Effects of hospitalization before hemodialysis on mortality in dialysis patients

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POSTER PRESENTATIONS

Relation of the Severity of Obstructive Sleep Apnea in Response to Anti-Arrhythmic Drugs in Patients With Atrial Fibrillation or Atrial Flutter

Background and Aims As the elderly population increases and nuclear families are formed, the number of elderly people who are managed in nursing facility is increasing. We investigated whether dialysis performed while residing in a nursing facility before dialysis affects the mortality rate of dialysis patients. Method We enrolled 2,597 patients who visited the hemodialysis clinics of 17 teaching hospitals and surveyed the characteristics of underlying diseases, laboratory findings, and medication between patients who started dialysis while admitted to a nursing facility and those who did not. Then, multivariate survival analysis was performed to see if starting dialysis after entering a nursing facility increased mortality. Results 9.1% (n=237) of the subjects underwent dialysis while admitted to a nursing facility. This group was predominantly female and older. Also the prevalence of diabetes, dementia, heart failure and atrial fibrillation was higher. There were many users of anti-platelet agents, warfarin, dementia drugs, and antidepressants. Additionally this group showed lower weight, lymphocyte, iPTH, albumin, phosphorus, and total cholesterol and higher duration of diabetes, and alkaline phosphatase. In multivariate analysis controlling for age, sex, access type, dementia, malignancy, ischemic heart disease, cerebrovascular accident, heart failure, atrial fibrillation, liver cirrhosis, fracture, coronary artery disease, ejection fraction, lymphocyte, platelet, BUN, Cr, albumin, phosphorus, total cholesterol, RAS blockade, B-blocker, calcium channel blocker, warfarin, hyperlipidemia drugs, Calcium-based phosphate binder, sevelamer, anti-depressant, and dementia medication, the HR of group receiving dialysis after being admitted to a nursing facility was 1.658 [1.309, 2.100]. Conclusion In summary, the current study suggests a correlation between starting dialysis in a nursing facility and a higher mortality rate among dialysis patients.

Heart failure (HF) represents a major and growing public health problem because of its prevalence, incidence, morbidity, mortality, and economic costs. The prevalence of HF is 2% to 3% of the general population.1 Five million Americans are affected, with >550 000 cases diagnosed each year.2 The mortality rate from severe HF remains >60% within 5 years of diagnosis, and 50% of hospitalized patients with HF require readmission within 6 months of discharge. In the US estimated costs amount to > $35 billion per year.3 Although several therapies (eg, β-blockers, angiotensin-converting enzyme [ACE] inhibitors, and cardiac resynchronization therapy) have been proven effective in improving HF outcomes, many unanswered questions about optimal treatment remain. One area of ongoing uncertainty is the appropriate role for antithrombotic therapy in patients with HF. Observational data suggest that patients with HF have an increased venous thromboembolism (VTE) risk (deep venous thromboembolism [DVT], pulmonary embolism [PE], peripheral arterial thromboembolism, and stroke).4 These epidemiological findings are supported by multiple mechanisms that can contribute to a hypercoagulable state in patients with HF. Despite this increased risk of VTE, the role of antithrombotic therapy remains unclear. In this article, we provide an overview of epidemiology, pathophysiology, clinical trial data, and therapeutic recommendations for prevention of thromboembolism in HF. We searched PubMed for articles published between 1958 and 2010 using the following search terms: epidemiology of heart failure , thromboembolism and heart failure , thrombogenesis and heart failure , anticoagulation in heart failure , antiplatelet agent and heart failure , aspirin and heart failure , bleeding risk and anticoagulation , and aspirin and angiotensin-converting enzyme inhibitors . We also studied abstracts from national and international cardiovascular meetings to identify unpublished studies using the key words anticoagulation and dilated cardiomyopathy . Data from published observational studies and secondary …

Section 11: Evaluation and Management of Patients With Heart Failure and Preserved Left Ventricular Ejection Fraction

