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