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Canadian Journal of Cardiology

Arrhythmias and Sudden Cardiac Death in End Stage Renal Disease: Epidemiology, Risk Factors, and Management

      Abstract

      Patients with end-stage renal disease (ESRD) are predisposed to heart rhythm disorders resulting in significant morbidity and mortality. Bradyarrhythmia appears to be more prevalent than ventricular tachyarrhythmias. There is also a high incidence of sudden cardiac death (SCD) in this group of patients, which cannot be explained only by traditional cardiac risk factors. The reported incidence and prevalence of arrhythmias and SCD is quite variable mainly because of the different study populations and recording techniques. The mechanism of SCD in patients with ESRD is also not clear. Although traditionally the thinking has been that ventricular arrhythmias are the main contributor to SCD, recent studies with implantable loop recorders have highlighted the role of bradyarrhythmias. The pathophysiological processes resulting in arrhythmia and SCD in patients with ESRD are unique. Some of the risk factors, including dialysate composition, timing, and frequency, are modifiable and hence provide an option for interventions to potentially reduce SCD. In addition, there might be a relationship with the timing of dialysis with SCD tending to occur during the long interdialytic period. Patients with ESRD have a higher likelihood of requiring pacemaker implantation; however, they also have a higher risk of device-related complications. The limited data available regarding the role of the implantable cardioverter defibrillator to prevent SCD in patients with ESRD have shown conflicting results. Future research is needed to develop appropriate risk stratification tools to identify patients who will benefit from such interventions and to assess their safety and efficacy.

      Résumé

      Les patients atteints d’insuffisance rénale en phase terminale (IRPT) sont prédisposés à des troubles du rythme cardiaque qui entraînent une augmentation considérable de la morbidité et de la mortalité. La bradyarythmie semble avoir une plus grande prévalence que les tachyarythmies ventriculaires. Dans ce groupe de patients, on note également une forte incidence de la mort subite d’origine cardiaque (MSOC), qui ne peut être expliquée que par les facteurs de risque cardiaque traditionnels. L’incidence et la prévalence des cas déclarés d’arythmies et de MSOC sont très variables principalement en raison des différentes populations étudiées et des techniques d’enregistrement. On ne connaît pas non plus le mécanisme de la MSOC chez les patients atteints d’une IRPT. Bien que traditionnellement on ait pensé que les arythmies ventriculaires contribuaient principalement à la MSOC, de récentes études sur les enregistreurs en boucle implantables ont mis en évidence le rôle des bradyarythmies. Les processus physiopathologiques qui entraînent l’arythmie et la MSOC chez les patients atteints d’une IRPT sont uniques. Certains des facteurs de risque, dont la composition, le moment et la fréquence de la dialyse, sont modifiables et, par conséquent, offrent aux interventions la possibilité de réduire la MSOC. De plus, il se pourrait qu’il existe une relation entre le moment de la dialyse et la tendance de la MSOC à survenir pendant les longues périodes interdialytiques. Les patients atteints de IRPT sont plus susceptibles d’avoir besoin de l’implantation d’un stimulateur cardiaque. Cependant, ils sont également exposés à un plus grand risque de complications liées au dispositif. Les quelques données disponibles sur le rôle du défibrillateur cardioverteur implantable dans la prévention de la MSOC des patients atteints d’une IRPT ont montré des résultats contradictoires. Des recherches ultérieures sont nécessaires à l’élaboration d’outils appropriés de stratification du risque pour déterminer les patients qui bénéficieront de ces interventions et pour évaluer leur innocuité et leur efficacité.
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