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Cardiovascular
spei
al stu
dies
168 Introduction 17
0 Characerisics
of pati
ents
with ca
rdia
c arr
est {
dem
ogra
phic
s} {r
ates
of c
ardi
ac a
rres
t, A
MI,
& h
eart
failu
re}
172 Characerisics of diabetic
patients
with ca
rdiac
arre
st {ra
tes o
f card
iac a
rres
t by d
iabe
tic st
atus
} {m
edic
atio
n us
e} {m
orta
lity
& co
mor
bidi
ty}
174 Cardiovascular event rates afte
r initi
ation of
dial
ysis
{dem
ogra
phics of
dia
lysis
pat
ients
} {co
mor
bidi
ty a
t ini
tiat
ion}
176 Diagnosis D treatment of cardiac d
isease
in dialys
is pa
tient
s {dia
gnos
tic &
trea
tmen
t pro
cedu
res}
17
8 Su
mmary
CHAPTER
How frail the human heart must be —a mirrored pool of thought. So deepand tremulous an instrumentof glass that can either sing,or weep.
“I thought that I could not be hurt”
SylviaPlathh
94 96 98 00 02
ksirt
asr
ae
yt
ne it
ap
00
0 ,1
re
pet
aR
0
200
400
600
800
94 96 98 00 020
20
40
60
80
94 96 98 00 020
20
40
60
80
100Heart failure AMI Cardiac arrest
Dialysis
General Medicare: CKD
General Medicare: non-CKD
Introducion168 Cardiovascular special studiesh
ardiac disease continues to be the single largest cause of mortality in the
ESRD population, both dialysis patients and renal transplant recipients.
As noted in past ADRs, cardiac disease accounts for about 45 percent of
all-cause mortality; approximately 20 percent of cardiac deaths are attributed to acute
myocardial infarction. The USRDS database implicates arrhythmic mechanisms as the
single largest cause of mortality, with the combination of “cardiac arrest cause unknown”
and arrhythmia identified in 61 percent of cardiac deaths. There are conflicting data on
cause-specific mortality in sudden cardiac death, and it is difficult to accurately apportion
the contribution of ischemic heart disease to the total picture of sudden cardiac death.
Investigators in the HEMO study have implicated ischemic heart disease as the single largest
cause of sudden cardiac death, but this distinction maybe less important than would super-
ficially appear as certain therapies (i.e. implantable cardioverter defibrillators) are effective
in reducing the mortality associated with sudden cardiac death, irrespective of ischemic
etiology.
In this chapter the Cardiovascular Special Studies Center (CSSC) focuses on two themes,
the first being the epidemiology of cardiac arrest/sudden cardiac death. There are few data
on sudden cardiac death in the general Medicare population with CKD, and we attempt to
frame the issue of cardiac arrest in CKD patients. It should be apparent from the following
spreads that the risk of all types of cardiovascular morbidity and mortality, including
sudden cardiac death, is greatly magnified in the dialysis population, but general Medicare
patients with CKD are also a high-risk population.
{9.1} Rates of heart failure, AMI, & cardiac arrestdialysis: period prevalent patients with Medicare as primary payor. General Medicare: period prevalent CKD & non-CKD Medicare patients, continuously enrolled in Medicare Parts A & B, with no HMO coverage, & without ESRD.CKD status determined from the two-year entry period. Rates adjusted for age, gender, race, & diabetic status; 2002cohort used as reference.
Chapt
er hi
ghlig
hts
169H2004 USRDS Annual Data Report
The estimation of the rate of sudden cardiac death in
CKD patients presents special difficulties, as the primary
source of data is different for ESRD patients than for general
Medicare patients with CKD, and there is no data source
equivalent to the Death Notification form (CMS 2746) that
is filed for patients with ESRD. We identified Medicare CKD
patients with ICD-9-CM codes for cardiac arrest/ventricu-
lar fibrillation; it is likely that we underestimated the true
incidence of sudden cardiac death with the restricted defini-
tion.
In the 2002 ADR we reported some favorable trends, in-
cluding a reduction in both all-cause and cardiac mortality
in dialysis patients. This appeared due in part to a reduced
risk of all-cause and cardiac death in incident dialysis pa-
tients in the three years following the initiation of dialysis.
One disturbing trend, however, was the apparent increase in
both cardiac arrest and acute myocardial infarction in dialy-
sis patients on the therapy for at least three years. There
appeared to be a non-proportional hazard related to dialy-
sis vintage, suggesting that long-term dialysis does have a
significant unfavorable impact on cardiovascular morbidity
and mortality.
In this Annual Data Report, we return to the epidemiol-
ogy of cardiac arrest in the prevalent dialysis population and
in the general Medicare population without end-stage renal
disease. As shown in Figure 9.1, the rate of acute myocardial
infarction has increased in prevalent dialysis patients from
54 per 1,000 patient years in 1994 to 79 in 2002. The rate of
cardiac arrest appears to have decreased in both ESRD
and general Medicare CKD patients. In the prevalent dialysis
population it has dropped from about 75 per 1,000 patient
years in 1994 to 62 in 2002, while in the general Medicare
population the cardiac arrest rate in CKD patients has fallen
from approximately 24 per 1,000 patient years to 17 over the
same time period.
