How to reduce sudden cardiac death in patients with renal failure

[...]this raises the question whether ICD implantation in these patients is appropriate for prevention of SCD or whether other more conservative treatment strategies are preferred with regard to safety and cost effectiveness. Ischaemic heart disease Present in 80% of patients dying suddenly in the g... Full description

[...]this raises the question whether ICD implantation in these patients is appropriate for prevention of SCD or whether other more conservative treatment strategies are preferred with regard to safety and cost effectiveness. Ischaemic heart disease Present in 80% of patients dying suddenly in the general population Highly prevalent and more severe in patients with chronic kidney disease (CKD) and end stage renal disease (ESRD) Most important predictor of sudden cardiac death (SCD) in patients with ESRD In patients with coronary artery disease, severity of CKD is associated with the occurrence of SCD Left ventricular hypertrophy (LVH) and myocardial fibrosis Develops in the early stages of CKD and prevalence increases with severity of CKD Results in phenomena which predispose to electric excitability and ventricular arrhythmias (ie, decreased myocardial capillary density, diastolic and systolic dysfunction) Development of LVH-especially worsening of LVH-are associated with increased risk for SCD Vascular calcification Intima calcification leads to luminal narrowing resulting in ischaemia Media calcification leads to a reduced vascular compliance resulting in vascular stiffening Coronary calcification has been associated with higher spatial QRS-T angles, an important marker for SCD Sympathetic over activation Important mechanism for cardiovascular complications In dialysis patients norepinephrine predicts survival and cardiovascular events Damaged kidneys trigger sympathetic overactivation Dialysis treatment Timely relation between occurrence of SCD and dialysis treatment Significant decline in incidence of SCD after renal transplantation Probably rapid fluid and electrolyte shifts play an important role Other risk factors These include age, diabetes mellitus, malnutrition, inflammation, electrolyte abnormalities and the use of vascular access catheters Ischaemic heart disease CAD is highly prevalent among patients with CKD and is more severe compared to patients without CKD.w1 In patients starting dialysis the prevalence of significant CAD is believed to be around 40%.w2 However, recent studies evaluating the presence of significant CAD in dialysis patients indicate that this is probably an underestimation of the actual incidence of CAD.