Pages 16-25

Öz

The aim of this study was to evaluate the value of BNP for detecting silent myocardial ischemia in dialysis patients. 53 hemodialysis patients with no anginal symptoms were included. Ambulatory electrocardiographic monitorisation were done to all patients in order to determine silent myocardial ischemia. BNP assays were done to all patients before the second hemodialysis session of the week. The median age of the participants was 50 (60 % male). Male sex and hyperlipidemia were more frequent in the silent ischemia group. Other demographic and echocardiographic parameters were similar in both groups. The median BNP concentration was significantly higher in the silent ischemia group (682,7 pg/mL vs 503,2, p= 0,006). Left ventricular mass index (r=0,502, p<0,001) and mitral E/ Em mean (r=0,604, p<0,001) showed significant positive correlation with basal BNP concentrations. Logistic regression analysis revealed BNP as an independent predictor of silent myocardial ischemia development in patients with no known coronary artery disease (OR=1,08, %95 CI: 1,006-1,159). ROC analysis in order to determine the usefulness of BNP as a screening test revealed %90 sensitivity and %57 specificity (area under the curve=0,773, p=0,006) for predicting silent myocardial ischemia. BNP might be of value in predicting silent myocardial ischemia determined with ambulatory electrocardiographic monitorisation in hemodialysis patients.

Anahtar Kelimeler

• Silent myocardial ischemia, B-type natriuretic peptide, end stage renal disease, hemodialysis

Son Dönem Böbrek Yetmezliği Olan Olgularda B-Tipi Natriüretik Peptidin Sessiz Miyokard İskemisini Öngördürmedeki Rolü

Öz

Bu çalışmanın amacı hemodiyaliz hastalarında sessiz miyokard iskemisini belirlemede BNP’nin ön gördürücü rolünü araştırmaktır. Çalışmaya anjinal yakınması olmayan toplam 53 hemodiyaliz hastası dâhil edildi. Sessiz miyokard iskemisini belirlemek amacı ile tüm olgulara saatlik ambulatuar elektrokardiyografik monitorizasyon yapılarak sessiz iskemisi olanlar ve olmayanlar olarak gruplandı. BNP düzeyleri için kanlar tüm hastalardan haftanın 2.hemodiyaliz seansı öncesi alındı. Çalışmaya katılan hastaların ortanca yaşı 50 (%60 erkek) idi. Erkek cinsiyet ve hiperlipidemi sıklığı sessiz iskemi olan grupta daha fazla idi bunun dışındaki demografik ve ekokardiyografik parametreler açısından gruplar arasında fark yoktu. Ortanca BNP konsantrasyonu sessiz iskemi olan grupta anlamlı derecede artmış bulundu [sırası ile 682,7 (234,7) pg/ml vs 503,2 (103,7) pg/ml, p=0.006]. Sol ventrikül kitle indeksi (r=0.502,p < 0.001) ilemitral E/Em ortalama (r=0.604,p

Anahtar Kelimeler

• Sessiz miyokard iskemisi, B-tipi natriüretik peptid, son dönem böbrek yetmezliği, hemodiyaliz

Kaynakça

1. US Renal Data System, USRDS 2002 Annual Data Report. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, National Institutes of Health; 2002
2. Herzog CA. Sudden cardiac death and acute myocardial infarction in dialysis patients: perspectives of a cardiologist. Semin Nephrol . 2005;25(6):363-6
3. Davidson NC, Pringle SD, Pringle TH. Right coronary artery stenosis is associated with impaired cardiac endocrine function during exercise. Eur Heart J. 1997; 18: 1749–54.
4. Goetze JP, Gore A, Moller CH.Acute myocardial hypoxia increases BNP gene expression FASEB J.2004;18(15):1928-30.
5. Goetze JP, Christoffersen C, Perko M. Increased cardiac BNP expression associated with myocardial ischemia. FASEB J. 2003;17(9):1105-7.
6. Hopkins W, Chen Z, Fukaguwa N. Increased atrial and brain natriuretic peptides in adults with cyanotic congenital heart disease. Circulation. 2004;109:2872–7
7. FooteRS, Pearlman JD, Siegel AH. Detection of exercise induced ischemiaby changes in B-type natriuretic peptides.J Am Coll Cardiol.2004;44:1980-7.
8. Marumoto K, Hamada M, Hiwada K. Increased secretion of atrial and brain natriuretic peptides during acute myocardial ischaemia induced by dynamic exercise in patients with angina pectoris. Clin Sci (Lond). 1995; 88: 551-6.