The second portion of this chapter focuses on cardiovas-
cular disease in dialysis patients and on the use of cardiac
procedures. The temporal pattern of procedure utilization
related to dialysis initiation is the subject of an entire spread,
intended to frame recent recommendations by the National
Kidney Foundation’s Kidney Disease Outcomes Quality
Initiative (K/DOQI) for the treatment of cardiovas-
cular disease in dialysis patients. One noteworthy
new guideline recommends echocardiography
for all incident dialysis patients. In this chap-
ter we present data relating to the use of
cardiac procedures, including echocar-
diography, in dialysis patients, and
it is the intention of the CSSC
to evaluate future procedure
utilization to evaluate
the impact of the K/
DOQI guide-
lines.
{9.2} Among
dialysis patients
with cardiac arrest,
the proportion of
elderly patients and of
patients with diabetes
mellitus as the primary cause of
ESRD rose from 1991 to 2002. {9.9}The use of ACE inhibitors/ARBs in
diabetic Medicare beneficiaries nearly
doubled from 1992 to 1999. {9.16} The CHF
event rate in both hemodialysis and peritoneal
dialysis patients is markedly increased in the first six
months after dialysis initiation. {9.23–25} Utilization of
diagnostic testing for the evaluation of ischemic heart disease
(stress testing and coronary angiography) increased from 1995 to
2000. Backcasted data in elderly dialysis patients reveal significant
procedure use in the two years prior to dialysis initiation.
170 Cardiovascular special studiesh
Male
Female
N Am
Other
Male
Female
Male
Female
stn
eita
pf
ot
necr
eP
White
Black
N Am
Asian
0-19
20-44
45-64
65-74
75+
AsianN Am
OtherAsian
0-19
20-44
45-64
65-74
75+
White
Black
N Am
Asian
Other
Diabetes
Hypertension
GN
Cystic kidney
Diabetes
HTN
GN
CK
94 96 98 00 02
stn
eita
pf
ot
necr
eP
0
20
40
60
80
100
94 96 98 00 02 94 96 98 00 02
Age Gender Race
67-74
75+
0
20
40
60
80
92 94 96 98 00 02
stn
eita
pf
ot
necr
eP
0
20
40
60
80
92 94 96 98 00 02
Dialysis I: Age Gender
Race Primary diagnosis
Male
Female
92 94 96 98 00 02 92 94 96 98 00 02
Dialysis II: Age Gender
Race Primary diagnosis
White
Black
White
Black
94 96 98 00 02
stn
eita
pf
ot
ne cr
eP
0
20
40
60
80
100
94 96 98 00 02 94 96 98 00 02
Age Gender Race
67-74
75+
0
20
40
60
80
100
Dialysis I
Dialysis II
General Medicare CKD
General Medicare non-CKD
0
20
40
60
80
100
0
20
40
60
80
100
1994 1996 1998 2000 20020
20
40
60
80
100
1994 1996 1998 2000 2002
AMI CHF
Coronary revascularization PVD
CVA/TIA Diabetes
Hypertension No history of comorbidity
{9.2} Dialysis patients with cardiac arrest
{9.3} General Medicare CKD patients with cardiac arrest
{9.4} General Medicare non-CKD patients with cardiac arrest
{9.5} Previous comorbidity of patients with cardiac arrest
n this spread we present an overview of the demograph-
ics, comorbidity, and geographic variations in cardiac ar-
rest rates in dialysis patients, general Medicare CKD
patients, and general Medicare patients without CKD. As noted in
the introductory section of this chapter, analyses of these rates in
the ESRD population are unique because of the availability of both
ICD-9-CM codes and data from the CMS Death Notification
form. For this reason, we present here two types of patient-specific
data for the dialysis population. Data for the Dialysis I analyses are
derived only from claims and can be thus compared to data on the
non-ESRD general Medicare population for which only claims
data are available. Data for the Dialysis II analyses also include
information from the Death Notification form, and therefore
Characerisics of patients with cardiac arrest
171H2004 USRDS Annual Data Report
69.6+ (77.7)62.9 to <69.656.1 to <62.949.4 to <56.1below 49.4 (45.3)
69.6+ (71.8)62.9 to <69.656.1 to <62.949.4 to <56.1below 49.4 (38.2)
118+ (139)106 to <118103 to <106
93 to <103below 93 (82)
118+ (133)106 to <118103 to <106
93 to <103below 93 (79)
29.8+ (35.8)25.8 to <29.823.8 to <25.817.2 to <23.8below 17.2 (10.7)
29.8+ (40.6)25.8 to <29.823.8 to <25.817.2 to <23.8below 17.2 (8.9)
8.54 + (9.48)7.51 to <8.546.75 to <7.515.52 to <6.75below 5.52 (4.65)
8.54+ (9.36)7.51 to <8.546.75 to <7.515.52 to <6.75below 5.52 (4.70)
66.6+ (76.1)56.0 to <66.647.0 to <56.040.0 to <47.0below 40.0 (35.6)
12.8+ (14.1)11.6 to <12.810.5 to <11.6
9.4 to <10.5below 9.4 (8.6)
472+ (548)411 to <472358 to <411312 to <358below 312 (278)
75.9+ (82.1)70.6 to <75.966.0 to <70.661.1 to <66.0below 61.1 (56.8)
{9.6} Geographic variations in cardiac arrest rates
{9.7} Geographic variations in rates of AMI & heart failure
Dialysis I, 1994–1995 Dialysis II, 1994–1995 General Medicare, CKD 1994–1995
Dialysis I, 2001–2002 Dialysis II, 2001–2002 General Medicare, CKD 2001–2002
General Medicare, AMI, 1998–2002
Dialysis: heart failure, 1998–2002 General Medicare, heart failure, 1998–2002
General Medicare, non-CKD 1994–1995
General Medicare, non-CKD 2001–2002
more closely approximate the “true” overall
cardiac arrest rate.
