Difficult to treat atrial fibrillation in a patient on haemodialysis
Fibrilación auricular de difícil tratamiento en una paciente en hemodiálisis
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Saurina i Solé, M. Pou Potau, K.R. Salas Gama, M. Ramírez de Arellano Serna" "autores" => array:5 [ 0 => array:4 [ "nombre" => "Juan Carlos" "apellidos" => "González Oliva" "email" => array:1 [ 0 => "jcdoctor2002@yahoo.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 1 => array:3 [ "Iniciales" => "A." "apellidos" => "Saurina i Solé" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 2 => array:3 [ "Iniciales" => "M." "apellidos" => "Pou Potau" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 3 => array:3 [ "Iniciales" => "K.R." "apellidos" => "Salas Gama" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 4 => array:3 [ "Iniciales" => "M." "apellidos" => "Ramírez de Arellano Serna" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:3 [ "entidad" => "Servicio de Nefrología, Hospital de Tarrassa. Consorcio Sanitari de Tarrassa, Terrassa, " "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Fibrilación auricular de difícil tratamiento en una paciente en hemodiálisis" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig1" "etiqueta" => "Tab. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "10344108_a24_t1.jpg" "Alto" => 162 "Ancho" => 708 "Tamanyo" => 25579 ] ] "descripcion" => array:1 [ "en" => "Chronological evolution of antiarrhythmic treatment" ] ] ] "textoCompleto" => "<p class="elsevierStylePara">Atrial fibrillation (AF) is the most frequent type of arrhythmia with a prevalence of 8.5%<span class="elsevierStyleSup">1 </span>in the general population, ranging between 13.6<span class="elsevierStyleSup">2 </span>and 23.4%<span class="elsevierStyleSup">3 </span>in patients on haemodialysis (HD). It tends to be associated with structural heart disease, particularly left atrial dilation, and electrolyte imbalances such as hypokalaemia and hypocalcaemia must be avoided as they can precipitate a cardiac arrhythmia. We present the case of a patient with chronic renal failure (CRF) on HD, with a flutter that was difficult to treat pharmacologically because of intolerance to various antiarrhythmic drugs. The patient required pacemaker implantation in order to introduce treatment with beta-blockers (BB) and control the heart rate (HR). The patient was 72 years old with end-stage CRF and a history of ischaemic heart disease, high blood pressure, diabetes mellitus, severe vascular disease, chronic AF, and inclusion in the HD programme since 2004. The history of heart disease began in November 2003 when the patient suffered an acute myocardial infarction with an episode of fluttering, which reverted after administering diltiazem retard in 120mg doses every 12 hours. The echocardiogram showed a non-dilated left ventricle with moderate septal hypertrophy (18mm), preserved ejection fraction (EF) and dilated left atrium. In August 2005, the patient presented a new episode of rapid AF and digoxin treatment was reinitiated with a dose of 0,125mg twice per week. Treatment was suspended after one week due to digitalis toxicity. In January 2005, due to a new episode of rapid AF, treatment was begun with 200mg amiodarone five days a week, with which we managed to achieve sinus rhythm (SR). Treatment was discontinued after one month due to hypothyroidism. Bisoprolol (5mg/dat) was added for persistent cardiac arrhythmia and the patient reverted to sinus rhythm, but it had to be discontinued ten days later due to bradycardia. In May 2006, the patient presented another AF episode despite being treated with diltiazem. Since it was ineffective, it was discontinued and treatment with bisoprolol was initiated once more. In August 2009, bisoprolol was increased to 7.5mg due to rapid AF. The drug was discontinued one month later due to symptomatic bradycardia of 38 beats/min (Table 1). No electrophysiological study was performed at any time during the course of events due to patient refusal. Given the treatment difficulty, we decided to implant a pacemaker in order to reintroduce BB treatment to control the HR. The patient