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Editorial

Moving from the "Check the Pulse" Era To "Check the ECG" in the Prevention of Thromboembolic Events in Atrial Fibrillation

Atrial fibrillation (AF) and chronic kidney disease (CKD) share common risk factors and often co-exist: 20% of patients with CKD have symptomatic AF, whereas around 50% of patients with AF will have some degree of renal impairment. Patients with both conditions have a five-fold increased risk of stroke, three-fold increased risk of congestive heart failure, higher cardiovascular morbidity, and all-cause mortality compared with patients who only have either AF or CKD. The incidence rates of AF in a large nationwide database from Taiwan were 5.0, 7.3, and 12.1 events per 1000 patient-years in the general population, the CKD cohort, and the end-stage kidney disease cohort, respectively. The risk of stroke or systemic embolismincreased by 7% for every 10 mL/min decline in eGFR. Early detection of AF may reduce the risk of stroke and other AF-related complications using oral anticoagulant therapy or left atrial appendage closure procedure.^.

In the first physician-based survey jointly conducted by European Heart Rhythm Association (EHRA) and European Renal Association (ERA)/European Dialysis and Transplantation Association (EDTA) in 2020 to gain insight into the management of AF in patients with CKD, when asked about screening for AF among CKD patient, overall, 132/295 respondents (44.7%) would routinely screen for the presence of AF in all CKD patients at their first presentation, 68/295 (23.1%) would screen for AF only in selected CKD patients, and 95/295 respondents (32.2%) would not screen for AF among CKD patients. Compared with ERA/EDTA respondents, EHRA respondents would more frequently screen for AF only in selected CKD patients (28.5% vs. 16.8%, p = 0.017 at their first presentation and 36.7% vs. 25.0%, p = 0.031 during follow-up). Therefore, there is a low utilization of screening for AF among CKD patients, most likely in patients with symptoms or a history of arrhythmia. More ERA/EDTA respondents would screen for AF among patients on dialysis or those with a functioning kidney transplant compared with EHRA respondents. The most common screening techniques were a single 12-lead electrocardiogram (ECG) recording (240/288 respondents, 83.3%) or ≥24-h Holter monitoring (181/288, 62.8%). The ERA/EDTA respondents still more frequently chose pulse palpation (67.4%), whereas the EHRA respondents more frequently opted for a cardiac rhythm monitoring strategy using a handheld device, telemetry, Holter monitoring, an implantable cardiac monitor, or cardiac implantable electronic device memory readings.

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Original Article

Subclinical Atrial Fibrillation Screening in Dialytic Chronic Kidney Disease Patients Using Portable Device

Adson Patrik Vieira Carvalho et al. Gabriel Assis Lopes do Carmo Cassia Aparecida Silva Ana Cecília Oliveira … Lucas Giandoni Perez Lilian Pires de Freitas do Carmo Antonio L. Ribeiro

Abstract

Background

Cardiovascular morbidity and mortality rates are higher in hemodialysis (HD) patients, with an increased prevalence of arrhythmias. Atrial fibrillation (AF) is an independent risk factor for mortality and thromboembolic events in dialysis patients. For a better understanding and management of AF in these patients, it is important to know its prevalence. The use of a portable device would be pioneering for this group of patients.

Objective

To screen HD patients for AF using a portable gadget and evaluate the device’s diagnostic performance.

Methods

HD patients at a tertiary hospital underwent AF screening during HD sessions using MyDiagnostick^® (Applied Biomedical Systems). Multiple data were collected to evaluate potential associations. Statistical significance was defined as p < 0.05.

Results

388 patients were evaluated (female, 40.7%; mean age of 56.8 years old, SD ± 14.7; and HD time of 27 months, 10-57). Screening was positive in 16 (4.1%) patients. AF was confirmed by electrocardiogram in 7 (1.8%) patients. Male sex (p = 0.019), older age (p = 0.007), altered baseline electrocardiogram (p < 0.001), increased serum potassium (p = 0.021), reduced systolic blood pressure at the beginning of dialysis (p = 0.007), and stable angina (0.011) were associated with positive screening for AF. The device presented a 91.74% specificity (95% CI, 86.65% to 96.91%) and 100% sensitivity (95% CI, 100% to 100%), with a negative predictive value of 100% (95% CI, 100% to 100%) for AF screening.