The proportion of elderly patients con-
tributing to the pool of cardiac arrest events
has steadily increased (Figure 9.2).
Few patients sustain a cardiac arrest with-
out some prior history of cardiovascularcomorbidity (Figure 9.5). In all four patient
groups the percent of patients with an AMI
prior to a cardiac arrest has doubled. One
potential explanation is that, as short-term
survival improves after acute myocardial
infarction, the number of long-term survi-
vors at increasing risk for cardiac arrest may
rise. Diabetes mellitus and congestive heart
failure are important comorbid medical con-
ditions in patients sustaining cardiac arrest.
In the general Medicare population there
does appear to be a persistent clustering in
the southern states of higher cardiac arrest
rates (Figure 9.6), a finding also reported in
the 2002 USRDS ADR (Figure 10.29). The
geographic distribution of heart failure in
the general Medicare population mirrors
that of cardiac arrest (Figure 9.7).
{Figures 9.2 & 9.5–6} Dialysis I, cardiac arrest eventdetermined only from claims data; Dialysis II, cardiacarrest event determined from claims data & the ESRDDeath Notification form. x {Figure 9.2} Medicareperiod prevalent dialysis patients. {Figure 9.3} generalMedicare CKD patients age 67 & older. {Figure 9.4}general Medicare non-CKD patients age 67 & older.{Figure 9.5} prevalent dialysis patients, & general
Medicare prevalent patients age 67 & older. {Figure9.6} per 1,000 patient years at risk, period prevalentdialysis patients, & general Medicare prevalent patientsage 67 & older, by state, unadjusted. {Figure 9.7} per1,000 patient years at risk, period prevalent dialysispatients, & general Medicare prevalent patients age 67& older, by HSA, unadjusted.
Dialysis: AMI, 1998-2002
172 Cardiovascular special studiesh
1993 1995 1997 1999
stn
eita
pf
ot
ne cr
eP
0
10
20
30
40
50
1993 1995 1997 1999
ACE/ARBs
Beta blockers
Ca++
channel blockers
Lipid lowering agents
Diabetic Non-diabetic
88.2+ (103.2)75.9 to <88.264.7 to <75.952.5 to <64.7below 52.5 (44.1)
153+ (187)133 to <153116 to <133
99 to <116below 99 (86)
13.5+ (15.7)11.6 to <13.510.0 to <11.6
8.3 to <10.0below 8.3 (7.1)
59.9+ (69.6)51.4 to <59.944.1 to <51.437.1 to <44.1below 37.1 (32.1)
6.92+ (7.59)6.20 to <6.925.38 to <6.204.41 to <5.38below 4.41 (3.90)
109.8+ (132.2)95.4 to <109.883.3 to <95.473.6 to <83.3
below 73.6 (64.1)
0
20
40
60
80
100
120
Sudden cardiac death, inpatient
Sudden cardiac death, outpatient
Inpatient death, not sudden cardiac
Outpatient death, not cardiac
sra
ey t
nei t
ap
00
0 ,1 r
ep
eta
R
0
20
40
60
80
100
120
140
91 92 93 94 95 96 97 98 99 00 01 020
20
40
60
80
100
120Non-diabetic
All
Diabetic
Inpatient death, not sudden cardiac
Inpatient death, not sudden cardiac
Sudden cardiac death, outpatient
Sudden cardiac death, inpatient
Sudden cardiac death, outpatient
Sudden cardiac death, inpatient
Outpatient death, not cardiac
Outpatient death, not cardiac
{9.8} Geographic variations in cardiac arrest rates, by diabetic status
{9.9} Medication use in Medicare beneficiaries, by diabetic status {9.10} Adjusted one-year mortality rates for sudden death, by location of event
s shown on the prior spread, the presence of diabetes is an
important contributor to the likelihood of cardiac arrest.
In this spread, we provide further detail relating to diabetic
status in cardiac arrest.
Figure 9.8 displays geographic variations in cardiac arrest rates
by diabetic status. Differences are most apparent in the general
Medicare population, particularly in patients without diabetes
mellitus. The southern states and Appalachia are characterized by
higher cardiac arrest rates.