9. Rana BS, Daviers JI, Band MM. B-type natriuretic peptide can detect silent myocardial ischaemia in asymptomatic type 2 diabetes. Heart. 2006; 92(4): 916Wong KY, Mc Swiggan S, Kennedy NS. B-type natriuretic peptide identifies silent myocardial ischaemia in stroke survivors.Heart. 2006;92(4): Nakamura T, Sakamoto K, Yamano T. Increased plasma brain natriuretic peptide level as a guide for silent myocardial ischemia in patients with nonobstructive hypertrophic cardiomyopathy.J Am Coll Cardiol. 2002; 39 (10): 1657 -63.
10. Dastoor H, Bernieh B, Boobes Y. Plasma BNP in patients on maintainance hemodialysis:A guide to management? J of Hypertension. 2005; 23: 23-8.
11. Nishikimi T, Futoo Y, Tamano K. Plasma brain natriuretic peptide levels in chronic haemodialysis patients: influence of coronary artery disease. Am J Kidney Dis. 2001; 37: 1201-1208.
12. Niizuma S, Iwanaga Y, Yahata T. Plasma B-type natriuretic peptide levels reflect the presence and severity of stable coronary artery disease in chronic haemodialysis patients.Nephrol Dial Transplant. 2009; 24: 597-603.
13. Zoccali C, Mallamaci F, Benedetto FA. CREED Investigators. Cardiac natriuretic peptides are related to left ventricular mass and function and predict mortality in dialysis patients. J Am Soc Nephrol. 2001; 12:1508–1515.
14. Conlon, PJ, Krucoff MW, Minda S, Schumm D, Schwab SJ. Incidence and long term significance of transient ST segment deviation in hemodialysis patients. Clin Nephrol. 1998; 49, 236–9.
15. Kremastinos D, Paraskevaidis I, Voudiklari S, Apostolou T, Kyriakides Z, Zirogiannis P, Toutouzas P. Painless myocardial ischemia in chronic hemodialysis patients.A real event? Nephron. 1992; 60: 164–70.
16. Mohiuddin K, Bali HK, Banerjee S. Silent Myocardial Ischemia and High-Grade Ventricular Arrhythmias in Patients on Maintenance Hemodialysis. Renal Failure. 2005; 27: 171–5.
17. Nakamura S, Uzu T, Inenaga T, Kimura G. Prediction of Coronary Artery Disease and Cardiac Events Using Electrocardiographic Changes During Hemodialysis. American Journal of Kidney Diseases. 2000; 36: 592- 9.
18. Aronow WS, Ahn C, Mercando AD. Prevalence of coronary artery disease, complex ventricular arrhythmias, and silent myocardial ischemia and incidence of new coronary events in older persons with chronic renal insufficiency and with normal renal function. Am J Cardiol.2000; 86:1142–3.
19. Cice G, Di Benedetto A, D’Andrea A. SustainedRelease Diltiazem Reduces Myocardial Ischemic Episodes in End-Stage Renal Disease: A DoubleBlind, Randomized, Crossover, Placebo-Controlled Trial. J Am Soc Nephrol. 2003;14: 1006–11.
20. D’Elia JA, Weinrauch LA, Gleason RE. Application of the ambulatory 24-hour electrocardiogram in the prediction of cardiac death in dialysis patients. Arch Intern Med. 1988;148: 2381–5
21. Narula AS, Jha V, Bali HK, Sakhuja V, Sapru RP. Cardiac arrhythmias and silent myocardial ischemia during hemodialysis. Ren Fail. 2000; 22: 355–68.
22. Schiller NB, Shah PM, Crawford M, DeMaria A, Devereux R, Feigenbaum H. Recommendations for quantitation of the left ventricle by twodimensional echocardiography: American Society of Echocardiography Committee on Standards, Subcommittee on Quantitation of Two-Dimensional Echocardiograms. J Am Soc Echocardiogr. 1989; 2: 358– 67.
23. Devereux RB, Alonso DR, Lutas EM. Echocardiographic assessment of left ventricular hypertrophy: comparison to necropsy findings. Am J Cardiol. 1986; 57: 450–8.
24. Ommen SR, Nishimura RA, Appleton CP. The clinical utility of Doppler echocardiography and tissue Doppler imaging in estimation of left ventricular filling pressures: a comparative simultaneous Dopplercatheterization study. Circulation. 2000;102:1788-94
25. Paulus WJ, Tschope C, Sanderson JE. How to diagnose diastolic heart failure: a consensus statement on the diagnosis of heart failure with normal left ventricular ejection fraction by the Heart Failure and Echocardiography Associations of the European Society of Cardiology. Eur Heart J. 2007; 28(20):2539-50.
26. Von Arnim T.Prognostic significance of transient ischemic episodes; response to treatment shows improved prognosis. Results of the Total Ischemic Burden Bisoprolol Study (TIBBS) follow-up. J Am Coll Cardiol. 1996; 28: 20-24.
27. Pepine CJ, Cohn PF, Deedwania PC.Effects of treatment on outcome in mildly symptomatic patients with ischemia during daily life. The Atenolol Silent Ischemia Study (ASIST). Circulation. 1994; 90: 762-8. Daviers RF, Goldberg AD, Forman S. Asymptomatic Cardiac Ischemia Pilot (ACIP) study two-year follow up:Outcomes of patients randomised to initial strategies of medical therapy versus revascularisation.Circulation. 1997; 95: 2037Hess OM, Schneider J, Nonogi H. Myocardial ischemia and structure in patients with exerciseinduced ischemia. Circulation. 1988; 77: 967-977. Yazışma Adresi: Yard. Doç. Dr. Fatih Poyraz
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