is currently asymptomatic and shows a good tolerance of the treatment. Treatment of AF consists of achieving SR and/or controlling the heart rate. Different drugs may be used: digoxin, beta blockers, non-dihydropyridine calcium channel blockers and amiodarone. However, they are not free from adverse effects in CRF patients. Digoxin is less effective for controlling heart rate, but it is very widely used in patients with a low EF. For patients on HD, it is recommended not to use loading doses, and the maintenance dose should be 0.0625mg/day or 0.125mg every other day. The most frequent adverse effects are supraventricular tachycardia and bradyarrythmia (to the point of atrioventricular block), bigeminy and gastrointestinal abnormalities.<span class="elsevierStyleSup">4 </span>BB and non-dihydropyridine calcium channel blockers are the correct drugs for preserved EF, but care must be taken with patients with decreased EF due to the drugs’ negative inotropic effects.<span class="elsevierStyleSup">4 </span>BBs with non-renal excretion can be safely prescribed depending on the heart rate and blood pressure. Amiodarone is the drug of choice in patients with a low EF whose HR cannot be controlled with digoxin. Its adverse affects are as follows: In the thyroid, hypothyroidism or hyperthyroidism; in the respiratory tract, pulmonary fibrosis; and in the heart, long-QT interval and bradycardia with atrioventricular block.<span class="elsevierStyleSup">4 </span>With HD, dosage for antiarrhythmics is a complicated topic, given the increase in its half life and multiple interactions with other drugs commonly used by these patients. Our patient presented numerous complications associated with different antiarrhythmic treatments without gaining control over the chronic AF and with frequent tachyarrhythmia episodes. He therefore required implantation of a permanent pacemaker in order to control HR using beta blockers, with no new cardiac incidents.     </p><p class="elsevierStylePara"><a href="grande/10344108_a24_t1.jpg" class="elsevierStyleCrossRefs"><img src="10344108_a24_t1.jpg" alt="Chronological evolution of antiarrhythmic treatment"></img></a></p><p class="elsevierStylePara">Table 1. Chronological evolution of antiarrhythmic treatment</p>" "pdfFichero" => "P1-E47-S1884-A10344-EN.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig1" "etiqueta" => "Tab. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "10344108_a24_t1.jpg" "Alto" => 162 "Ancho" => 708 "Tamanyo" => 25579 ] ] "descripcion" => array:1 [ "en" => "Chronological evolution of antiarrhythmic treatment" ] ] ] "bibliografia" => array:2 [ "titulo" => "Bibliography" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:4 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Cea Calvo L, Redón J, Lozano JV, Fernández-Pérez C, Martí JC, Listerri J, et al, en representación de los investigadores del estudio PREV-ICTUS. Prevalencia de fibrilación auricular en la población española de 60 o más años de edad. Estudio PREV-ICTUS. Rev Esp Cardiol 2007;60:616-24." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 1 => array:3 [ "identificador" => "bib2" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Vázquez E, Sánchez-Perales C, Borrego F, García-Cortés MJ. Influence of atrial fibrillation on the morbido-mortality of patients on hemodialysis. Am Heart J 2000;140:886-90. <a href="http://www.ncbi.nlm.nih.gov/pubmed/11099992" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 2 => array:3 [ "identificador" => "bib3" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Fabbian F, Catalano C, Lambertini D, Tarroni G. Clinical characteristics associated to atrial fibrillation in chronic hemodialysis patients. Clin Nephrol 2000;54:234-9. <a href="http://www.ncbi.nlm.nih.gov/pubmed/11020022" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 3 => array:3 [ "identificador" => "bib4" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Martindale. Guía completa de consulta farmacoterapéutica. Cardiología (2.ª ed.). 2006. Barcelona: Pharma Editores; 2006." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/20132514/0000003000000002/v0_201502091606/X2013251410035999/v0_201502091606/en/main.assets" "Apartado" => array:4 [ "identificador" => "35437" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor - Brief Case Reports" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/20132514/0000003000000002/v0_201502091606/X2013251410035999/v0_201502091606/en/P1-E47-S1884-A10344-EN.pdf?idApp=UINPBA000064&text.app=https://revistanefrologia.com/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X2013251410035999?idApp=UINPBA000064" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 6 | 6 | 12 |