We have attempted here to estimate the rate of sudden cardiac
death in outpatients and inpatients, a daunting task. On the out-
patient side, we have utilized claims data and Death Notification
form (2746) data in the following manner: a sudden cardiac death
is defined in a patient not surviving to be hospitalized (e.g. dying in
an emergency room or at home), with either a claim (cardiac arrest
Characerisics of diabetic patients with cardiac arres
Dialysis I, diabetic, 1998–2002 General Medicare, diabetic, 1998–2002
Dialysis I, non-diabetic, 1998–2002 Dialysis II, non-diabetic, 1998–2002 General Medicare, non-diabetic, 1998–2002
Dialysis II, diabetic, 1998–2002
173H2004 USRDS Annual Data Report
0
20
40
60
80
100
Dialysis I
Dialysis II
General Medicare CKD
General Medicare non-CKD
stn
eita
pf
ot
necr
eP
0
20
40
60
80
100
1994 1996 1998 2000 20020
20
40
60
80
100
1994 1996 1998 2000 2002
AMI CHF
Coronary revascularization PVD
CVA/TIA Hypertension
87.7+ (111.3)68.4 to <87.755.1 to <68.441.1 to <55.1below 41.1 (32.1)
25.0+ (29.4)21.3 to <25.018.8 to <21.315.9 to <18.8below 15.9 (13.7)
598+ (694)513 to <598447 to <513380 to <447below 380 (338)
160+ (178)144 to <160133 to <144121 to <133below 121 (110)
{9.11} Previous comorbidity in diabetic patients with cardiac arrest
{9.12} Geographic variations in rates of AMI & heart failure in diabetic patients
Dialysis, AMI, 1998–2002 General Medicare, AMI, 1998–2002
Dialysis, heart failure, 1998–2002 General Medicare, heart failure, 1998–2002
or ventricular flutter/fibrillation) or any cardiac death cause (from
the 2746 form). On the inpatient side, we have defined sudden
cardiac death in the same manner used for the Dialysis II analyses
on the previous spread—a claim for cardiac arrest or ventricular/
fibrillation, or a listing, on the 2746 form, of cardiac arrest or
arrhythmia as the cause of death.
In our analyses of one-year mortality rates for sudden death, a
striking finding is the relative stability over a decade in the rates of
outpatient and inpatient sudden cardiac death and of outpatient
deaths unrelated to cardiac etiologies (Figure 9.10). For inpatient
sudden cardiac death, for example, this rate was 36 per 1,000 pa-
tient years in 1991 and 37 in 2002. For outpatient sudden cardiac
death, the rate was 57 in 1991 and the same in 2002, and for
outpatient non-cardiac etiologies it was 64 per 1,000 patient years
in 1991 and 65 in 2002.
The major decrease in mortality rates has been in inpatients
with non-sudden cardiac etiologies; the rate dropped from 115 per
1,000 patient years in 1991 to 92 in 2002. Prior studies of patients
with ischemic heart disease and congestive heart failure have dem-
onstrated the importance of beta-blockers, lipid lowering agents,
and angiotensin converting enzyme(ACE) inhibitors or angiotensin
receptor blockers (ARBs) for improving cardiovascular outcomes.
There has been a striking increase over time in the use of lipid
lowering agents and ACE/ARBs in Medicare beneficiaries with
diabetes (Figure 9.9)
Figure 9.11 displays the distribution of prior cardiovascular mor-
bidity in diabetic patients with cardiac arrest. From 1994 to 2002
the proportion of patients with a history of
congestive heart failure increased. In 2002,
86–87 percent of all dialysis patients and
general Medicare patients with CKD had a
history of congestive heart failure; this was
also true in 65 percent of the general Medi-
care beneficiaries without CKD who sus-
tained a cardiac arrest. The most common
comorbid condition is a history of hyper-
tension, with nearly all patients (95–99
percent) in 2002 having a history of hyper-
tension before cardiac arrest.
{Figure 9.8} per 1,000 patient years at risk; periodprevalent Medicare dialysis patients, & general Medi-care prevalent patients age 67 & older, by HSA, unad-justed. Dialysis I, cardiac arrest event determined onlyfrom claims data; Dialysis II, cardiac arrest event de-termined from claims data & the ESRD Death Notifi-cation form. {Figure 9.9} MCBS patients, age 65 &older; data from MCBS “Cost & Use” file. {Figure9.10} Medicare period prevalent dialysis patients; datafor “all” adjusted for age, gender, race, primary diag-nosis, & vintage; data by diabetic status adjusted forage, gender, race, & vintage; 2002 cohort used as ref-erence population. {Figure 9.11} prevalent Medicarediabetic dialysis patients, & general Medicare diabeticpatients age 67 & older. {Figure 9.12} per 1,000 pa-tient years at risk, period prevalent dialysis patients, &general Medicare prevalent patients age 67 & older, byHSA, unadjusted.
