cardiovascular diseases in hd
TRANSCRIPT
CVD IN HD
• 62 y- male, smoker 20 ys • HTN , DM on insulin ,• diabetic retinopathy , nephropathy 7 ys ago • HD from A-V fistula 6m ago 3 sessions / week
onset of last HD session :
acute compressing retrosternal pain , nausea and dizziness
Fully conscious BP : 90/60Pulse : 100 / min RR : 28 / min Temp : 37º Chest exam : BVB Cardiac aus : NAD NO edema LL
Next step?
• Trendelenburg position• Pump 200 ml / min• UF 0 ml/ hr• O2• Saline 0.9 % ( 200 cc)• SL Nitrate
Still chest pain !
• Session terminated • SL Nitrate • ECG
• Cardiac enzymesTroponin I : 0.05 ng /ml ( n : < 0.04 ng /ml)
POSSIBLE DIAGNOSIS ??
Chest pain during HD
• CVD • PULMONARY • GI • MUSCULOSKELTAL • OTHERS Air embolism , tunneled catheter malposition anaphylaxis
• Mortality due to CVD 10-30 > general populations
• CVM in 30y –old HD ptn = CVM in 80 y-old general population
Why cvs ?
1- IHD
Diagnosis challenges• Silent ischemia • CKD patients → chronic minor elevation in troponin • ECG strain pattern → LVH • Cardiac catheterization → RKF
Helpful clues • Dynamic changes in ECG • AHA :Minor elevation of troponin → no injury Acute rising or falling → acute MI
• Echo : segmental wall motion abnormality• Angiography
Management
Risk factors Anti ischemic
Angioplasty & CABG
Thrombolytic &anticoagulants
1- Risk factors
Risk factors
Traditional RF Non traditional RF
BP DM Smoking Dyslipidemia
BMD Anemia Oxidative stress
Dyslipidemia• Risk factors :oGlucose absorption from peritoneal dialysateoHigh CHO diet o↓ Lipoprotein lipase oHeparin o↓ hepatic BFR • Diagnosis :KDIGO 2013Measured at least once D ↑↑↑ Cholesterol ≥1000mg/dl exclude 2ry causes
TTT
RF : • Exercise ,• Alcohol avoidance, • CHO restriction • Salt restriction
Statins :Indications :KDIGO 2013 o Statin , statin ezetimibe combinations shouldn’t be initiated
in HD PTN ″ Long life expectancy , recent ACS ″ o PTN already treated with statins should be continuedCaution :o CYT P450 co -metabolism :CNI ,macrolides, CCB ,antifungal, fibrates→ ↑ Bl level → myopathy
Fibrates :• Indications : KDIGO 2013 Fibric acid derivatives not recommended to ↓ CV risk or prevent pancreatitis in adults with CKD & hypertriglyceridemia ″ > 500 mg/dl balance between risks ″• Caution : o Avoid with statins oDose modification ( fenofibrate 100 mg/d)
Others :• Sevelamere : ↓ LDL cholesterol • Necotinic acid : 1st line in ↑↑ TG • Ezetimibe : limited data
2-Anti ischemic drugs : • ACEI : ?? Regression LVH• BB carvedilol• Nitrates • Antiplatelet :
o conflicting reports that it worsen HF outcomes in patients with CKD
o BleedingHowever ,in HD PTN with CHD :no sufficient evidence to recommend against its use
3-Thrombolytics & anticoagulants
• LMWH :o superior to UFH but high risk of bleeding o Dose reduced• Plt glycoptn 2b 3a :o eptifibatide dose adjust • Thrombolytics :o given if indicated o CI :Catheter insertion 14 day Recent renal biopsy Active PU Uremic Pericarditis Uncontrolled HTN ( i.e. : > 220/110 )
4-CABG & ANGIOPLASTY • Dialysis before angioplasty • Hemofilteration during CABG
Hyperhomocystinemia & CVD IN HD
• Sulphur containing AA• Normal : 5-10 Mmol / L • Metabolism :
• RISKS :General population studies : HHCY risk factor CVDWhether this apply to ptn WITH RRT : unclear Mechanism :Activation of coagulation cascade Endothelial damage ( oxidative stress , lipid peroxidation)
HHCY & dialysis PTN :• 85 -100 % HD PTN • Sever HHCY :• >50 Mmol/L, • rare ,• non traditional risk factors for 50 % mortality from
CVD
TTT
Can HD session precipitate MI?
• Hypersensitivity → Mast cell activation → coronary spasm → MI
Back to CASE
Ptn was admitted for :• Anti ischemic• Echo : segmental ant wall hypokinesia • Serial Troponin I : .09 ng/ml• ECG :
• CORONARY Angiography : o total occlusion of lt ant descending coronary artery o all other vessels patent & EF 40 %o Aspiration thrombectomy o 2.5 *15 mm stent was implanted in diseased
segment
Cardiomyopathy
• KIDOQI 2005 : • ECHO at dialysis initiation after dry wt →every 3 years TTT :• Euvolemia more important > drugs • ACEI • BB• Spironolactone (k)• Lanoxin ( .0625 -0.125 mcg/d)• High flow fistula • L –carnitine symptomatic resistant HF
Pericarditis
• TYPES :Dialysis related Uremic pericarditis • Diagnosis :• TTT :Monitor > 100 ccIntensification of dialysis 5-7 /w – heparin free Drugs : NSAIDS –steroids not indicatedSurgical drainage : tamponade
Arrhythmia
• Acute : Terminate session Electrolytes Hemodynamic unstable : cardioversion • Chronic :Rate , rhythm control :BB ,CCB ,Digoxin, Amiodarone Interaction () warfarin , amiodarone , digoxin Anticoagulant : bleeding calciphylaxis 2014 AHA warfarin → HD PTN , non valvular AF , CHAD-VASC score > or = 2 + individualized
THANK YOU