This study sought to evaluate inappropriate prescribing practices in an atrial fibrillation (AF) population, as outlined by the 2016 ACC/AHA Clinical Performance and Quality Measures for Adults with Atrial Fibrillation or Atrial Flutter document. The 2016 AF quality measures document specified medications to avoid in certain AF populations, including aspirin and anticoagulant combination therapy in patients without cardiovascular disease, and non-dihydropyridine calcium channel blockers in patients with reduced ejection fraction. Using data from the NCDR PINNACLE registry, a national outpatient cardiology practice registry, we assessed rates of inappropriate prescription of two types of medications among AF outpatients from 5/1/2008-5/1/2016. Overall rates of inappropriate prescription and variation by practice were calculated. Patient and practice factors associated with inappropriate prescription were assessed in adjusted analyses. A total of 107,759 of 658,250 (16.4%) patients without cardiovascular disease were inappropriately prescribed an antiplatelet and anticoagulant together, and 5,731 of 150,079 (3.8%) patients with reduced ejection fraction were inappropriately prescribed a non-dihydropyridine calcium channel blocker. Overall, 14.8% of AF patients were prescribed medications that were not recommended. Both patient and practice factors were associated with inappropriate prescribing, and the adjusted practice-level median odds ratio for inappropriate prescription was 1.70 (95% CI: 1.61-1.82), indicating a 70% likelihood that 2 random practices would treat identical AF patients differently. In a large registry of AF patients treated in cardiology practices, overall rates of inappropriate prescription practices, as defined by the 2016 AF quality measures, were relatively low, but significant practice variation was present.

Sex differences have the potential to impact diagnostic and therapeutic interventions in a wide variety of medical conditions, and cardiac arrhythmias are no exception.1 Studies evaluating pathophysiology, disease course, and therapeutic options for cardiac arrhythmias have been performed predominantly in male patients. However, catheter and device-based therapies coupled with landmark clinical trials have contributed to an improved understanding of this important aspect. The objective of this review is to present the current state of knowledge on sex differences in cardiac arrhythmias with a focus on clinical management, while highlighting gaps in knowledge that would benefit from future investigation. ### Atrial Fibrillation and Atrial Flutter #### Disease Burden Atrial fibrillation (AF) and atrial flutter (AFL) are the most commonly encountered tachyarrhythmias in clinical practice, with significant implications for public health and healthcare costs. Stroke, hospitalization, and loss of productivity are the major consequences of AF.2 The incidence of AF (per 1000 person-years) is reported to be between 1.6 and 2.7 in women and between 3.8 and 4.7 in men.2 The age-adjusted incidence and prevalence of AF is lower in women compared with that in men, and accordingly, the lifetime risk of AF from the Framingham Heart Study at 40 years of age was higher in men (26.0% for men versus 23.0% for women).3 Another analysis from the Framingham Heart Study demonstrated no significant sex differences in the risk of developing AFL.4 The prevalence of AF continues to rise among both men and women. In a study investigating the global burden of disease from 1980 to 2010, there was not only an increase in overall burden, incidence, and prevalence of AF, but most importantly an increase in AF-associated mortality in both men and women (Figure 1).5 The age-adjusted mortality for women was consistently higher compared with that for men from 1990 to 2010 (Figure …

Sleep is generally considered to be a protected period, when the cardiovascular system benefits from the restorative influences of the sleeping brain. However, the dynamics of cardiovascular control during sleep can tax the capacity of the diseased coronary circulation and myocardium with surges in sleep-state–related autonomic activity and disruptions in airway function and central nervous system regulation. In this regard, sleep may constitute an autonomic stress test for the heart. The scope of sleep-related risk for atrial and ventricular arrhythmias is substantial. The major subgroups susceptible to adverse influences of surges in autonomic activity during sleep are those with ischemic heart disease, heart failure, and channelopathies (Table).1 It is significant that 20% of myocardial infarctions and 15% of sudden deaths occur at night in the United States.2 Most atrial arrhythmias in patients younger than 61 years of age have nocturnal onset.3 The young are not immune to risk, as sudden infant death syndrome (SIDS) claims 2500 lives in the United States annually.4 Cardiovascular risk is compounded by comorbid factors, most notably apnea, which affects an estimated 4% to 9% of the general population5 and is considerably more prevalent among obese individuals.6 The more common form is obstructive sleep apnea (OSA), with partial or complete collapse of the pharynx. Half of heart failure patients experience either OSA or central sleep apnea (CSA) with central nervous system–mediated periodic breathing, commonly referred to as Cheyne-Stokes respiration. Such cardiorespiratory disturbances profoundly alter autonomic nervous system activity and increase risk of arrhythmia, hypertension, and myocardial infarction. View this table: Table. Patient Groups at Potentially Increased Risk for Nocturnal Cardiac Events It is surprising, as recently underscored by Malhotra and Loscalzo,7 that the significance of cardiovascular risk during sleep may not be duly recognized within the cardiology community. The reasons are …

Atrial fibrillation: understanding the serious consequences and learning about the causes.

