Cardiovascular

spei

al stu

dies

168 Introduction 17

0 Characerisics

of pati

ents

with ca

rdia

c arr

est {

dem

ogra

phic

s} {r

ates

of c

ardi

ac a

rres

t, A

MI,

& h

eart

failu

re}

172 Characerisics of diabetic

patients

with ca

rdiac

arre

st {ra

tes o

f card

iac a

rres

t by d

iabe

tic st

atus

} {m

edic

atio

n us

e} {m

orta

lity

& co

mor

bidi

ty}

174 Cardiovascular event rates afte

r initi

ation of

dial

ysis

{dem

ogra

phics of

dia

lysis

pat

ients

} {co

mor

bidi

ty a

t ini

tiat

ion}

176 Diagnosis D treatment of cardiac d

isease

in dialys

is pa

tient

s {dia

gnos

tic &

trea

tmen

t pro

cedu

res}

17

8 Su

mmary

CHAPTER

How frail the human heart must be —a mirrored pool of thought. So deepand tremulous an instrumentof glass that can either sing,or weep.

“I thought that I could not be hurt”

SylviaPlathh

94 96 98 00 02

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0

200

400

600

800

94 96 98 00 020

20

40

60

80

94 96 98 00 020

20

40

60

80

100Heart failure AMI Cardiac arrest

Dialysis

General Medicare: CKD

General Medicare: non-CKD

Introducion168 Cardiovascular special studiesh

ardiac disease continues to be the single largest cause of mortality in the

ESRD population, both dialysis patients and renal transplant recipients.

As noted in past ADRs, cardiac disease accounts for about 45 percent of

all-cause mortality; approximately 20 percent of cardiac deaths are attributed to acute

myocardial infarction. The USRDS database implicates arrhythmic mechanisms as the

single largest cause of mortality, with the combination of “cardiac arrest cause unknown”

and arrhythmia identified in 61 percent of cardiac deaths. There are conflicting data on

cause-specific mortality in sudden cardiac death, and it is difficult to accurately apportion

the contribution of ischemic heart disease to the total picture of sudden cardiac death.

Investigators in the HEMO study have implicated ischemic heart disease as the single largest

cause of sudden cardiac death, but this distinction maybe less important than would super-

ficially appear as certain therapies (i.e. implantable cardioverter defibrillators) are effective

in reducing the mortality associated with sudden cardiac death, irrespective of ischemic

etiology.

In this chapter the Cardiovascular Special Studies Center (CSSC) focuses on two themes,

the first being the epidemiology of cardiac arrest/sudden cardiac death. There are few data

on sudden cardiac death in the general Medicare population with CKD, and we attempt to

frame the issue of cardiac arrest in CKD patients. It should be apparent from the following

spreads that the risk of all types of cardiovascular morbidity and mortality, including

sudden cardiac death, is greatly magnified in the dialysis population, but general Medicare

patients with CKD are also a high-risk population.

{9.1} Rates of heart failure, AMI, & cardiac arrestdialysis: period prevalent patients with Medicare as primary payor. General Medicare: period prevalent CKD & non-CKD Medicare patients, continuously enrolled in Medicare Parts A & B, with no HMO coverage, & without ESRD.CKD status determined from the two-year entry period. Rates adjusted for age, gender, race, & diabetic status; 2002cohort used as reference.

Chapt

er hi

ghlig

hts

169H2004 USRDS Annual Data Report

The estimation of the rate of sudden cardiac death in

CKD patients presents special difficulties, as the primary

source of data is different for ESRD patients than for general

Medicare patients with CKD, and there is no data source

equivalent to the Death Notification form (CMS 2746) that

is filed for patients with ESRD. We identified Medicare CKD

patients with ICD-9-CM codes for cardiac arrest/ventricu-

lar fibrillation; it is likely that we underestimated the true

incidence of sudden cardiac death with the restricted defini-

tion.

In the 2002 ADR we reported some favorable trends, in-

cluding a reduction in both all-cause and cardiac mortality

in dialysis patients. This appeared due in part to a reduced

risk of all-cause and cardiac death in incident dialysis pa-

tients in the three years following the initiation of dialysis.

One disturbing trend, however, was the apparent increase in

both cardiac arrest and acute myocardial infarction in dialy-

sis patients on the therapy for at least three years. There

appeared to be a non-proportional hazard related to dialy-

sis vintage, suggesting that long-term dialysis does have a

significant unfavorable impact on cardiovascular morbidity

and mortality.

In this Annual Data Report, we return to the epidemiol-

ogy of cardiac arrest in the prevalent dialysis population and

in the general Medicare population without end-stage renal

disease. As shown in Figure 9.1, the rate of acute myocardial

infarction has increased in prevalent dialysis patients from

54 per 1,000 patient years in 1994 to 79 in 2002. The rate of

cardiac arrest appears to have decreased in both ESRD

and general Medicare CKD patients. In the prevalent dialysis

population it has dropped from about 75 per 1,000 patient

years in 1994 to 62 in 2002, while in the general Medicare

population the cardiac arrest rate in CKD patients has fallen

from approximately 24 per 1,000 patient years to 17 over the

same time period.