174 Cardiovascular special studiesh
Female Other
Cystic kidney Glomerulonephritis
Hypertension
Hemodialysis: Age Gender Race Primary diagnosis
Male
95 96 97 98 99 00 01 020
20
40
60
80
100
95 96 97 98 99 00 01 02 95 96 97 98 99 00 01 02 95 96 97 98 99 00 01 02
stn
eita
psisyl
aid
fo
tn
ecre
P 0
20
40
60
80
100
Diabetes
Peritoneal dialysis
95 96 97 98 99 00 01 02
Hemodialysis Peritoneal dialysis
95 96 97 98 99 00 01 02
ytidi
bro
moc
htiw
stn
eita
pf
o%
0
10
20
30
40
50
60
70
80
ASHD
CHF
Other cardiac
CVA/TIA
PVD
45-64
20-44
75+
65-74
Other
Asian
Native American
Black
White
he proportion of older and diabetic patients in the inci-
dent dialysis population rose between 1995 and 2002
(Figure 9.13). In patients of both modalities the percent
with cardiovascular comorbidity has also grown. Forty-two percent
of new hemodialysis patients in 1995 had comorbid atheroscle-
rotic heart disease, compared to 52 percent in 2002; in the perito-
neal dialysis population growth was from 36 to 43 percent.Figures 9.15–22 display event rates and event-free probabilities
for cardiovascular disease and mortality. Due to the Medicare claims
structure, fatal cardiovascular events within 90 days of dialysis initia-
tion are not identified in patients younger than 65. Another meth-
odological issue here is “informative censoring.” As peritoneal dialysis
patients have a differential rate of transplantation related to vin-
tage, the event rate over time may change because patients who are
not transplanted have different characteristics than those who are.
Figure 9.15 shows event rates related to AMI. Although an early
hazard of AMI has been previously reported in dialysis patients
(Herzog et al. NEJM 1998), this temporal clustering is not evident
here. In contrast, there is a higher event rate for congestive heart
failure at the time of initiation, which drops over time. This is
presumably related to better control of intravascular volume.
Figure 9.17 illustrates event rates for cardiac arrest. It appears
that in incident hemodialysis patients there is an initial early hazard,
with the event rate of 14 per 1,000 patient months in the first
month dropping to 10 by six months. In peritoneal dialysis patients,
in contrast, the rate is essentially unchanged over the first six months,
then slowly increases with dialysis vintage. In the hemodialysis co-
hort the cardiac arrest rate appears to stabilize at month six and
remains fairly constant over the ensuing 30 months. By three years
the event-free probability is approximately 70 percent in both he-
modialysis and peritoneal dialysis patients. A similar pattern is noted
for CHF and cerebrovascular events (Figures 9.16 and 9.18).
{9.13} Demographics of the dialysis population at initiation
{9.14} Cardiovascular comorbidity at the initiation of dialysis
Cardiovascular event rates after the initiation of dialysis
The overall rate of coronary revascularization is relatively low in
dialysis patients, despite their burden of ASHD (Figure 9.19). At
three years the event-free probability is approximately 90 percent
for each modality. The second most common cardiovascular disease
in dialysis patients (after CHF) is PVD. At three years the event-free
probability for PVD is 43 percent in hemodialysis patients, and 51
percent in peritoneal dialysis patients (Figure 9.20). This compares
with 37 and 46 percent, respectively, free of CHF at three years.
There are contrasting patterns, related to modality, of early mor-
tality in incident dialysis patients (Figure 9.21), patterns also seen
for cardiac arrest, implying that some of the temporal pattern of
all-cause death might be explained by cardiac arrest. It is plausible
that this early hazard might be heightened in the dialysis population
right after initiation, as the event rates shown are those after day 90.
{Figures 9.13–14} incident Medicare dialysis patients, age 20 & older; comorbiditiesidentified from the Medical Evidence form. {Figures 9.15–22} incident Medicaredialysis patients, 1998–2000 combined, age 20 & older; adjusted for age, gender,race, & primary diagnosis. Monthly event rates during the first six months, & meanmonthly event rates during each following six-month interval.
