The European Society of Cardiology has published its first guidelines for treating cardiac arrhythmias in chronic kidney disease patients in the journal Europace. The recommendations were presented June 24 at the EHRA EUROPACE – CARDIOSTIM 2015 in Milan.
The paper was produced by the European Heart Rhythm Association (EHRA), a registered branch of the European Society of Cardiology (ESC), and is endorsed by the Heart Rhythm Society (HRS) in the US and the Asia Pacific Heart Rhythm Society (APHRS).
The paper was written by an international group of nephrologists and cardiologists specialized in arrhythmia management.
“CKD occurs in more than 10% of adults and has a major impact on treatment decisions in patients with arrhythmias,” said Professor Giuseppe Boriani, chair of the writing group. “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.”
The authors offer recommendations on the following topics:
- 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.
“The kidney exerts multiple functions, and pathophysiological interactions between the kidney and the heart have important clinical implications, but it has only recently become clear that these interactions should be studied across the whole spectrum of reduced kidney function and not only in cases with severe, end-stage renal disease (ESRD), as has been done for many years,” the authors wrote in the introduction.
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.
“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,” said Boriani.
Patients with advanced CKD are at higher risk of adverse outcomes associated with cardiac devices including pacemakers and defibrillators, the authors wrote. This needs to be taken into account when conducting a risk-benefit analysis on whether or not implant a device. The risk of device infection is higher in patients with renal impairment and requires personalized decision making on where to place leads.
“Increasing specialization 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,” said Boriani. “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.”
Collaboration is also needed in research to improve the definition of risk-benefit of specific therapies; find new anticoagulants that can be used in patients with severe renal function; and create care delivery models for patients who have severely compromised renal function, the authors wrote.