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Tuesday, March 4, 2008

Take Steps to Keep Your Heart Healthy on Dialysis

What is cardiovascular disease?

Cardiovascular disease means having problems with your heart and the blood vessels throughout your body, including brain, lungs and legs. Heart and blood vessel disease is common in people with chronic kidney disease (CKD). Over time, the blood vessels that bring blood to the heart and brain can become blocked from a buildup of cells, fat and cholesterol. This reduces blood flow to the heart and brain and can cause heart attacks and strokes.

Are there different kinds of heart and blood vessel disease?

Yes. Some of the most common ones are:

  • Coronary artery disease – The most common form of heart disease. It affects blood vessels of the heart and causes angina (chest pain) and heart attacks.
  • Left ventricular hypertrophy – The muscle on the left side of the heart becomes thicker and does not working as well.
  • Heart failure – The heart is not able to pump blood around the body as well as it should. Heart failure develops slowly over time. It can have a large impact on ability to perform daily activities.
  • Stroke – Lack of blood flow to the brain. A stroke may be caused by a blood clot or bleeding in the brain from a broken blood vessel.

Do dialysis patients have an increased risk for heart and blood vessel disease?

Yes. Dialysis patients are much more likely than the general population to develop heart and blood vessel disease. This increased risk is related to kidney disease and other health problems like diabetes and high blood pressure. For this reason, it’s very important for dialysis patients to follow the steps to help prevent heart and blood vessel problems (see next section). If heart and blood vessel problems occur, patients need to follow their treatment plan carefully to avoid complications like heart attacks and strokes.

Can dialysis patients do anything to help prevent heart and blood vessel disease?

Yes. Take steps to control health problems that can lead to heart and blood vessel disease, especially diabetes and high blood pressure. Follow a healthy lifestyle-eat the right foods, exercise regularly and stop smoking.

Here are some steps that can help prevent heart and blood vessel disease. Speak to your doctor about them. The doctor and other members of your health care team will work with you to develop a care plan that meets your needs.

Control blood sugar if you have diabetes

Check your blood sugar as often as your doctor tells you to. Follow your treatment plan of medications, diet and exercise.

Keep high blood pressure controlled

Follow your treatment plan carefully to control high blood pressure. The blood pressure pills usually preferred for people with CKD are called angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs). They help to protect your heart. Be sure to follow your fluid and sodium (salt) limits to keep fluid from building up in your body and increasing your blood pressure. Ask your health care team about other steps to help prevent fluid buildup.

The target blood pressure for dialysis patients before a dialysis treatment is less than 140/90. The target blood pressure after a dialysis treatment is less than 130/80. Ask your doctor or nurse if your blood pressure readings are on target. If you check your own blood pressure at home, keep a record of your daily blood pressures and show this to your doctor at each visit. If your blood pressure readings are not on target, ask your doctor what can be done to improve them.

Reduce high cholesterol levels

High blood levels of fats like cholesterol increase your chance of developing heart and blood vessel problems. You will have blood tests to check for total cholesterol and other fats in your blood. If your levels are too high, you may need to follow a low-fat diet and exercise more. Some patients may also need to take pills (such as a Statin) to help lower cholesterol.

Follow a heart-healthy diet

Your diet should have the right amount of protein and calories to keep you at a healthy weight. Your doctor and dietitian may also ask you to:

  • Reduce foods that are high in saturated fats and cholesterol like eggs, whole milk, cheese and fried foods. (See NKF booklet “Heart Health on Dialysis: How Lipids Can Affect Your Heart”) for more information.
  • Eat more foods that are rich in heart-healthy omega-3 fatty acids. These include cold water fish like salmon, albacore tuna, lake trout and sardines, and other foods like flaxseed oil, canola oil and walnuts.

If you are on a protein or potassium modified diet, speak to your doctor and dietitian before making any changes in your diet.

Increase physical activity

Be sure to ask your doctor about an exercise program that is right for you. Regular exercise helps you:

  • Lower high cholesterol levels
  • Control blood sugar levels if you have diabetes
  • Reduce high blood pressure
  • Lose excess weight
  • Improve the fitness of your heart and lungs
  • Increase your energy level
  • Improve emotional well-being.

Treat anemia

CKD patients often develop anemia-a low red blood cell count. This makes you feel tired and can lead to a heart problem called left ventricular hypertrophy. This is a thickening of the muscle on the left side of the heart. Anemia can be treated with a hormone called erythropoietin (EPO) and extra iron. Correcting anemia helps to keep your heart healthy.

Keep important minerals—calcium and phosphorus—in balance.

