Bradycardia without “classical” EKG changes in hyperkalemic hemodialysis patients

Abstract

While the classic electrocardiographic (EKG) findings of hyperkalemia are well known to clinicians, the association between hyperkalemia and bradycardia is not widely appreciated. Three cases of profound bradycardia due to hyperkalemia in patients with End Stage Renal Disease (ESRD) on hemodialysis are described to provide a base for discussion of specific issues in the management of such patients. The patients presented with hyperkalemia and severe bradycardia that did not improve after administration of atropine. Urgent hemodialysis in two cases led to resolution of the bradycardia. In the third case, the failure to recognize that bradycardia was the consequence of the hyperkalemia led to unnecessary interventions and delays in initiating dialysis. These cases highlight the causal relation between hyperkalemia and bradycardia in ESRD patients and emphasize the need for increased awareness of this association.

Update to Practice Standards for Electrocardiographic Monitoring in Hospital Settings: A Scientific Statement From the American Heart Association

“…375 Bradycardia may occur in severe hyperkalemia as a re sult of the extremely prolonged PR and QRS. 373,375,376 Finally, a sine wave pattern, VF, and asystole or pulse less electrical activity may be seen at potassium lev els exceeding 10 mmol/L. 372,374 It is important to note, however, that electrocardiographic manifestations for hyperkalemia vary among individuals and may not be predictable.…”

Evaluation of Potassium Levels Before Hemodialysis Access Procedures

“…In two patients, however, with potassium of 5.6 and 6.0 mEq/l there were no ECG changes noted at all (15). In some hemodialysis patients, bradycardia may be the only symptom of hyperkalemia (16). ECG changes seen in renal failure patients may be very different than those seen in patients with normal renal function.…”

Chronic hyperkalemia in non-dialysis CKD: controversial issues in nephrology practice

“…Chronic hyperkalemia is easily diagnosed by common laboratory tests, paying attention to exclude pseudohyperkalemia (Table 2 ) [ 24 ]. Bradycardia is an early sign of acute severe hyperkalemia that requires increased awareness, especially in the dialysis setting [ 25 ]. In chronic hyperkalemia, where bradycardia is uncommon because of adaptive mechanisms, electrocardiogram (ECG) monitoring allows to gain clinical insight into the severity of abnormalities related to sK-dependent changes in cardiac rhythm (Fig.…”