175H2004 USRDS Annual Data Report
0 6 12 18 24 30 36
ytilib
ab
orp
eerf-t
ne
vE
0.0
0.2
0.4
0.6
0.8
1.0
Months after day 90
0 6 12 18 24 30 36
ksirt
as
htn
om
tn
eita
p0
00,
1r
ep
e ta
R 0
40
80
120
160
200
Hemodialysis
Peritoneal dialysis
0 6 12 18 24 30 36
ytilib
ab
orp
eerf-t
ne
vE
0.7
0.8
0.9
1.0
Months after day 90
0 6 12 18 24 30 36
ksirt
as
htn
om
tn
eita
p0
00,
1r
ep
eta
R 0
2
4
6
8
10
12Event rates Event-free probabilities Event rates Event-free probabilities
Event rates Event-free probabilities Event rates Event-free probabilities
Event rates Event-free probabilities Event rates Event-free probabilities
Event rates Event-free probabilities Event rates Event-free probabilities
Hemodialysis
Peritoneal dialysis
0 6 12 18 24 30 36
ytilib
ab
orp
eerf-t
ne
vE
0.6
0.7
0.8
0.9
1.0
Months after day 90
0 6 12 18 24 30 36
ksirt
as
htn
om
tn
eita
p0
00,
1r
ep
eta
R 2
4
6
8
10
12
14
16
Hemodialysis
Peritoneal dialysis
0 6 12 18 24 30 36
ytilib
ab
orp
eer f-t
ne
vE
0.85
0.90
0.95
1.00
Months after day 90
0 6 12 18 24 30 36
ksirt
as
htn
om
tn
eita
p0
00,
1r
ep
e ta
R 2
3
4
5
Hemodialysis
Peritoneal dialysis
0 6 12 18 24 30 36
ytilib
ab
orp
ee rf- t
ne
vE
0.4
0.5
0.6
0.7
0.8
0.9
1.0
Months after day 90
0 6 12 18 24 30 36
ksirt
as
htn
om
tn
eita
p0
00,
1r
ep
e ta
R 10
15
20
25
30
35
Hemodialysis
Peritoneal dialysis
0 6 12 18 24 30 36
ytilib
ab
orp
eerf-t
ne
vE
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.0
Months after day 90
0 6 12 18 24 30 36
ksirt
as
htn
om
tn
eita
p0
00,
1r
ep
eta
R 0
20
40
60
80
100
120
Hemodialysis
Peritoneal dialysis
0 6 12 18 24 30 36
ytilib
ab
orp
eerf-t
ne
vE
0.6
0.7
0.8
0.9
1.0
Months after day 90
0 6 12 18 24 30 36
ksirt
as
htn
om
tn
eita
p0
00,
1r
ep
eta
R 0
5
10
15
20
25
30
Hemodialysis
Peritoneal dialysis
0 6 12 18 24 30 36
ytilib
ab
orp
eerf-t
ne
vE
0.4
0.5
0.6
0.7
0.8
0.9
1.0
Months after day 90
0 6 12 18 24 30 36
ksirt
as
htn
om
tn
eita
p0
00,
1r
ep
eta
R 0
10
20
30
40
50
60
70
Hemodialysis
Peritoneal dialysis
{9.15} Event rates & event-free probabilities: acute myocardial infarction
{9.17} Event rates & event-free probabilities: cardiac arrest
{9.19} Event rates & event-free probabilities: coronary revascularization
{9.16} Event rates & event-free probabilities: congestive heart failure
{9.18} Event rates & event-free probabilities: CVA/TIA
{9.20} Event rates & event-free probabilities: peripheral vascular disease
{9.21} Event rates & event-free probabilities: all-cause death {9.22} Event rates & event-free probabilities: any CV event or death
176 Cardiovascular special studiesh
0
10
20
30
1995-1996
1997-1998
1999-2000
Months after day 90
0 6 12 18 24 30 36
stn
eita
pf
ot
necr
ep
evit
alu
mu
C
0
10
20
30
Hemodialysis: age 20+
Peritoneal dialysis: age 20+
Months
-24 -18 -12 -6 0 6 12 18 24 30 360
10
20
30
40
50
601995
1996
1997
1998
1999
All: age 67+
0
5
10
15
20
1995-1996
1997-1998
1999-2000
Months after day 90
0 6 12 18 24 30 36
stn
eita
pf
ot
necr
ep
evit
alu
mu
C
0
5
10
15
20
Hemodialysis: age 20+
Peritoneal dialysis: age 20+
Months
-24 -18 -12 -6 0 6 12 18 24 30 360
5
10
15
20
25
301995
1996
1997
1998
1999
All: age 67+
0
2
4
6
8
1995-1996
1997-1998
1999-2000
Months after day 90
0 6 12 18 24 30 36
stn
eita
pf
ot
necr
ep
ev it
alu
mu
C
0
2
4
6
8
Hemodialysis: age 20+
Peritoneal dialysis: age 20+
Months
-24 -18 -12 -6 0 6 12 18 24 30 360
3
6
9
12
151995
1996
1997
1998
1999
1995
1996
1997
1998
1999
All: age 67+
0
10
20
30
40
1995-1996
1997-1998
1999-2000
Months after day 90
0 6 12 18 24 30 36
stn
eita
pf
ot
necr
ep
evit
alu
mu
C
0
10
20
30
40
Hemodialysis: age 20+
Peritoneal dialysis: age 20+
Months
-24 -18 -12 -6 0 6 12 18 24 30 360
10
20
30
40
50
601995
1996
1997
1998
1999
All: age 67+
0
10
20
30
40
50
1995-1996
1997-1998
1999-2000
Months after day 90
0 6 12 18 24 30 36
stn
eita
pf
ot
necr
ep
evit
alu
mu
C
0
10
20
30
40
50
Hemodialysis: age 20+
Peritoneal dialysis: age 20+
Months
-24 -18 -12 -6 0 6 12 18 24 30 360
10
20
30
40
50
60
70All: age 67+
0
10
20
30
40
1995-1996
1997-1998
1999-2000
Months after day 90
0 6 12 18 24 30 36
stn
eita
pf
ot
ne cr
ep
evit
a lu
mu
C
0
10
20
30
40
Hemodialysis: age 20+
Peritoneal dialysis: age 20+
Months
-24 -18 -12 -6 0 6 12 18 24 30 360
10
20
30
40
50
601995
1996
1997
1998
1999
All: age 67+
{9.23} Stress tests in dialysis patients
{9.26} Echocardiograms in dialysis patients
{9.24} Coronary angiography in dialysis patients
{9.27} Coronary revascularization in dialysis pts
{9.25} Cor. angiography/stress tests in dialysis pts
{9.28} Lipid testing in dialysis patients
Diagnosis D treatment of cardiac disease in dialysis patients
177H2004 USRDS Annual Data Report
0
20
40
60
80
100
1995-1996
1997-1998
