Management of Demand Ischemia in End-Stage Renal Disease

Introduction to Demand Ischemia

The American College of Cardiology suggests that in patients with end-stage renal disease (ESRD), a flat troponin pattern indicates chronic myocardial stress or injury rather than acute plaque rupture/thrombosis, and recommends identifying and treating the underlying precipitant 1, 2.

The European Heart Journal recommends obtaining troponin measurements at presentation and 3-6 hours later to document lack of dynamic change in patients with ESRD 4, 2.
The Journal of the American College of Cardiology suggests that blood samples should be drawn before dialysis if the patient is on hemodialysis, as dialysis can decrease high-sensitivity troponin T by 10-12% 1.
The European Heart Journal recommends obtaining a 12-lead ECG to look for ischemic changes, but recognizes that baseline ECG abnormalities from left ventricular hypertrophy and electrolyte disturbances are common in ESRD 5, 2.

The European Heart Journal identifies severe anemia as a common precipitant of demand ischemia in ESRD patients, which increases myocardial oxygen demand 6.
The American College of Cardiology suggests that volume overload, uncontrolled hypertension, tachyarrhythmias, hypotension, severe electrolyte abnormalities, and infection/sepsis are potential precipitants of demand ischemia in ESRD patients 1, 4, 5.

The European Heart Journal recommends correcting anemia to reduce oxygen supply-demand mismatch in ESRD patients with demand ischemia 6.
The American College of Cardiology suggests optimizing volume status through adjusted ultrafiltration goals and dry weight reassessment 1.
The European Heart Journal recommends controlling blood pressure with appropriate antihypertensive adjustments, though being cautious with ACE inhibitors/ARBs given renal function 6, 5.
The Journal of the American College of Cardiology suggests treating arrhythmias with rate or rhythm control as clinically indicated 4.

The European Heart Journal recommends applying the same therapeutic strategies as for patients with normal renal function, but with dose adjustments for renally cleared medications 5.
The European Heart Journal suggests continuing aspirin and statin therapy for secondary prevention, as these remain indicated despite ESRD 5.
The European Heart Journal notes that the benefit of P2Y12 inhibitors is uncertain in stage 5 CKD due to insufficient safety and efficacy data 5.

The American College of Cardiology suggests that elevated troponin predicts 30-day myocardial infarction and death more strongly in CKD patients than in those without CKD 2.
The European Heart Journal notes that the 2-year mortality rate among STEMI patients with ESRD is substantially higher than in the general population 6.