Painless Myocardial Ischemia in Chronic Hemodialysed Patients: A Real Event?

Kremastinos, Dimitrios Th.; Paraskevaidis, Ioannis; Voudiklari, S; Αποστολου, Θωμασ; Kyriakides, Zenon S.; Zirogiannis, Panos; Toutouzas, P.

doi:10.1159/000186733

Cited by 31 publications

(24 citation statements)

References 31 publications

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“…The echocardiographic findings of dialysisinduced LV RWMA that were seen in both our previous study and in these results are strongly suggestive of subclinical ischemia, analogous to dobutamine stress echocardiography (16). In addition to the work from our center, one study demonstrated dialysis-induced perfusion defects using single photon emission computed tomography (7), and there are 10 reports of silent intradialytic ST depression detected by Holter monitoring (6,(17)(18)(19)(20)(21)(22)(23)(24)(25). Although initially there was concern that some electrocardiographic changes that were observed during dialysis were related to changes in electrolyte concentrations as opposed to myocardial hypoperfusion, the demonstration of dialysis-induced ischemia by electrocardiographic, echocardiographic, and isotopic techniques certainly suggests that such findings are attributable to ischemia.…”

Section: Discussionmentioning

confidence: 99%

Dialysis-Induced Regional Left Ventricular Dysfunction Is Ameliorated by Cooling the Dialysate

Selby

Burton

Chesterton

et al. 2006

Clinical Journal of the American Society of Nephrology

155

166

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Dialysis patients who develop cardiac failure have a poor prognosis. Recurrent subclinical myocardial ischemia is important in the genesis of heart failure in nondialysis patients. It has previously been demonstrated that subclinical ischemia occurs during hemodialysis; therefore, this study examined whether the improved stability of cool-temperature dialysis lessens this phenomenon. Ten patients who were prone to intradialytic hypotension entered a randomized, crossover study to compare the development of dialysis-induced left ventricular (LV) regional wall motion abnormalities (RWMA) at dialysate temperatures of 37 and 35°C. Serial echocardiography with quantitative analysis was used to assess ejection fraction and regional systolic LV function. BP and hemodynamic variables were measured using continuous pulse wave analysis. The severity of thermal symptoms was scored using a simple questionnaire. Forty-nine new RWMA developed in nine patients during hemodialysis with dialysate at 37°C (HD 37 ), compared with thirteen RWMA that developed in four patients during HD 35 (odds ratio 3.8; 95% confidence interval 2.1 to 6.9). The majority of RWMA displayed improved function by 30 min after dialysis. Overall, regional systolic LV function was significantly more impaired during HD 37 (P < 0.001). BP was higher during HD 35 , with fewer episodes of hypotension as a result of a higher peripheral resistance and no difference in stroke volume. The development of thermal symptoms was heterogeneous, with most patients tolerating HD 35 well. This study confirms previous findings of reversible LV RWMA that develop during hemodialysis. It also shows that this phenomenon can be ameliorated by reducing dialysate temperature, a simple intervention with no cost implications.

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Section: Discussionmentioning

confidence: 99%

Dialysis-Induced Regional Left Ventricular Dysfunction Is Ameliorated by Cooling the Dialysate

Selby

Burton

Chesterton

et al. 2006

Clinical Journal of the American Society of Nephrology

155

166

View full text Add to dashboard Cite

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“…Coronary angiography was not done in most studies; where it was performed, the results did not correlate with SMI during HD. [9,10] Only 20% of the patients developing SMI in this study showed significant epicardial CAD. Angiography delineates coronary anatomy but provides no pathophysiological information about coronary function.…”

Section: Discussionmentioning

confidence: 59%

“…A correlation between LV hypertrophy and SMI has been reported in some studies. [9,10] We used echocardiography, a more sensitive and specific tool compared with surface ECG used in these studies for detecting LV hypertrophy.…”

Section: Discussionmentioning

confidence: 99%

Silent Myocardial Ischemia and High-Grade Ventricular Arrhythmias in Patients on Maintenance Hemodialysis

et al. 2005

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The occurrence of silent myocardial ischemia (SMI) and serious arrhythmias during hemodialysis (HD) has been well documented. However, it is unclear whether these changes are due to epicardial coronary artery disease (CAD). We conducted a prospective study to assess whether SMI and arrhythmias during HD correlated with angiographically demonstrable CAD. Twenty-three patients with end-stage renal disease on maintenance HD underwent 48-hour Holter monitoring, beginning 24 hours prior to a HD session. All patients underwent biochemical evaluation, coronary angiography, and echocardiography. Holter monitoring showed SMI during HD in 22% cases. A significant increase in the frequency of ventricular ectopics (VEs) was noted during and after HD. Patients who showed SMI during HD and VEs prior to initiation of dialysis were more likely to develop significant ventricular arrhythmias during and after HD. Epicardial CAD was documented in four patients, and it did not correlate with SMI. To conclude, HD is an arrhythmogenic process. SMI during dialysis is probably not due to epicardial CAD but predisposes to clinically significant ventricular arrhythmias during and after HD. The cause of SMI during HD in patients without demonstrable CAD needs further investigation.

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“…Previous investigators have noted the frequent occurrence of transient silent myocardial ischemia during the hemodialysis procedure [7][8][9] . Kremastinos noted silent ischemia among 15% of hemodialysis patients, and he observed that the majority of these episodes were during the latter part of dialysis 10 . Linear regression analysis demonstrated di erences in serum potassium concentration before and after dialysis correlated with the likelihood of demonstrating ischemia.…”

Section: Discussionmentioning

confidence: 99%

Normalization of Hematocrit in Hemodialysis Patients Does Not Affect Silent Ischemia

et al. 2000

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Transient ST-segment depression measured on ambulatory ECG monitors has been described as representing silent ischemia. Patients who demonstrate silent ischemia have been reported to show increased mortality compared to patients without silent ischemia. We undertook this study to determine if the correction of anemia in End Stage Renal Disease (ESRD) patients from(AE standard deviation) 30 AE 3 to 42 AE 3 with the use of Epoetin alfa would result in decreased silent ischemia in patients with clinically evident ischemic heart disease or congestive heart failure.Methods: Thirty one ESRD patients with congestive heart failure or patients with clinically-evident ischemic heart disease were randomized into one of two arms. Patients in Group A had their hematocrit increased with the use of slowly escalating doses of Epoetin alfa to 42 AE 3% and patients in Group B were maintained with a hematocrit of 30 AE 3% throughout the course of the study. All patients had a 24 hour Holter monitor recording at baseline and at 28 weeks after randomization ( when they had reached their target hematocrit). Signi®cant silent ischemia was considered to be present if patients demonstrated at least 60 seconds of ! 1 mm ST segment depression.

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Painless Myocardial Ischemia in Chronic Hemodialysed Patients: A Real Event?

Cited by 31 publications

References 31 publications

Dialysis-Induced Regional Left Ventricular Dysfunction Is Ameliorated by Cooling the Dialysate

Dialysis-Induced Regional Left Ventricular Dysfunction Is Ameliorated by Cooling the Dialysate

Silent Myocardial Ischemia and High-Grade Ventricular Arrhythmias in Patients on Maintenance Hemodialysis

Normalization of Hematocrit in Hemodialysis Patients Does Not Affect Silent Ischemia

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