1999-2000
Months after day 90
0 6 12 18 24 30 36
stn
eita
pf
ot
necr
ep
evit
alu
mu
C
0
20
40
60
80
100
Hemodialysis: age 20+
Peritoneal dialysis: age 20+
Months
-24 -18 -12 -6 0 6 12 18 24 30 360
20
40
60
80
100
1995
1996
1997
1998
1999
All: age 67+
stn
eita
pf
ot
necr
ep
evit
alu
mu
C
0
10
20
30
40
50
60
70
Stress test
Coronary angiography
Stress test or
coronary angiography
Echocardiogram
Coronary revascularization
Defibrillator
Hemodialysis: Prior to cardiac arrest (all patients, n=21,930)
Months
-24 -21 -18 -15 -12 -9 -6 -3 00
10
20
30
40
50
60
70Peritoneal dialysis (n=1,596)
0 2 4 6 8 10 12
After cardiac arrest (surviving pts, n=12,394)
ytilib
ab
orp
ev it
alu
mu
C
0.0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0 2 4 6 8 10 120.0
0.1
0.2
0.3
0.4
0.5
0.6
0.7(n=814)
Probability: after cardiac arrest (surviving pts, n=12,394)
(n=814)
{9.29} ECGs in dialysis patients {9.30} Cardiac procedures in prevalent dialysis patients
he use of diagnostic and therapeutic procedures relating
to cardiovascular disease plays a significant role in ESRDpatient outcomes. In 1999–2000, 25 percent of hemodi-
alysis patients had a stress test in the three years after initiation
(Figure 9.23). Thirteen percent of incident dialysis patients age 67
and older in 1999 underwent coronary angiography within two
years prior to initiation, and an additional 9 percent had the proce-
dure in the year following initiation (Figure 9.24).
One issue in the cardiac management of dialysis patients is the
use of testing for the diagnosis of ischemic heart disease. Of hemo-
dialysis patients incident in 1999–2000, 31 percent received a stress
test or coronary angiogram (a reflection of the total diagnostic
effort for the evaluation of coronary artery disease) within three
years of initiation (Figure 9.25). In the elderly dialysis population,
nearly 30 percent had a stress test or coronary angiogram in the two
years before initiation and another 12 percent in the year following.
Coronary revascularization is still relatively uncommon in di-
alysis patients. In the 1999–2000 cohort, 6.5 percent of hemodi-
alysis patients underwent coronary revascularization in the three
years after initiation (Figure 9.27). In the elderly population, 6
percent had the procedure in the two years prior to initiation, and
14 percent in the three years following.
The recent K/DOQI Cardiovascular Practice Guidelines recom-
mend echocardiography shortly after dialysis initiation. Approxi-
mately 11 percent of 1999–2000 incident hemodialysis patients
received echocardiograms in the first three months, and 31 percent
in the first year; the numbers were 8 and 26 percent for peritoneal
dialysis patients (Figure 9.26). In the population age 67 and older,
55 percent received an echocardiogram in the two years before
initiation, and 25 percent in the year before; in the year followinginitiation, an additional 17 percent were tested. It is remarkable
that the use of echocardiography exceeds the frequency of lipid
testing; only 39 percent of hemodialysis patients receive any lipid
tests in the three years after dialysis initiation (Figure 9.28).
In the two years prior to a cardiac arrest, about 36 percent of
hemodialysis patients are evaluated for coronary artery disease (Fig-
ure 9.30). Sixty-two percent have echocardiograms, implying that
the majority of patients at risk for an arrest have left ventricular
ejection fractions assessed before the event. There is a striking
underutilization of implantable cardioverter defibrillators in arrest
survivors. In hemodialysis patients surviving cardiac arrest, the prob-
ability of receiving a defibrillator within one year is only 3 percent.
The change in the slope of procedure use curves at the time of
initiation for patients age 67 and older implies that the 90-day
period following initiation is an “unstable” period for cardiovascu-
lar event rates. There are several explanations for this finding,
including an actual change in cardiovascular event rates, access to
care at the beginning of Medicare coverage, and, in the case of
coronary revascularization, perhaps a conscious decision on the
part of clinicians to delay intervention until the initiation of dialy-
sis. These figures imply that this 90-day period may represent a
distinctly different period in the life of a dialysis patient.
{Figures 9.23–29} top two graphs: incident Medicare dialysis patients age 20 &older; bottom graph: incident Medicare dialysis patients age 67 & older, includingpatients with unknown dialysis modality. {Figure 9.30} period prevalent dialysispatients, age 20 & older, 2001, with cardiac arrest in the same year.
