Risk factors for de novo acute cardiac events in patients initiating hemodialysis with no previous cardiac symptom

Abstract

An initial major adverse cardiac event (MACE) is an important predictor of future cardiovascular events in patients with chronic kidney disease (CKD). We sought to identify factors influencing occurrence of initial MACE in new maintenance hemodialysis patients without previous cardiac symptoms during the predialysis phase of CKD. Among 112 participating patients with no predialysis cardiac history, 57 underwent coronary angiography, whereas the other 55 underwent stress thallium-201 single-photon emission computed tomography within 1 month of beginning hemodialysis to detect asymptomatic coronary artery disease (CAD). In subsequent follow-up for a median of 24 months, subjects experiencing an initial MACE were compared with those who did not have such an event based on several clinical parameters at the end of predialysis phase. Asymptomatic CAD was present in 47 patients (42%), who had a higher cumulative MACE rate, than subjects without CAD (49 vs 3%, P<0.001). Multivariate Cox's regression analysis showed that three variables independently predicted initial MACE: asymptomatic CAD (hazard ratio or HR, 611.31; 95% confidence interval or CI, 14.07-26549.23; P<0.001), diabetes (HR, 20.41; 95% CI, 2.07-200.00; P=0.010), and each 1 mg/l increment in C-reactive protein (CRP) (HR, 1.94; 95% CI, 1.27-2.94; P=0.002). In conclusion, detection of asymptomatic CAD, presence of diabetes, or elevated CRP at the end of the predialysis phase were significantly associated with occurrence of an initial MACE in CKD patients starting hemodialysis who had no CAD symptoms.

Cardiac Survival after Pre-emptive Coronary Angiography in Transplant Patients and Those Awaiting Transplantation

“…Cardiac disease is the major cause of death of patients on dialysis (29,30), and our study raises the question of whether or not asymptomatic patients on dialysis who are not considering transplantation should be offered screening and intervention in the same way. Evidence in the literature would support this, with a number of studies reporting the poor prognosis associated with angiographically severe CAD and death or major adverse cardiac event within 1 year of dialysis (31,32). The same group has also demonstrated improved long-term outcomes in dialysis patients with CAD after revascularization (33).…”

Declining Prevalence of Coronary Artery Disease in Incident Dialysis Patients Over the Past Two Decades

“…Both statins and RAS-Is play important roles in preventing the progression of coronary atherosclerosis in the general population 8,9) . A recent large cohort study in Japan 10) demonstrated a prevalence of CAD of approximately 30% among asymptomatic hemodialysis patients, which is lower than the 42% reported in a previous study 11) . These findings imply that changes in the medical management of CKD have favorably modified risk factors for atherosclerosis and may conceivably reduce the prevalence of CAD in patients with CKD.…”

“…Chronic inflammation is thought to comprise one of the central reasons for the high incidence and prevalence of atherosclerotic cardiovascular disease in patients with CKD 22) . Moreover, the level of CRP, a marker of inflammation, is closely associated with the severity of atherosclerosis and cardiovascular events in patients with CKD 11,23) . Therefore, the decrease in the CRP levels over time may be another causal contributor to the improvement in the uCAD prevalence.…”

Prognostic study of cardiac events in Japanese patients with chronic kidney disease using ECG-gated myocardial Perfusion imaging: Final 3-year report of the J-ACCESS 3 study

“…Hase et al also significantly associated elevated CRP levels at the end of the predialysis phase among patients who had CKD but no CAD symptoms, with the occurrence of an initial cardiac event. 32 Thus, inflammation might be a predictor of cardiovascular events in patients with CKD.…”