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Patients with end stage renal disease (ESRD) have a high mortality, about 15-30 times the age matched general population, most of these are from cardiovascular events. We hypothesized that a dedicated cardiology clinic to address risk factors and delivering guideline based therapies and optimizing volume status would improve their survival.
We established a dedicated cardiology clinic for ESRD patients being evaluated for renal transplant. On the first visit a complete history including medications, physical examination, electrocardiogram, echocardiogram and lipid profiles were obtained. Guideline based therapies were instituted, risk factors including blood pressure and lipids were optimized and euvolemic status was obtained working closely with in-network and outside nephrologists before the patients were “cleared” for renal transplant from cardiac standpoint.
Baseline characteristics were: age 58+11 years, 60% men, hypertension in 97%, diabetes mellitus 77%, 77% on hemodialysis and 10% on peritoneal dialysis, LV ejection fraction 61+11%, 26% had documented CAD, 30% had HF by Framingham criteria and 45% had pulmonary artery systolic pressures >40 mmHg attributable to volume excess. During the period of optimization, guideline based aspirin therapy increased from 30% to 88%, statin use from 50% to 81%, beta blocker and ACE inhibitor in those with LV ejection fraction <40% to 76% and 62% respectively. Euvolemic status and normalization of pulmonary artery pressure were achieved in 95% of patients. Mortality in this cohort was markedly lower at 46 compared to the US national average of 140 per 1000 patients-years in age matched ESRD patients on dialysis (CDC data). In patients with CAD, this rate was 49 per 1000 patient-years and for HF 68 per 1000 patient years.
1)Patients with ESRD are grossly under-treated in terms of risk factor modification, guideline based preventive therapies and volume status. 2)A dedicated cardiology clinic improves management of many potential therapeutic targets. 3)Observed mortality in such diligently managed ESRD patients is about one third that of age matched national average.
Poster Sessions, Expo North
Saturday, March 09, 2013, 10:00 a.m.-10:45 a.m.
Session Title: Coronary Risk Factors and Management
Abstract Category: 28. Quality of Care and Outcomes Assessment
Presentation Number: 1115-102
- 2013 American College of Cardiology Foundation