The second portion of this chapter focuses on cardiovas-

cular disease in dialysis patients and on the use of cardiac

procedures. The temporal pattern of procedure utilization

related to dialysis initiation is the subject of an entire spread,

intended to frame recent recommendations by the National

Kidney Foundation’s Kidney Disease Outcomes Quality

Initiative (K/DOQI) for the treatment of cardiovas-

cular disease in dialysis patients. One noteworthy

new guideline recommends echocardiography

for all incident dialysis patients. In this chap-

ter we present data relating to the use of

cardiac procedures, including echocar-

diography, in dialysis patients, and

it is the intention of the CSSC

to evaluate future procedure

utilization to evaluate

the impact of the K/

DOQI guide-

lines.

{9.2} Among

dialysis patients

with cardiac arrest,

the proportion of

elderly patients and of

patients with diabetes

mellitus as the primary cause of

ESRD rose from 1991 to 2002. {9.9}The use of ACE inhibitors/ARBs in

diabetic Medicare beneficiaries nearly

doubled from 1992 to 1999. {9.16} The CHF

event rate in both hemodialysis and peritoneal

dialysis patients is markedly increased in the first six

months after dialysis initiation. {9.23–25} Utilization of

diagnostic testing for the evaluation of ischemic heart disease

(stress testing and coronary angiography) increased from 1995 to

2000. Backcasted data in elderly dialysis patients reveal significant

procedure use in the two years prior to dialysis initiation.

170 Cardiovascular special studiesh

Male

Female

N Am

Other

Male

Female

Male

Female

stn

eita

pf

ot

necr

eP

White

Black

N Am

Asian

0-19

20-44

45-64

65-74

75+

AsianN Am

OtherAsian

0-19

20-44

45-64

65-74

75+

White

Black

N Am

Asian

Other

Diabetes

Hypertension

GN

Cystic kidney

Diabetes

HTN

GN

CK

94 96 98 00 02

stn

eita

pf

ot

necr

eP

0

20

40

60

80

100

94 96 98 00 02 94 96 98 00 02

Age Gender Race

67-74

75+

0

20

40

60

80

92 94 96 98 00 02

stn

eita

pf

ot

necr

eP

0

20

40

60

80

92 94 96 98 00 02

Dialysis I: Age Gender

Race Primary diagnosis

Male

Female

92 94 96 98 00 02 92 94 96 98 00 02

Dialysis II: Age Gender

Race Primary diagnosis

White

Black

White

Black

94 96 98 00 02

stn

eita

pf

ot

ne cr

eP

0

20

40

60

80

100

94 96 98 00 02 94 96 98 00 02

Age Gender Race

67-74

75+

0

20

40

60

80

100

Dialysis I

Dialysis II

General Medicare CKD

General Medicare non-CKD

0

20

40

60

80

100

0

20

40

60

80

100

1994 1996 1998 2000 20020

20

40

60

80

100

1994 1996 1998 2000 2002

AMI CHF

Coronary revascularization PVD

CVA/TIA Diabetes

Hypertension No history of comorbidity

{9.2} Dialysis patients with cardiac arrest

{9.3} General Medicare CKD patients with cardiac arrest

{9.4} General Medicare non-CKD patients with cardiac arrest

{9.5} Previous comorbidity of patients with cardiac arrest

n this spread we present an overview of the demograph-

ics, comorbidity, and geographic variations in cardiac ar-

rest rates in dialysis patients, general Medicare CKD

patients, and general Medicare patients without CKD. As noted in

the introductory section of this chapter, analyses of these rates in

the ESRD population are unique because of the availability of both

ICD-9-CM codes and data from the CMS Death Notification

form. For this reason, we present here two types of patient-specific

data for the dialysis population. Data for the Dialysis I analyses are

derived only from claims and can be thus compared to data on the

non-ESRD general Medicare population for which only claims

data are available. Data for the Dialysis II analyses also include

information from the Death Notification form, and therefore

Characerisics of patients with cardiac arrest

171H2004 USRDS Annual Data Report

69.6+ (77.7)62.9 to <69.656.1 to <62.949.4 to <56.1below 49.4 (45.3)

69.6+ (71.8)62.9 to <69.656.1 to <62.949.4 to <56.1below 49.4 (38.2)

118+ (139)106 to <118103 to <106

93 to <103below 93 (82)

118+ (133)106 to <118103 to <106

93 to <103below 93 (79)

29.8+ (35.8)25.8 to <29.823.8 to <25.817.2 to <23.8below 17.2 (10.7)

29.8+ (40.6)25.8 to <29.823.8 to <25.817.2 to <23.8below 17.2 (8.9)

8.54 + (9.48)7.51 to <8.546.75 to <7.515.52 to <6.75below 5.52 (4.65)

8.54+ (9.36)7.51 to <8.546.75 to <7.515.52 to <6.75below 5.52 (4.70)

66.6+ (76.1)56.0 to <66.647.0 to <56.040.0 to <47.0below 40.0 (35.6)