Atrial fibrillation (AF) is a relatively common arrhythmia encountered by the family nurse practitioner (FNP) in outpatient clinics, emergency departments, and inpatient units. The FNP must be able to gather a relevant history, perform a focused exam, and order appropriate diagnostic tests to accurately diagnose, classify, and treat the patient with AF. Current diagnostic and treatment strategies are discussed in this case study in the context of new onset AF in a 61 year-old woman. This patient was encountered in the emergency department of a rural hospital. The patient was subsequently followed on an outpatient basis with input from cardiology. The literature review for this case was conducted using CINAHL and Ovid databases, utilizing various combinations of the following keywords: atrial fibrillation, AF, underlying disease, evaluation, treatment, and CHADS2 (congestive heart failure, hypertension, age more than or equal to 75, diabetes mellitus, and stroke or transient ischemic attack history). Reference lists for the resulting articles were further explored for relevant research. ATRIAL FIBRILLATION 3 Introduction and Background Atrial fibrillation (AF) is a relatively common arrhythmia characterized by ineffective atrial contraction due to chaotic atrial depolarization (Patterson, Wolfe, & Bower, 2010). It is more prevalent in men and incidence rises in both sexes with increasing age (Go et al, 2001). Failure to diagnose and treat AF leads to a higher incidence of stroke due to the formation of atrial emboli that may become systemic (Aronow, 2008). In addition, adverse cardiac events may be increased due to a rapid ventricular response to AF. This can also lead to tachycardia-related cardiomyopathy (Aronow, 2008). Increased mortality rates in patients with untreated AF result from these higher incidences of cerebrovascular and cardiovascular events. The minimum evaluation of the patient with AF consists of a history, physical examination, specific laboratory diagnostics, and electrocardiogram (EKG), with echocardiogram after hemodynamic stabilization (Fuster, Ryden, & Cannom et al, 2006). Onset of symptoms, frequency and duration of symptoms, associated symptoms, and past treatment— as well as response—all contribute to the development of appropriate AF classification as outlined in Table 1 (Podrid, Zimetbaum, & Saperia, 2010). In addition, personal and family history can help the clinician determine if the AF could be secondary to an underlying disease process like diabetes or hypertension (Kannel, Wolf, Benjamin, & Levy, 1998). Gathering a social history is also important; those with a history of tobacco use have a higher incidence of AF (Kannel et al, 1998). ATRIAL FIBRILLATION 4 Table 1 AF Classification Paroxysmal Episodes terminate spontaneously in less than seven days, usually less than 24 hours. Persistent Episodes fail to spontaneously terminate in seven days, but may still do so. Cardioversion may be necessary. These patients often have paroxysmal events after initial conversion. Permanent Episode has lasted for more than one year; cardioversion has either been unsuccessful or not attempted. Lone Any type of AF that exists in patients with structural heart disease, usually applied to patients under 60 years of age. Appropriate diagnostics also assist in the classification and treatment of AF. Certain underlying physiologic conditions may be correctable and lead to resolution of AF. Serum studies, including complete blood count (CBC), comprehensive metabolic profile (CMP), thyroid stimulating hormone (TSH), and Troponin I are indicated. Inflammation and infection can contribute to the pathogenesis of AF (Ichiki, Orihara, & Hamasaki, 2009). Electrolyte imbalances can lead to a variety of dangerous arrhythmias, including AF (Nishimura, Nakayama, & Ishikawa, 1996). Untreated or undiagnosed hyperthyroidism can also cause AF (BieleckaDabrowa, Mikhailidis, Rysz, & Banach, 2009). In addition to laboratory tests, an EKG must be performed to evaluate the electrophysiology of the heart and an echocardiogram to assess the structural condition of the heart. Ischemic heart disease, congestive heart failure, pericarditis, and valvular disease are all examples of clinically relevant pathologies that should be considered ATRIAL FIBRILLATION 5 because they can contribute to the development of AF (Nattel, Shiroshita-Takeshita, Brundel, & Rivard, 2005). Treatment of AF has three main objectives: rate control, correction of the arrhythmia, and prevention of thromboembolism (Patterson et al, 2010). Control of the heart rate and rhythm is usually accomplished by using beta-blockers, calcium channel blockers, amiodarone, or digoxin (Patterson et al, 2010). If the heart does not respond to medications, electrical cardioversion or surgical ablation of accessory atrial pathways is considered. The CHADS2 (congestive heart failure, hypertension, age more than or equal to 75, diabetes mellitus, and stroke or transient ischemic attack history) scoring system helps identify the need for anticoagulation and direct its management based on the patient’s co-morbidities (Table 2). A score of 0-1 indicates that aspirin therapy is sufficient, while a score of 2-6 indicates the need for warfarin in the absence of other contraindications (Patterson et al, 2010). Table 2 CHADS2 Scoring System

