Hemodialysis Procedure–Associated Autonomic Imbalance and Cardiac Arrhythmias: Insights From Continuous 14-Day ECG Monitoring

Nichole M. Rogovoy, Stacey J. Howell, Tiffany L. Lee, Christopher Hamilton, Erick A. Perez-Alday, Muammar M. Kabir, Yanwei Zhang, Esther D. Kim, Jessica Fitzpatrick, Jose M. Monroy-Trujillo, Michelle M. Estrella, Stephen M. Sozio, Bernard G. Jaar, Rulan S. Parekh, Larisa G. Tereshchenko

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    20 Scopus citations


    Background: In patients with end-stage kidney disease, sudden cardiac death is more frequent after a long interdialytic interval, within 6 hours after the end of a hemodialysis session. We hypothesized that the occurrence of paroxysmal arrhythmias is associated with changes in heart rate and heart rate variability in different phases of hemodialysis. Methods and Results: We conducted a prospective ancillary study of the Predictors of Arrhythmic and Cardiovascular Risk in End Stage Renal Disease cohort. Continuous ECG monitoring was performed using an ECG patch, and short-term heart rate variability was measured for 3 minutes every hour (by root mean square of the successive normal-to-normal intervals, spectral analysis, Poincaré plot, and entropy), up to 300 hours. Out of enrolled participants (n=28; age 54±13 years; 57% men; 96% black; 33% with a history of cardiovascular disease; left ventricular ejection fraction 70±9%), arrhythmias were detected in 13 (46%). Nonsustained ventricular tachycardia occurred more frequently during/posthemodialysis than pre-/between hemodialysis (63% versus 37%, P=0.015). In adjusted for cardiovascular disease time-series analysis, nonsustained ventricular tachycardia was preceded by a sudden heart rate increase (by 11.2 [95% CI 10.1–12.3] beats per minute; P<0.0001). During every-other-day dialysis, root mean square of the successive normal-to-normal intervals had a significant circadian pattern (Mesor 10.6 [95% CI 0.9–11.2] ms; amplitude 1.5 [95% CI 1.0–3.1] ms; peak at 02:01 [95% CI 20:22–03:16] am; P<0.0001), which was replaced by a steady worsening on the second day without dialysis (root mean square of the successive normal-to-normal intervals −1.41 [95% CI −1.67 to −1.15] ms/24 h; P<0.0001). Conclusions: Sudden increase in heart rate during/posthemodialysis is associated with nonsustained ventricular tachycardia. Every-other-day hemodialysis preserves circadian rhythm, but a second day without dialysis is characterized by parasympathetic withdrawal.

    Original languageEnglish (US)
    Article numbere013748
    JournalJournal of the American Heart Association
    Issue number19
    StatePublished - Oct 1 2019


    • electrocardiography
    • heart rate/heart rate variability
    • hemodialysis
    • trigger clusters
    • ventricular arrhythmia

    ASJC Scopus subject areas

    • Cardiology and Cardiovascular Medicine


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