Conclusion

The use of this device proved to be practical, with high sensitivity and excellent negative predictive value. Subclinical AF has a high prevalence and may be underestimated in this population.

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Artigo Original

Myocardial Revascularization in Dyalitic Patients: In-Hospital Period Evaluation

Matheus Miranda et al. Nelson Américo Hossne Jr. João Nelson Rodrigues Branco Guilherme Flora Vargas … José Honório de Almeida Palma da Fonseca José Osmar Medina de Abreu Pestana Yara Juliano Enio Buffolo

Background:

Coronary artery bypass grafting currently is the best treatment for dialytic patients with multivessel coronary disease, but hospital morbidity and mortality related to procedure is still high.

Objective:

Evaluate results and in-hospital outcomes of coronary artery bypass grafting in dialytic patients.

Methods:

Retrospective unicentric study including 50 consecutive and not selected dialytic patients, who underwent coronary artery bypass grafting in a tertiary university hospital from 2007 to 2012.

Results:

High prevalence of cardiovascular risk factors was observed (100% hypertensive, 68% diabetic and 40% dyslipidemic). There was no intra-operative death and 60% of the procedures were performed off-pump. There were seven (14%) in-hospital deaths. Postoperative infection, previous heart failure, cardiopulmonary bypass, abnormal ventricular function and surgical re-exploration were associated with increased mortality.

Conclusion:

Coronary artery bypass grafting is feasible to dialytic patients although high in-hospital morbidity and mortality. It is necessary better understanding about metabolic aspects to plan adequate interventions.

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Artigo Original

Echocardiographic parameters as cardiovascular event predictors in hemodialysis patients

Thayse Mayara Aragão Siqueira et al. Pedro Antônio Muniz Ferreira Francisco das Chagas Monteiro Júnior Natalino Salgado Filho … Adalgisa de Souza Paiva Ferreira Eugênio dos Santos Neto Francival Leite de Souza Paulo de Tarso Cardoso

BACKGROUND: Patients with chronic kidney disease (CKD) on hemodialysis have high rates of cardiovascular morbidity and mortality. Although structural and functional echocardiographic alterations in patients undergoing hemodialysis have been the subject of several survival analysis studies, the prognostic value of these alterations is not well established in literature. OBJECTIVE: To determine the prognostic value of echocardiographic parameters in patients with CKD on hemodialysis. METHODS: Sixty consecutive patients with CKD on hemodialysis were clinically evaluated and underwent Doppler echocardiography, being followed for 19 ± 6 months. The outcome measures were fatal and nonfatal cardiovascular events and overall mortality. The predictive value of echocardiographic variables was evaluated by Cox regression model and survival curves were constructed using the Kaplan-Meier method and log rank test to compare them. RESULTS: Rates of survival free of cardiovascular events, of cardiovascular and overall mortality in two years were 79.4%, 88.5% and 83% respectively. Diabetes, previous diagnosis of cardiovascular disease (CVD), ejection fraction, fractional shortening, left ventricular systolic diameter and E/e’ ratio were predictors of cardiovascular outcome at univariate analysis. In the multivariate analysis, previous history of CVD (HR = 6.17, 95%CI: 1.7 – 22.2, p = 0.005) and moderate to severe diastolic dysfunction (HR = 3.76, 95%CI: 1.05 – 13.4, p = 0.042) were independent risk factors for cardiovascular events. CONCLUSION: Moderate to severe diastolic dysfunction is an independent predictor of cardiovascular events in hemodialysis patients.

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Moving from the "Check the Pulse" Era To "Check the ECG" in the Prevention of Thromboembolic Events in Atrial Fibrillation

Subclinical Atrial Fibrillation Screening in Dialytic Chronic Kidney Disease Patients Using Portable Device

Abstract

Background

Objective

Methods

Results

Conclusion

Myocardial Revascularization in Dyalitic Patients: In-Hospital Period Evaluation

Background:

Objective:

Methods:

Results:

Conclusion:

Echocardiographic parameters as cardiovascular event predictors in hemodialysis patients

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