The management of atrial fibrillation, even in the modern era, remains complex and challenging. Preventing atrial fibrillation occurrence by identifying and favorably improving modifiable risk factors thus assumes great importance. It is well known that hypertension and resultant structural heart disease contributes significantly to the incidence of atrial fibrillation.1,2 The Losartan Intervention For End point reduction in hypertension (LIFE) study thus far has shown us that angiotensin-receptor blockade and reduction in left ventricular hypertrophy, irrespective of blood pressure–lowering, reduces the incidence of new-onset atrial fibrillation.1,3 Article see p 337 In recent years, accumulating evidence has linked high resting sinus heart rates (HR) directly and indirectly to adverse cardiovascular outcomes.4,5 Epidemiological studies show resting HR to be an independent predictor of cardiovascular and all-cause mortality in general population as well as in hypertensive patients.6 The cardiovascular benefits offered by β-blockade in coronary artery disease and heart failure have, in part, been attributed to β-blocker–mediated HR reduction.7,8 Other studies have linked high baseline HR to the development of hypertension, to the progression of coronary artery disease, and to the triggering of myocardial infarction, ventricular dysfunction, and ventricular arrhythmias.6,9–11 In this issue of Circulation: Arrhythmia and Electrophysiology , Okin and colleagues12 examines the relationship of HR changes over time on risk of atrial fibrillation in hypertensive patients as part of the LIFE study. In this post hoc analysis of the prospective LIFE study, 8828 hypertensive patients with left ventricular hypertrophy by ECG but without a history of atrial fibrillation were followed for a mean of 4.7±1.1 years. New onset atrial fibrillation was determined by 12-lead ECG performed on an intermittent, infrequent basis (at baseline, 6 months, and yearly thereafter). Hypertension was treated with losartan or atenolol. Using a variety of analyses, higher in-treatment HR on serial …

52-Year-Old Woman With Palpitations, Abdominal Distension, and Severe Abdominal Pain

Aspirin in heart failure: don't throw the baby (aspirin) out with the bathwater.

Objective: To describe current antihypertensive drug therapy in Sweden in the very old, in relation to gender, age and comorbidity. Design and method: By use of the Stockholm County Council database, comprising all healthcare consultations, hospitalizations, and dispensed drugs for 2.1 million inhabitants living in the Greater Stockholm region in 2013, we identified all persons a recorded diagnosis of hypertension during 2009–2013, their comorbidity, and their dispensed antihypertensive drugs during 2013. Results: We identified 12 436 patients aged between 90–109 (mean 92.6) years; 9 362 (75%) were women. The most common comorbidities were congestive heart failure (30%), atrial fibrillation (28%) and ischemic heart disease (26%) in women, and atrial fibrillation (37%), congestive heart failure (35%), and ischemic heart disease (34%) in men. The most common antihypertensive drug classes in women and men were diuretics (49 and 49%;), beta blockers (48 and 46%;), calcium channel blockers (30 and 28%), ACE inhibitors (23 and 29%, P < 0.001), ARB (19 and 18%). Beta blockers were more common with concomitant ischemic heart disease, atrial fibrillation, and heart failure (63, 63, and 59%, respectively); whereas ACE inhibitors/ARB were more common with diabetes and congestive heart failure (56 and 52%, respectively). Hypertensive men with diabetes more often than women received ACE inhibitors/ARB (60 vs 52%, P < 0.001). The proportions with 0, 1, 2, 3 and >4 antihypertensive drug classes were 14, 23, 27, 20, and 17% in women, and 15, 22, 25, 21, and 17% in men. The most common combinations of 2 drugs in were beta blockers and diuretics (29%), calcium channel blockers and diuretics (16%), and beta blockers and calcium channel blockers (15%) in women; and in men beta blockers and diuretics (28%), ACE inhibitors and diuretics (17%), and beta blockers and ACE inhibitors (15%). Conclusions: Antihypertensive drug therapy in the very old is not uncommon. Gender differences in antihypertensive drug therapy persist also in patients aged 90 years and above. Our recent and earlier findings suggest that age and comorbidity do not entirely explain these gender differences. The use of combination therapy appears low.