Electrocardiographic predictors of mortality and sudden cardiac death in patients with end stage renal disease on hemodialysis

Abstract

Patients with end stage renal disease (ESRD) on hemodialysis experience a high incidence of cardiovascular mortality, and sudden cardiac death (SCD) accounts for approximately 25% of all deaths in this patient population. Despite this high risk of SCD, many non-invasive SCD risk stratification tools that are frequently applied to other patient populations (such as those with prior myocardial infarction and reduced left ventricular systolic function) may be less useful markers of increased SCD risk in ESRD. Improved SCD risk stratification tools for use specifically in patients on hemodialysis are therefore necessary to optimally target use of primary prevention interventions aimed at decreasing SCD incidence. Electrocardiography is an effective, non-invasive SCD risk stratification tool in hemodialysis patients. This article reviews data supporting the association between various ECG parameters (QT interval, spatial QRS-T angle, signal averaged ECG, heart rate variability, and T-wave alternans) and mortality/SCD in the dialysis population. Despite the association between abnormal ECG parameters and SCD, it remains unclear if these abnormal parameters (such as prolonged QT interval) are mechanistically related to SCD and/or ventricular arrhythmias, or if they are simply markers for more severe cardiac disease, such as left ventricular hypertrophy, that may independently predispose to SCD. Current obstacles that impair widespread implementation of ECG risk stratification in the hemodialysis population are also discussed..

TpTe and TpTe/QT: novel markers to predict sudden cardiac death in ESRD?

“… 1 , 18 Unfortunately, traditional risk factors for cardiovascular (CV) disease, which are ubiquitous among patients with ESRD, provide little predictive discrimination for those at higher risk of developing CV events, especially SCD. 5 - 7 Traditional markers provide general assessments of vascular health and may not be specific enough to influence adequate risk reduction measures in regard to SCD in patients with ESRD. The majority of SCD cases are presumed to be related to ventricular arrhythmias, although the possibility of PEA/asystole or bradycardic arrest is not ruled out in analyses focusing on baseline ECG parameters, as ours.…”

“… 5 To date, there is no reliable risk stratification marker to identify dialysis patients at high arrhythmic risk for sudden cardiac arrest. 5 - 7 …”

Cycles, Arrows and Turbulence: Time Patterns in Renal Disease, a Path from Epidemiology to Personalized Medicine?

“…24 23 22 21 20 19 18 17 16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 Different disease states, including ESRD, are associated with alterations in HRV, related to the autonomic dysfunction. Disturbances in physiological HRV are associated with an adverse prognosis [91]. In a study of 383 HD patients, a standard deviation of RR intervals below 75 ms was associated with increased cardiovascular and all-cause mortality [92].…”

Effects of Marine n-3 Polyunsaturated Fatty Acids on Heart Rate Variability and Heart Rate in Patients on Chronic Dialysis: A Randomized Controlled Trial

“…Cardiovascular disease (CVD) is the leading cause of death and sudden cardiac death (SCD) accounts for approximately 30% of total deaths in patients with end-stage renal disease (ESRD) in the Western world [ 1 , 2 ]. SCD is frequently caused by malignant ventricular arrhythmias [ 3 ], but the reasons for the substantial increased risk of SCD in patients with ESRD are not fully understood. A combination of risk factors that are associated with ESRD and dialysis treatment may be part of the explanation.…”