12.8+ (14.1)11.6 to <12.810.5 to <11.6

9.4 to <10.5below 9.4 (8.6)

472+ (548)411 to <472358 to <411312 to <358below 312 (278)

75.9+ (82.1)70.6 to <75.966.0 to <70.661.1 to <66.0below 61.1 (56.8)

{9.6} Geographic variations in cardiac arrest rates

{9.7} Geographic variations in rates of AMI & heart failure

Dialysis I, 1994–1995 Dialysis II, 1994–1995 General Medicare, CKD 1994–1995

Dialysis I, 2001–2002 Dialysis II, 2001–2002 General Medicare, CKD 2001–2002

General Medicare, AMI, 1998–2002

Dialysis: heart failure, 1998–2002 General Medicare, heart failure, 1998–2002

General Medicare, non-CKD 1994–1995

General Medicare, non-CKD 2001–2002

more closely approximate the “true” overall

cardiac arrest rate.

The proportion of elderly patients con-

tributing to the pool of cardiac arrest events

has steadily increased (Figure 9.2).

Few patients sustain a cardiac arrest with-

out some prior history of cardiovascularcomorbidity (Figure 9.5). In all four patient

groups the percent of patients with an AMI

prior to a cardiac arrest has doubled. One

potential explanation is that, as short-term

survival improves after acute myocardial

infarction, the number of long-term survi-

vors at increasing risk for cardiac arrest may

rise. Diabetes mellitus and congestive heart

failure are important comorbid medical con-

ditions in patients sustaining cardiac arrest.

In the general Medicare population there

does appear to be a persistent clustering in

the southern states of higher cardiac arrest

rates (Figure 9.6), a finding also reported in

the 2002 USRDS ADR (Figure 10.29). The

geographic distribution of heart failure in

the general Medicare population mirrors

that of cardiac arrest (Figure 9.7).

{Figures 9.2 & 9.5–6} Dialysis I, cardiac arrest eventdetermined only from claims data; Dialysis II, cardiacarrest event determined from claims data & the ESRDDeath Notification form. x {Figure 9.2} Medicareperiod prevalent dialysis patients. {Figure 9.3} generalMedicare CKD patients age 67 & older. {Figure 9.4}general Medicare non-CKD patients age 67 & older.{Figure 9.5} prevalent dialysis patients, & general

Medicare prevalent patients age 67 & older. {Figure9.6} per 1,000 patient years at risk, period prevalentdialysis patients, & general Medicare prevalent patientsage 67 & older, by state, unadjusted. {Figure 9.7} per1,000 patient years at risk, period prevalent dialysispatients, & general Medicare prevalent patients age 67& older, by HSA, unadjusted.

Dialysis: AMI, 1998-2002

172 Cardiovascular special studiesh

1993 1995 1997 1999

stn

eita

pf

ot

ne cr

eP

0

10

20

30

40

50

1993 1995 1997 1999

ACE/ARBs

Beta blockers

Ca++

channel blockers

Lipid lowering agents

Diabetic Non-diabetic

88.2+ (103.2)75.9 to <88.264.7 to <75.952.5 to <64.7below 52.5 (44.1)

153+ (187)133 to <153116 to <133

99 to <116below 99 (86)

13.5+ (15.7)11.6 to <13.510.0 to <11.6

8.3 to <10.0below 8.3 (7.1)

59.9+ (69.6)51.4 to <59.944.1 to <51.437.1 to <44.1below 37.1 (32.1)

6.92+ (7.59)6.20 to <6.925.38 to <6.204.41 to <5.38below 4.41 (3.90)

109.8+ (132.2)95.4 to <109.883.3 to <95.473.6 to <83.3

below 73.6 (64.1)

0

20

40

60

80

100

120

Sudden cardiac death, inpatient

Sudden cardiac death, outpatient

Inpatient death, not sudden cardiac

Outpatient death, not cardiac

sra

ey t

nei t

ap

00

0 ,1 r

ep

eta

R

0

20

40

60

80

100

120

140

91 92 93 94 95 96 97 98 99 00 01 020

20

40

60

80

100

120Non-diabetic

All

Diabetic

Inpatient death, not sudden cardiac

Inpatient death, not sudden cardiac

Sudden cardiac death, outpatient

Sudden cardiac death, inpatient

Sudden cardiac death, outpatient

Sudden cardiac death, inpatient

Outpatient death, not cardiac

Outpatient death, not cardiac

{9.8} Geographic variations in cardiac arrest rates, by diabetic status

{9.9} Medication use in Medicare beneficiaries, by diabetic status {9.10} Adjusted one-year mortality rates for sudden death, by location of event

s shown on the prior spread, the presence of diabetes is an

important contributor to the likelihood of cardiac arrest.

In this spread, we provide further detail relating to diabetic

status in cardiac arrest.

Figure 9.8 displays geographic variations in cardiac arrest rates

by diabetic status. Differences are most apparent in the general

Medicare population, particularly in patients without diabetes

mellitus. The southern states and Appalachia are characterized by

higher cardiac arrest rates.