Chap
terJo
summary
Chapter summary178 Cardiovascular special studiesh
Cardiovascular event rates after the initiation of dialysis{Figure 9.14 In the incident hemodialysis and peritoneal dialysis populations, the percentage of patients with cardiovascular disease increased progres-sively between 1995 and 2002.} {Figure 9.16 The most common cardiovascular condition in dialysis patients is congestive heart failure. The CHF eventrate in both hemodialysis and peritoneal dialysis patients is markedly increased in the first six months after dialysis initiation.} {Figure 9.17 Forhemodialysis patients there is an early hazard of increased cardiac arrest event rates. In peritoneal dialysis patients, in contrast, the risk of cardiac arrest islower at the time of dialysis initiation and rises continuously related to dialysis vintage. At three years the probability of cardiac arrest in both populationsis about 30 percent.} {Figure 9.18 There is an early hazard of CVA/TIA in both hemodialysis and peritoneal dialysis patients in the first six months afterdialysis initiation.} {Figure 9.21 In the first six months after dialysis initiation there is a increased hazard of death in hemodialysis patients but not inperitoneal dialysis patients.}
Diagnosis & treatment of cardiac disease in dialysis patients{Figures 9.23–25 Utilization of diagnostic testing for the evaluation of ischemic heart disease (stress testing and coronary angiography)increased from 1995 to 2000. Backcasted data in elderly dialysis patients reveals significant procedure use in the two years prior to dialysisinitiation.} {Figure 9.26 At least half of all hemodialysis patients receive an echocardiogram within 36 months after dialysis initiation.Nearly half of elderly dialysis patients have received an echocardiogram in the two years prior to initiation.} {Figure 9.28 After dialysisinitiation, the cumulative frequency of a lipid test in hemodialysis patients is less than that of an echocardiogram.} {Figure 9.30 Nearly two-thirds of prevalent dialysis patients in 2001 who sustained a cardiac arrest in the same year had echocardiography performed in the two yearsprior to the arrest. Implantable cardioverter defibrillators are underutilized in dialysis patients who survive a cardiac arrest. Theprobability of receiving a defibrillator within one year after cardiac arrest is 3–4 percent in dialysis patients who survive the arrest.}
Maps: National means & patient populationsFigure number 9.6 9.6 9.6 9.6 9.6 9.6 9.6 9.6 9.7 9.7 9.7 9.7
94–95 01–02 94–95 01–02 94–95 01–02 94–95 01–02 AMI AMI CHF CHFDial I Dial I Dial II Dial II CKD CKD NCKD NCKD Dial I GMed Dial I GMed
Overall value for all pts 64.5 57.5 105.2 107.1 27.3 22.2 7.7 7.0 54.5 11.1 390.2 69.2Total patients 231,086 328,154 231,086 328,154 29,946 49,340 1,237,107 1,577,102 492,171 6,309,798 492,171 6,309,798Overall value for pts mapped 64.8 57.8 105.7 107.4 27.4 23.7 7.8 7.2 54.8 11.8 391.3 69.2Missing HSA/state: pts dropped 3,607 4,971 3,607 4,971 292 736 11,396 19,544 8,230 86,955 8,230 86,955
Figure number 9.8 9.8 9.8 9.8 9.8 9.8 9.12 9.12 9.12 9.12DM NDM DM NDM DM NDM AMI AMI CHF CHF
Dial I Dial I Dial II Dial II GMed GMed Dial I GMed Dial I GMedOverall value for all pts 76.0 51.9 131.0 92.3 13.6 7.1 69.3 22.6 486.5 140.2Total patients 206,383 285,788 206,383 285,788 1,143,498 5,166,300 206,383 1,143,498 206,383 1,143,498Overall value for pts mapped 76.5 52.4 131.6 92.8 13.8 13.8 69.6 22.4 487.9 140.0Missing HSA/state: pts dropped 4,502 3,728 4,502 3,728 31,652 55,303 4,502 31,652 4,502 31,652
Characteristics of diabetic patients with cardiac arrest{Figure 9.9 The use of ACE inhibitors/ARBs in diabetic Medicare beneficiaries nearly doubledfrom 1992 to 1999.} {Figure 9.10 In prevalent dialysis patients, rates of inpatient and outpatientsudden cardiac death and non-cardiac death have remained fairly constant between 1991 and2002. The rate of inpatient non-cardiac death has declined, which appears to be the primaryexplanation for the falling mortality rates.}
Characteristics of patients with cardiac disease{Figure 9.2 Among dialysis patients with cardiac arrest, the proportion of elderly patients and of patients with diabetesmellitus as the primary cause of ESRD rose from 1991 to 2002.} {Figures 9.3–4 In general Medicare patients with a historyof cardiac arrest, the proportion of elderly patients has grown since 1994.} {Figure 9.5 Few dialysis or general Medicarepatients with cardiac arrest have no history of comorbidity. Congestive heart failure and hypertension are the most commoncomorbid medical conditions in dialysis and general Medicare patients with cardiac arrest.} {Figures 9.6–7 Rates of cardiacarrest and congestive heart failure are high in the southern states and Appalachia.}
Introduction{Figure 9.1 In prevalent dialysis patients the rate of acute myocardial infarctionincreased between 1994 and 2002, while rates of congestive heart failure andcardiac arrest have remained relatively stable.}