| 2024 October | 116 | 44 | 160 |
| 2024 September | 103 | 33 | 136 |
| 2024 August | 78 | 46 | 124 |
| 2024 July | 110 | 33 | 143 |
| 2024 June | 101 | 49 | 150 |
| 2024 May | 106 | 41 | 147 |
| 2024 April | 99 | 36 | 135 |
| 2024 March | 89 | 28 | 117 |
| 2024 February | 86 | 42 | 128 |
| 2024 January | 83 | 27 | 110 |
| 2023 December | 90 | 36 | 126 |
| 2023 November | 84 | 39 | 123 |
| 2023 October | 106 | 40 | 146 |
| 2023 September | 101 | 31 | 132 |
| 2023 August | 81 | 27 | 108 |
| 2023 July | 96 | 21 | 117 |
| 2023 June | 96 | 25 | 121 |
| 2023 May | 66 | 37 | 103 |
| 2023 April | 95 | 15 | 110 |
| 2023 March | 84 | 18 | 102 |
| 2023 February | 101 | 28 | 129 |
| 2023 January | 79 | 20 | 99 |
| 2022 December | 72 | 25 | 97 |
| 2022 November | 82 | 33 | 115 |
| 2022 October | 84 | 47 | 131 |
| 2022 September | 84 | 35 | 119 |
| 2022 August | 72 | 44 | 116 |
| 2022 July | 91 | 42 | 133 |
| 2022 June | 98 | 41 | 139 |
| 2022 May | 81 | 20 | 101 |
| 2022 April | 88 | 61 | 149 |
| 2022 March | 94 | 45 | 139 |
| 2022 February | 100 | 43 | 143 |
| 2022 January | 82 | 29 | 111 |
| 2021 December | 93 | 45 | 138 |
| 2021 November | 65 | 30 | 95 |
| 2021 October | 106 | 46 | 152 |
| 2021 September | 62 | 27 | 89 |
| 2021 August | 69 | 44 | 113 |
| 2021 July | 44 | 31 | 75 |
| 2021 June | 39 | 21 | 60 |
| 2021 May | 59 | 33 | 92 |
| 2021 April | 137 | 73 | 210 |
| 2021 March | 60 | 26 | 86 |
| 2021 February | 59 | 13 | 72 |
| 2021 January | 51 | 14 | 65 |
| 2020 December | 34 | 11 | 45 |
| 2020 November | 47 | 12 | 59 |
| 2020 October | 28 | 11 | 39 |
| 2020 September | 26 | 6 | 32 |
| 2020 August | 43 | 12 | 55 |
| 2020 July | 32 | 7 | 39 |
| 2020 June | 38 | 7 | 45 |
| 2020 May | 60 | 10 | 70 |
| 2020 April | 47 | 16 | 63 |
| 2020 March | 42 | 16 | 58 |
| 2020 February | 50 | 14 | 64 |
| 2020 January | 62 | 21 | 83 |
| 2019 December | 52 | 34 | 86 |
| 2019 November | 59 | 15 | 74 |
| 2019 October | 22 | 9 | 31 |
| 2019 September | 39 | 14 | 53 |
| 2019 August | 35 | 7 | 42 |
| 2019 July | 24 | 20 | 44 |
| 2019 June | 37 | 16 | 53 |
| 2019 May | 26 | 12 | 38 |
| 2019 April | 56 | 26 | 82 |
| 2019 March | 34 | 15 | 49 |
| 2019 February | 24 | 16 | 40 |
| 2019 January | 37 | 19 | 56 |
| 2018 December | 62 | 31 | 93 |
| 2018 November | 68 | 10 | 78 |
| 2018 October | 76 | 12 | 88 |
| 2018 September | 61 | 19 | 80 |
| 2018 August | 54 | 18 | 72 |
| 2018 July | 41 | 8 | 49 |
| 2018 June | 52 | 16 | 68 |
| 2018 May | 51 | 16 | 67 |
| 2018 April | 62 | 8 | 70 |
| 2018 March | 52 | 8 | 60 |
| 2018 February | 37 | 9 | 46 |
| 2018 January | 98 | 9 | 107 |
| 2017 December | 111 | 10 | 121 |
| 2017 November | 58 | 11 | 69 |
| 2017 October | 30 | 7 | 37 |
| 2017 September | 40 | 10 | 50 |
| 2017 August | 25 | 10 | 35 |
| 2017 July | 32 | 9 | 41 |
| 2017 June | 29 | 24 | 53 |
| 2017 May | 37 | 7 | 44 |
| 2017 April | 23 | 4 | 27 |
| 2017 March | 27 | 30 | 57 |
| 2017 February | 40 | 4 | 44 |
| 2017 January | 19 | 8 | 27 |
| 2016 December | 53 | 7 | 60 |
| 2016 November | 63 | 2 | 65 |
| 2016 October | 76 | 5 | 81 |
| 2016 September | 86 | 3 | 89 |
| 2016 August | 129 | 6 | 135 |
| 2016 July | 107 | 5 | 112 |
| 2016 June | 120 | 0 | 120 |
| 2016 May | 146 | 0 | 146 |
| 2016 April | 71 | 0 | 71 |
| 2016 March | 90 | 0 | 90 |
| 2016 February | 70 | 0 | 70 |
| 2016 January | 87 | 0 | 87 |
| 2015 December | 116 | 0 | 116 |
| 2015 November | 72 | 0 | 72 |
| 2015 October | 70 | 0 | 70 |
| 2015 September | 64 | 0 | 64 |
| 2015 August | 66 | 0 | 66 |
| 2015 July | 46 | 0 | 46 |
| 2015 June | 24 | 0 | 24 |
| 2015 May | 55 | 0 | 55 |
| 2015 April | 5 | 0 | 5 |
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