We have attempted here to estimate the rate of sudden cardiac

death in outpatients and inpatients, a daunting task. On the out-

patient side, we have utilized claims data and Death Notification

form (2746) data in the following manner: a sudden cardiac death

is defined in a patient not surviving to be hospitalized (e.g. dying in

an emergency room or at home), with either a claim (cardiac arrest

Characerisics of diabetic patients with cardiac arres

Dialysis I, diabetic, 1998–2002 General Medicare, diabetic, 1998–2002

Dialysis I, non-diabetic, 1998–2002 Dialysis II, non-diabetic, 1998–2002 General Medicare, non-diabetic, 1998–2002

Dialysis II, diabetic, 1998–2002

173H2004 USRDS Annual Data Report

0

20

40

60

80

100

Dialysis I

Dialysis II

General Medicare CKD

General Medicare non-CKD

stn

eita

pf

ot

necr

eP

0

20

40

60

80

100

1994 1996 1998 2000 20020

20

40

60

80

100

1994 1996 1998 2000 2002

AMI CHF

Coronary revascularization PVD

CVA/TIA Hypertension

87.7+ (111.3)68.4 to <87.755.1 to <68.441.1 to <55.1below 41.1 (32.1)

25.0+ (29.4)21.3 to <25.018.8 to <21.315.9 to <18.8below 15.9 (13.7)

598+ (694)513 to <598447 to <513380 to <447below 380 (338)

160+ (178)144 to <160133 to <144121 to <133below 121 (110)

{9.11} Previous comorbidity in diabetic patients with cardiac arrest

{9.12} Geographic variations in rates of AMI & heart failure in diabetic patients

Dialysis, AMI, 1998–2002 General Medicare, AMI, 1998–2002

Dialysis, heart failure, 1998–2002 General Medicare, heart failure, 1998–2002

or ventricular flutter/fibrillation) or any cardiac death cause (from

the 2746 form). On the inpatient side, we have defined sudden

cardiac death in the same manner used for the Dialysis II analyses

on the previous spread—a claim for cardiac arrest or ventricular/

fibrillation, or a listing, on the 2746 form, of cardiac arrest or

arrhythmia as the cause of death.

In our analyses of one-year mortality rates for sudden death, a

striking finding is the relative stability over a decade in the rates of

outpatient and inpatient sudden cardiac death and of outpatient

deaths unrelated to cardiac etiologies (Figure 9.10). For inpatient

sudden cardiac death, for example, this rate was 36 per 1,000 pa-

tient years in 1991 and 37 in 2002. For outpatient sudden cardiac

death, the rate was 57 in 1991 and the same in 2002, and for

outpatient non-cardiac etiologies it was 64 per 1,000 patient years

in 1991 and 65 in 2002.

The major decrease in mortality rates has been in inpatients

with non-sudden cardiac etiologies; the rate dropped from 115 per

1,000 patient years in 1991 to 92 in 2002. Prior studies of patients

with ischemic heart disease and congestive heart failure have dem-

onstrated the importance of beta-blockers, lipid lowering agents,

and angiotensin converting enzyme(ACE) inhibitors or angiotensin

receptor blockers (ARBs) for improving cardiovascular outcomes.

There has been a striking increase over time in the use of lipid

lowering agents and ACE/ARBs in Medicare beneficiaries with

diabetes (Figure 9.9)

Figure 9.11 displays the distribution of prior cardiovascular mor-

bidity in diabetic patients with cardiac arrest. From 1994 to 2002

the proportion of patients with a history of

congestive heart failure increased. In 2002,

86–87 percent of all dialysis patients and

general Medicare patients with CKD had a

history of congestive heart failure; this was

also true in 65 percent of the general Medi-

care beneficiaries without CKD who sus-

tained a cardiac arrest. The most common

comorbid condition is a history of hyper-

tension, with nearly all patients (95–99

percent) in 2002 having a history of hyper-

tension before cardiac arrest.

{Figure 9.8} per 1,000 patient years at risk; periodprevalent Medicare dialysis patients, & general Medi-care prevalent patients age 67 & older, by HSA, unad-justed. Dialysis I, cardiac arrest event determined onlyfrom claims data; Dialysis II, cardiac arrest event de-termined from claims data & the ESRD Death Notifi-cation form. {Figure 9.9} MCBS patients, age 65 &older; data from MCBS “Cost & Use” file. {Figure9.10} Medicare period prevalent dialysis patients; datafor “all” adjusted for age, gender, race, primary diag-nosis, & vintage; data by diabetic status adjusted forage, gender, race, & vintage; 2002 cohort used as ref-erence population. {Figure 9.11} prevalent Medicarediabetic dialysis patients, & general Medicare diabeticpatients age 67 & older. {Figure 9.12} per 1,000 pa-tient years at risk, period prevalent dialysis patients, &general Medicare prevalent patients age 67 & older, byHSA, unadjusted.

