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First ESC recommendations for arrhythmias and CKD published

The first European Society of Cardiology (ESC) recommendations for patients with cardiac arrhythmias and chronic kidney disease (CKD) were presented recently at the EHRA Europace Cardiostim 2015 meeting, and published in EP Europace.1

The paper was written by an international group of cardiologists specialised in arrhythmia management and nephrologists. It outlines:

  • How to stage and monitor CKD
  • The association between CKD and hypertension, heart failure and atrial fibrillation
  • How CKD affects management of patients with arrhythmias or cardiac devices
  • Risk of stroke and bleeding in patients with atrial fibrillation and CKD
  • How arrhythmias and cardiac devices affect management of CKD.

The authors’ recommendations include using estimated glomerular filtration rate (eGFR) as a more reliable method for classifying the severity of CKD than serum creatinine. Kidney function should be measured and monitored in all patients with a cardiac disease or rhythm disturbance, such as atrial fibrillation or sustained ventricular tachyarrhythmias, to detect CKD.

Professor Giuseppe Boriani, chair of the writing group, said: “CKD occurs in more than 10% of adults and has a major impact on treatment decisions in patients with arrhythmias. Choice of antiarrhythmic strategy, drugs and specifically anticoagulants, and whether or not to implant a cardiac device should take impairment in renal function into account.”

“There is increasing awareness in the cardiology community that renal impairment influences how we treat patients with arrhythmias,” added Professor Boriani. “The introduction of non-vitamin K oral anticoagulants (also called new oral anticoagulants or NOACs) as an alternative to warfarin brought this issue to the fore since renal function determines whether or not they can be prescribed. The ESC decided it was a good time to introduce recommendations.”

Professor Phil Kalra (Salford Royal NHS Foundation Trust)

Professor Phil Kalra (Salford Royal NHS Foundation Trust)

Doctors are urged to choose medication dosages according to the extent to which a drug is eliminated through the kidney. When renal function is markedly reduced some drugs, including NOACs, may be contraindicated.

Thromboprophylaxis in patients with atrial fibrillation and end-stage CKD is a controversial issue and the authors recommend when to use NOACs or warfarin. Professor Boriani said: “Patients with atrial fibrillation and CKD have a greater risk of both thromboembolism and major bleeding which makes decision making particularly challenging in this setting.”

“Increasing specialisation in internal medicine is a positive evolution overall but there is a need for more communication between cardiologists and nephrologists to improve the care of very complex patients…The association between kidney disease and cardiovascular disease is growing as the population ages, leading to higher costs and a greater imperative to manage patients together,” Professor Boriani concluded.

Speaking to BJC Arrhythmia Watch on the paper’s key points, Consultant Nephrologist Professor Phil Kalra (Salford Royal NHS Foundation Trust) said: “Cardiac arrhythmias are a huge problem for patients with CKD, especially those receiving dialysis therapies. Sustained atrial fibrillation develops in 5–10%, whereas paroxysmal episodes are frequent, and often go unnoticed and certainly untreated. Guidelines for management have been required for some time, especially as the risk: benefit balance of anticoagulation in advanced CKD is distorted by a higher gastrointestinal and central nervous system bleeding risk than in other patient groups.”

“Sudden cardiac death is thought to lead to around 3% of all dialysis deaths each year; many of these are due to serious tachy- or bradyarrhythmia. Although much more research is required to understand which patients are at greatest risk, and to determine whether targeted device therapy will lengthen lives, the current outline guidelines at least provide a framework for further organised investigation,” Professor Kalra added.

References

1. Boriani G, Savelieva I, Dan GA, et al. Chronic kidney disease in patients with cardiac rhythm disturbances or implantable electrical devices: clinical significance and implications for decision making-a position paper of the European Heart Rhythm Association endorsed by the Heart Rhythm Society and the Asia Pacific Heart Rhythm Society. Europace 2015. http://dx.doi.org/10.1093/europace/euv202

Published on: July 30, 2015

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  • Anticoagulation Europe
  • Atrial Fibrillation Association
 

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