These important minerals get out of balance when you have CKD. As a result, bones lose calcium and weaken over time. Some calcium may end up in parts of your body where it does not belong, like your heart and blood vessels. This makes your blood vessels get stiffer and narrower. When this happens, you are more likely to have a heart attack or stroke. You may need to:

  • Follow a diet that is low in high-phosphorus foods like cola drinks, dairy foods, dried beans and peas and nuts and seeds. Discuss this diet with a registered dietitian.
  • Take medications called phosphate binders. These help to keep your blood phosphorus level in a healthy range.
  • Take an active form of vitamin D if your doctor orders it for you.

Speak to your doctor about taking aspirin to prevent heart attacks

Your doctor may ask you to take aspirin to help prevent heart attacks. Sometimes aspirin can cause bleeding problems. Ask your doctor what signs and symptoms you should look for to check for bleeding problems caused by aspirin.

Reduce high homocysteine levels

Homocysteine is an amino acid that is made in your body. High levels of homocysteine in your blood are associated with an increased chance of having heart and blood vessel problems. Getting enough folic acid, vitamin B6 and vitamin B12 helps keep homocysteine levels in the normal range. Ask your doctor to give you the name of a vitamin that contains the right amounts of folic acid, vitamin B6 and vitamin B12 for people with kidney disease.

Stop smoking if you are a smoker

If you are a smoker, ask your doctor about a program to help you quit.

Smoking makes you more likely to develop heart and blood vessel disease.

Maintain emotional well-being

At times, dialysis patients may feel depressed, angry or upset. These feelings can make it harder for you to follow your treatment plan, improve your health and return to your normal routine. They may also increase your chance of developing heart disease or of making it worse. It’s important to get treatment if you have these feelings. Talk to your dialysis social worker or your doctor to find out if counseling and/or medications may be helpful.

Should dialysis patients have tests for heart and blood vessel disease?

Yes. To check how well your heart is working, you should have:

  • An electrocardiogram (ECG) when you first start dialysis and then once a year after that.
  • An echocardiogram when you first start dialysis.

If these tests show any problem, you may also need to have:

  • A stress echocardiogram (a type of echocardiogram that includes exercise, usually on a treadmill) or a nuclear imaging test. These are done to check for a blocked artery.
  • An angiogram (an x-ray of the heart or arteries) to locate a blocked area and help plan treatment.

What type of treatment will I need if I have heart and blood vessel disease?

Your treatment will depend on the exact type of heart and blood vessel disease you have. See the chart to find out about some of the treatments used for the most common types of heart and blood vessel disease. If you have a different type, your doctor will speak to you about the treatment you need.

What if I have more questions?

You should speak to your doctor and other members of your health care team. You may also want to check the following information from the National Kidney Foundation (NKF):

Type of Heart Problem Description Common Symptoms or Findings Potential Treatments
Coronary Artery Disease One or more of the arteries that supplies blood to your heart is narrow or clogged. Chest pain (angina) or shortness of breath, especially on exertion. History of heart attack. Abnormal ECG,
Abnormal heart rhythm.
Low blood pressure during hemodialysis treatments.
A. Medications your doctor may prescribe: · Aspirin to reduce blood clotting & risk of heart attack (check with your doctor)
· Beta blockers to slow heart beat & reduce angina (chest pain)
· Nitrates to dilate blood vessels & reduce angina
· Lipid-lowering drugs
B. Angioplasty:
A procedure in which a catheter (tube) with an inflatable balloon is used to widen a narrowed artery.
C. Coronary bypass
: A procedure in which a vein, usually from your leg, is used to bypass the clogged or narrow area in the artery.
Left Ventricular Hypertrophy Thickening of the muscle of the left side of the heart, which prevents the heart from working as well. Usually no symptoms.
Abnormal ECG.
· Controlling blood pressure (see “Keep high blood pressure controlled” for goals of high blood pressure treatment)
· Treating anemia with medications (EPO & iron).
Heart Failure May occur due to coronary artery disease or left ventricular hypertrophy.
Causes reduced output of blood from the heart and buildup of fluid in the lungs and legs.
Shortness of breath, especially with exertion or when lying flat.
Leg swelling, especially when standing.
Low blood pressure during hemodialysis treatments.
A. Medications:
· ACE inhibitors to dilate blood vessels and reduce strain on the heart.
· Beta blockers to reduce strain on the heart.
· Digitalis to make the heart beat stronger.
B. Stricter sodium (salt) and fluid restrictions: To help reduce fluid accumulation.
C. Adjusting your target weight after dialysis (dry weight).

Abbreviations: ACE=angiotensin converting enzyme; ECG=electrocardiogram; EPO=erythropoietin.

See also in this A-Z guide:

  • Dialysis
  • Dialysis Patient's Bill of Rights and Responsibilities
  • Living Well on Dialysis: A Cookbook for Patients and Their Families
  • Keeping Your Heart Healthy When You Have Chronic Kidney Disease (Stages 1-4)

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