174 Cardiovascular special studiesh

Female Other

Cystic kidney Glomerulonephritis

Hypertension

Hemodialysis: Age Gender Race Primary diagnosis

Male

95 96 97 98 99 00 01 020

20

40

60

80

100

95 96 97 98 99 00 01 02 95 96 97 98 99 00 01 02 95 96 97 98 99 00 01 02

stn

eita

psisyl

aid

fo

tn

ecre

P 0

20

40

60

80

100

Diabetes

Peritoneal dialysis

95 96 97 98 99 00 01 02

Hemodialysis Peritoneal dialysis

95 96 97 98 99 00 01 02

ytidi

bro

moc

htiw

stn

eita

pf

o%

0

10

20

30

40

50

60

70

80

ASHD

CHF

Other cardiac

CVA/TIA

PVD

45-64

20-44

75+

65-74

Other

Asian

Native American

Black

White

he proportion of older and diabetic patients in the inci-

dent dialysis population rose between 1995 and 2002

(Figure 9.13). In patients of both modalities the percent

with cardiovascular comorbidity has also grown. Forty-two percent

of new hemodialysis patients in 1995 had comorbid atheroscle-

rotic heart disease, compared to 52 percent in 2002; in the perito-

neal dialysis population growth was from 36 to 43 percent.Figures 9.15–22 display event rates and event-free probabilities

for cardiovascular disease and mortality. Due to the Medicare claims

structure, fatal cardiovascular events within 90 days of dialysis initia-

tion are not identified in patients younger than 65. Another meth-

odological issue here is “informative censoring.” As peritoneal dialysis

patients have a differential rate of transplantation related to vin-

tage, the event rate over time may change because patients who are

not transplanted have different characteristics than those who are.

Figure 9.15 shows event rates related to AMI. Although an early

hazard of AMI has been previously reported in dialysis patients

(Herzog et al. NEJM 1998), this temporal clustering is not evident

here. In contrast, there is a higher event rate for congestive heart

failure at the time of initiation, which drops over time. This is

presumably related to better control of intravascular volume.

Figure 9.17 illustrates event rates for cardiac arrest. It appears

that in incident hemodialysis patients there is an initial early hazard,

with the event rate of 14 per 1,000 patient months in the first

month dropping to 10 by six months. In peritoneal dialysis patients,

in contrast, the rate is essentially unchanged over the first six months,

then slowly increases with dialysis vintage. In the hemodialysis co-

hort the cardiac arrest rate appears to stabilize at month six and

remains fairly constant over the ensuing 30 months. By three years

the event-free probability is approximately 70 percent in both he-

modialysis and peritoneal dialysis patients. A similar pattern is noted

for CHF and cerebrovascular events (Figures 9.16 and 9.18).

{9.13} Demographics of the dialysis population at initiation

{9.14} Cardiovascular comorbidity at the initiation of dialysis

Cardiovascular event rates after the initiation of dialysis

The overall rate of coronary revascularization is relatively low in

dialysis patients, despite their burden of ASHD (Figure 9.19). At

three years the event-free probability is approximately 90 percent

for each modality. The second most common cardiovascular disease

in dialysis patients (after CHF) is PVD. At three years the event-free

probability for PVD is 43 percent in hemodialysis patients, and 51

percent in peritoneal dialysis patients (Figure 9.20). This compares

with 37 and 46 percent, respectively, free of CHF at three years.

There are contrasting patterns, related to modality, of early mor-

tality in incident dialysis patients (Figure 9.21), patterns also seen

for cardiac arrest, implying that some of the temporal pattern of

all-cause death might be explained by cardiac arrest. It is plausible

that this early hazard might be heightened in the dialysis population

right after initiation, as the event rates shown are those after day 90.

{Figures 9.13–14} incident Medicare dialysis patients, age 20 & older; comorbiditiesidentified from the Medical Evidence form. {Figures 9.15–22} incident Medicaredialysis patients, 1998–2000 combined, age 20 & older; adjusted for age, gender,race, & primary diagnosis. Monthly event rates during the first six months, & meanmonthly event rates during each following six-month interval.

