse HF or CKD stages were associated withincreased risk of both arrhythmic andnonarrhythmic death 20
  21. 21. The increase in the risk of nonarrhythmic deathin the worst HF stage was disproportionatelyhigher than that of arrhythmic death, and thisdisproportionate effect was more exaggerated inthe presence of more advanced CKD.ConclusionWhile advanced CKD and HF stages areassociated with increased risk of arrhythmic andnonarrhythmic death, benefits of ICDs inpatients with more advanced disease may belimited by the preponderance of nonarrhythmicdeath. 21
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  23. 23. Figure shows the association of HF and CKD stage witharrhythmic death. Subjects with the most advancedstages of HF and CKD (HF 4/CKD 4) had 13.0 times(95% CI 4.9-34.2) the hazard of dying of an arrhythmiacompared with patients in the least advanced stages(HF 1/CKD 1). 23
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  25. 25. Summary of Studies on Noninvasive Risk Assessment in Dialysis Patients Investigated Outcome PatientStudies Salient Findings Marker Measure Characteristics 1253 patients with LVH associated with aKrane et al, LVH SCD type 2 diabetes on 60% higher relative200924 HD risk of SCD 196 asymptomatic LF/HF ratio in HRVNishimura et HRV+LVH SCD HD patients with was an independental37 LVH predictor of SCD 25
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  27. 27. Questions:-What are the predictors of SD in CKD?-What are the indications of ICD in CKD?Answer :slide 13- What is the appropriate INR in Marevantreated CKD pts? Answer: 2-What are suitable antiarrhythmic drugs inCKD pts? Answer : Amiodarone,Propafenon (if LV wall< 14 mm) 27
  28. 28. What are the predictors of SD in CKD?-LVH-LVF-HR Variability-Mutlivessel coronary disease-Acute myocardial infarction-K hyper or hypo-Withdrawal-Cardiomyopathy 28
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  30. 30. CONCLUSIONSChronic kidney disease was associated withan increased risk of stroke or systemicthromboembolism and bleeding amongpatients with atrial fibrillation. Warfarintreatment was associated with a decreasedrisk of stroke or systemic thromboembolismamong pnts with CKD, whereas warfarinand aspirin were associated with anincreased risk of bleeding. 30
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