175H2004 USRDS Annual Data Report

0 6 12 18 24 30 36

ytilib

ab

orp

eerf-t

ne

vE

0.0

0.2

0.4

0.6

0.8

1.0

Months after day 90

0 6 12 18 24 30 36

ksirt

as

htn

om

tn

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p0

00,

1r

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R 0

40

80

120

160

200

Hemodialysis

Peritoneal dialysis

0 6 12 18 24 30 36

ytilib

ab

orp

eerf-t

ne

vE

0.7

0.8

0.9

1.0

Months after day 90

0 6 12 18 24 30 36

ksirt

as

htn

om

tn

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p0

00,

1r

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eta

R 0

2

4

6

8

10

12Event rates Event-free probabilities Event rates Event-free probabilities

Event rates Event-free probabilities Event rates Event-free probabilities

Event rates Event-free probabilities Event rates Event-free probabilities

Event rates Event-free probabilities Event rates Event-free probabilities

Hemodialysis

Peritoneal dialysis

0 6 12 18 24 30 36

ytilib

ab

orp

eerf-t

ne

vE

0.6

0.7

0.8

0.9

1.0

Months after day 90

0 6 12 18 24 30 36

ksirt

as

htn

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p0

00,

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R 2

4

6

8

10

12

14

16

Hemodialysis

Peritoneal dialysis

0 6 12 18 24 30 36

ytilib

ab

orp

eer f-t

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vE

0.85

0.90

0.95

1.00

Months after day 90

0 6 12 18 24 30 36

ksirt

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p0

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R 2

3

4

5

Hemodialysis

Peritoneal dialysis

0 6 12 18 24 30 36

ytilib

ab

orp

ee rf- t

ne

vE

0.4

0.5

0.6

0.7

0.8

0.9

1.0

Months after day 90

0 6 12 18 24 30 36

ksirt

as

htn

om

tn

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p0

00,

1r

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R 10

15

20

25

30

35

Hemodialysis

Peritoneal dialysis

0 6 12 18 24 30 36

ytilib

ab

orp

eerf-t

ne

vE

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

Months after day 90

0 6 12 18 24 30 36

ksirt

as

htn

om

tn

eita

p0

00,

1r

ep

eta

R 0

20

40

60

80

100

120

Hemodialysis

Peritoneal dialysis

0 6 12 18 24 30 36

ytilib

ab

orp

eerf-t

ne

vE

0.6

0.7

0.8

0.9

1.0

Months after day 90

0 6 12 18 24 30 36

ksirt

as

htn

om

tn

eita

p0

00,

1r

ep

eta

R 0

5

10

15

20

25

30

Hemodialysis

Peritoneal dialysis

0 6 12 18 24 30 36

ytilib

ab

orp

eerf-t

ne

vE

0.4

0.5

0.6

0.7

0.8

0.9

1.0

Months after day 90

0 6 12 18 24 30 36

ksirt

as

htn

om

tn

eita

p0

00,

1r

ep

eta

R 0

10

20

30

40

50

60

70

Hemodialysis

Peritoneal dialysis

{9.15} Event rates & event-free probabilities: acute myocardial infarction

{9.17} Event rates & event-free probabilities: cardiac arrest

{9.19} Event rates & event-free probabilities: coronary revascularization

{9.16} Event rates & event-free probabilities: congestive heart failure

{9.18} Event rates & event-free probabilities: CVA/TIA

{9.20} Event rates & event-free probabilities: peripheral vascular disease

{9.21} Event rates & event-free probabilities: all-cause death {9.22} Event rates & event-free probabilities: any CV event or death

176 Cardiovascular special studiesh

0

10

20

30

1995-1996

1997-1998

1999-2000

Months after day 90

0 6 12 18 24 30 36

stn

eita

pf

ot

necr

ep

evit

alu

mu

C

0

10

20

30

Hemodialysis: age 20+

Peritoneal dialysis: age 20+

Months

-24 -18 -12 -6 0 6 12 18 24 30 360

10

20

30

40

50

601995

1996

1997

1998

1999

All: age 67+

0

5

10

15

20

1995-1996

1997-1998

1999-2000

Months after day 90

0 6 12 18 24 30 36

stn

eita

pf

ot

necr

ep

evit

alu

mu

C

0

5

10

15

20

Hemodialysis: age 20+

Peritoneal dialysis: age 20+

Months

-24 -18 -12 -6 0 6 12 18 24 30 360

5

10

15

20

25

301995

1996

1997

1998

1999

All: age 67+

0

2

4

6

8

1995-1996

1997-1998

1999-2000

Months after day 90

0 6 12 18 24 30 36

stn

eita

pf

ot

necr

ep

ev it

alu

mu

C

0

2

4

6

8

Hemodialysis: age 20+

Peritoneal dialysis: age 20+

Months

-24 -18 -12 -6 0 6 12 18 24 30 360

3

6

9

12

151995

1996

1997

1998

1999

1995

1996

1997

1998

1999

All: age 67+

0

10

20

30

40

1995-1996

1997-1998

1999-2000

Months after day 90

0 6 12 18 24 30 36

stn

eita

pf

ot

necr

ep

evit

alu

mu

C

0

10

20

30

40

Hemodialysis: age 20+

Peritoneal dialysis: age 20+

Months

-24 -18 -12 -6 0 6 12 18 24 30 360

10

20

30

40

50

601995

1996

1997

1998

1999

All: age 67+

0

10

20

30

40

50

1995-1996

1997-1998

1999-2000

Months after day 90

0 6 12 18 24 30 36

stn

eita

pf

ot

necr

ep

evit

alu

mu

C

0

10

20

30

40

50

Hemodialysis: age 20+

Peritoneal dialysis: age 20+

Months

-24 -18 -12 -6 0 6 12 18 24 30 360

10

20

30

40

50

60

70All: age 67+

0

10

20

30

40

1995-1996

1997-1998

1999-2000

Months after day 90

0 6 12 18 24 30 36

stn

eita

pf

ot

ne cr

ep

evit

a lu

mu

C

0

10

20

30

40

Hemodialysis: age 20+

Peritoneal dialysis: age 20+

Months

-24 -18 -12 -6 0 6 12 18 24 30 360

10

20

30

40

50

601995

1996

1997

1998

1999

All: age 67+

{9.23} Stress tests in dialysis patients

{9.26} Echocardiograms in dialysis patients

{9.24} Coronary angiography in dialysis patients

{9.27} Coronary revascularization in dialysis pts

{9.25} Cor. angiography/stress tests in dialysis pts

{9.28} Lipid testing in dialysis patients

Diagnosis D treatment of cardiac disease in dialysis patients

177H2004 USRDS Annual Data Report

0

20

40

60

80

100

1995-1996

1997-1998

1999-2000

Months after day 90

0 6 12 18 24 30 36

stn

eita

pf

ot

necr

ep

evit

alu

mu

C

0

20

40

60

80

100

Hemodialysis: age 20+

Peritoneal dialysis: age 20+

Months

-24 -18 -12 -6 0 6 12 18 24 30 360

20

40

60

80

100

1995

1996

1997

1998

1999

All: age 67+

stn

eita

pf

ot

necr

ep

evit

alu

mu

C

0

10

20

30

40

50

60

70

Stress test

Coronary angiography

Stress test or

coronary angiography

Echocardiogram

Coronary revascularization

Defibrillator

Hemodialysis: Prior to cardiac arrest (all patients, n=21,930)

Months

-24 -21 -18 -15 -12 -9 -6 -3 00

10

20

30

40

50

60

70Peritoneal dialysis (n=1,596)

0 2 4 6 8 10 12

After cardiac arrest (surviving pts, n=12,394)

ytilib

ab

orp

ev it

alu

mu

C

0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0 2 4 6 8 10 120.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7(n=814)

Probability: after cardiac arrest (surviving pts, n=12,394)

(n=814)

{9.29} ECGs in dialysis patients {9.30} Cardiac procedures in prevalent dialysis patients

he use of diagnostic and therapeutic procedures relating

to cardiovascular disease plays a significant role in ESRDpatient outcomes. In 1999–2000, 25 percent of hemodi-

alysis patients had a stress test in the three years after initiation

(Figure 9.23). Thirteen percent of incident dialysis patients age 67

and older in 1999 underwent coronary angiography within two

years prior to initiation, and an additional 9 percent had the proce-

dure in the year following initiation (Figure 9.24).

One issue in the cardiac management of dialysis patients is the

use of testing for the diagnosis of ischemic heart disease. Of hemo-

dialysis patients incident in 1999–2000, 31 percent received a stress

test or coronary angiogram (a reflection of the total diagnostic

effort for the evaluation of coronary artery disease) within three

years of initiation (Figure 9.25). In the elderly dialysis population,

nearly 30 percent had a stress test or coronary angiogram in the two

years before initiation and another 12 percent in the year following.

Coronary revascularization is still relatively uncommon in di-

alysis patients. In the 1999–2000 cohort, 6.5 percent of hemodi-

alysis patients underwent coronary revascularization in the three

years after initiation (Figure 9.27). In the elderly population, 6

percent had the procedure in the two years prior to initiation, and

14 percent in the three years following.

The recent K/DOQI Cardiovascular Practice Guidelines recom-

mend echocardiography shortly after dialysis initiation. Approxi-

mately 11 percent of 1999–2000 incident hemodialysis patients

received echocardiograms in the first three months, and 31 percent

in the first year; the numbers were 8 and 26 percent for peritoneal

dialysis patients (Figure 9.26). In the population age 67 and older,

55 percent received an echocardiogram in the two years before

initiation, and 25 percent in the year before; in the year followinginitiation, an additional 17 percent were tested. It is remarkable

that the use of echocardiography exceeds the frequency of lipid

testing; only 39 percent of hemodialysis patients receive any lipid

tests in the three years after dialysis initiation (Figure 9.28).

In the two years prior to a cardiac arrest, about 36 percent of

hemodialysis patients are evaluated for coronary artery disease (Fig-

ure 9.30). Sixty-two percent have echocardiograms, implying that

the majority of patients at risk for an arrest have left ventricular

ejection fractions assessed before the event. There is a striking

underutilization of implantable cardioverter defibrillators in arrest

survivors. In hemodialysis patients surviving cardiac arrest, the prob-

ability of receiving a defibrillator within one year is only 3 percent.

The change in the slope of procedure use curves at the time of

initiation for patients age 67 and older implies that the 90-day

period following initiation is an “unstable” period for cardiovascu-

lar event rates. There are several explanations for this finding,

including an actual change in cardiovascular event rates, access to

care at the beginning of Medicare coverage, and, in the case of

coronary revascularization, perhaps a conscious decision on the

part of clinicians to delay intervention until the initiation of dialy-

sis. These figures imply that this 90-day period may represent a

distinctly different period in the life of a dialysis patient.

{Figures 9.23–29} top two graphs: incident Medicare dialysis patients age 20 &older; bottom graph: incident Medicare dialysis patients age 67 & older, includingpatients with unknown dialysis modality. {Figure 9.30} period prevalent dialysispatients, age 20 & older, 2001, with cardiac arrest in the same year.

Chap

terJo

summary

Chapter summary178 Cardiovascular special studiesh

Cardiovascular event rates after the initiation of dialysis{Figure 9.14 In the incident hemodialysis and peritoneal dialysis populations, the percentage of patients with cardiovascular disease increased progres-sively between 1995 and 2002.} {Figure 9.16 The most common cardiovascular condition in dialysis patients is congestive heart failure. The CHF eventrate in both hemodialysis and peritoneal dialysis patients is markedly increased in the first six months after dialysis initiation.} {Figure 9.17 Forhemodialysis patients there is an early hazard of increased cardiac arrest event rates. In peritoneal dialysis patients, in contrast, the risk of cardiac arrest islower at the time of dialysis initiation and rises continuously related to dialysis vintage. At three years the probability of cardiac arrest in both populationsis about 30 percent.} {Figure 9.18 There is an early hazard of CVA/TIA in both hemodialysis and peritoneal dialysis patients in the first six months afterdialysis initiation.} {Figure 9.21 In the first six months after dialysis initiation there is a increased hazard of death in hemodialysis patients but not inperitoneal dialysis patients.}

Diagnosis & treatment of cardiac disease in dialysis patients{Figures 9.23–25 Utilization of diagnostic testing for the evaluation of ischemic heart disease (stress testing and coronary angiography)increased from 1995 to 2000. Backcasted data in elderly dialysis patients reveals significant procedure use in the two years prior to dialysisinitiation.} {Figure 9.26 At least half of all hemodialysis patients receive an echocardiogram within 36 months after dialysis initiation.Nearly half of elderly dialysis patients have received an echocardiogram in the two years prior to initiation.} {Figure 9.28 After dialysisinitiation, the cumulative frequency of a lipid test in hemodialysis patients is less than that of an echocardiogram.} {Figure 9.30 Nearly two-thirds of prevalent dialysis patients in 2001 who sustained a cardiac arrest in the same year had echocardiography performed in the two yearsprior to the arrest. Implantable cardioverter defibrillators are underutilized in dialysis patients who survive a cardiac arrest. Theprobability of receiving a defibrillator within one year after cardiac arrest is 3–4 percent in dialysis patients who survive the arrest.}

Maps: National means & patient populationsFigure number 9.6 9.6 9.6 9.6 9.6 9.6 9.6 9.6 9.7 9.7 9.7 9.7

94–95 01–02 94–95 01–02 94–95 01–02 94–95 01–02 AMI AMI CHF CHFDial I Dial I Dial II Dial II CKD CKD NCKD NCKD Dial I GMed Dial I GMed

Overall value for all pts 64.5 57.5 105.2 107.1 27.3 22.2 7.7 7.0 54.5 11.1 390.2 69.2Total patients 231,086 328,154 231,086 328,154 29,946 49,340 1,237,107 1,577,102 492,171 6,309,798 492,171 6,309,798Overall value for pts mapped 64.8 57.8 105.7 107.4 27.4 23.7 7.8 7.2 54.8 11.8 391.3 69.2Missing HSA/state: pts dropped 3,607 4,971 3,607 4,971 292 736 11,396 19,544 8,230 86,955 8,230 86,955

Figure number 9.8 9.8 9.8 9.8 9.8 9.8 9.12 9.12 9.12 9.12DM NDM DM NDM DM NDM AMI AMI CHF CHF

Dial I Dial I Dial II Dial II GMed GMed Dial I GMed Dial I GMedOverall value for all pts 76.0 51.9 131.0 92.3 13.6 7.1 69.3 22.6 486.5 140.2Total patients 206,383 285,788 206,383 285,788 1,143,498 5,166,300 206,383 1,143,498 206,383 1,143,498Overall value for pts mapped 76.5 52.4 131.6 92.8 13.8 13.8 69.6 22.4 487.9 140.0Missing HSA/state: pts dropped 4,502 3,728 4,502 3,728 31,652 55,303 4,502 31,652 4,502 31,652

Characteristics of diabetic patients with cardiac arrest{Figure 9.9 The use of ACE inhibitors/ARBs in diabetic Medicare beneficiaries nearly doubledfrom 1992 to 1999.} {Figure 9.10 In prevalent dialysis patients, rates of inpatient and outpatientsudden cardiac death and non-cardiac death have remained fairly constant between 1991 and2002. The rate of inpatient non-cardiac death has declined, which appears to be the primaryexplanation for the falling mortality rates.}

Characteristics of patients with cardiac disease{Figure 9.2 Among dialysis patients with cardiac arrest, the proportion of elderly patients and of patients with diabetesmellitus as the primary cause of ESRD rose from 1991 to 2002.} {Figures 9.3–4 In general Medicare patients with a historyof cardiac arrest, the proportion of elderly patients has grown since 1994.} {Figure 9.5 Few dialysis or general Medicarepatients with cardiac arrest have no history of comorbidity. Congestive heart failure and hypertension are the most commoncomorbid medical conditions in dialysis and general Medicare patients with cardiac arrest.} {Figures 9.6–7 Rates of cardiacarrest and congestive heart failure are high in the southern states and Appalachia.}

Introduction{Figure 9.1 In prevalent dialysis patients the rate of acute myocardial infarctionincreased between 1994 and 2002, while rates of congestive heart failure andcardiac arrest have remained relatively stable.}