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— cardio-met (@cardiomet_CE) October 9, 2021
1) Welcome to this CE/#CME-accredited #tweetorial: The Kidney as “the Canary in the Coal Mine for Cardiovascular Health.”
— cardio-met (@cardiomet_CE) October 11, 2021
I’m your author, Tejas Desai (@nephondemand), and, as @chriscuomo would say, “Let’s get after it!”–and earn 0.75h FREE credit! pic.twitter.com/EnNjbj9KGN
3) So what is a “canary in the coal mine”? It’s an old phrase used by coal miners in the 19th century. They would take canaries into the coal mines as a “biological sensor” for polluted air, such as with high levels of carbon monoxide.
— cardio-met (@cardiomet_CE) October 11, 2021
5) So, the Kidney as the Canary in the Coal Mine for cardiovascular health means that poor kidney function should alert us to poor cardiovascular health *earlier* than traditional cardiac tests.
— cardio-met (@cardiomet_CE) October 11, 2021
Let’s look at this notion through this #tweetorial .
7) The most obvious cardiac derangement observed “consisted chiefly of hypertrophy”https://t.co/AGEuKczm76 pic.twitter.com/lMNDPJImaE
— cardio-met (@cardiomet_CE) October 11, 2021
9) CV mortality is 2x higher in CKD-3 and 3x higher in CKD-4. Life span is 17 years shorter in CKD-3 with CV disease and 25 years shorter in CKD-4 with CV disease. https://t.co/OCFbi2zqKh pic.twitter.com/VyD84JJXAI
— cardio-met (@cardiomet_CE) October 11, 2021
11) When it comes to LVH, nothing promotes its development more than CKD! And don’t get me started on ESRD. Dialysis patients aged 25-64 years have a 50x increase in cardiovascular mortality compared to non-dialysis age-matched patients. pic.twitter.com/vGH1KMLzCz
— cardio-met (@cardiomet_CE) October 11, 2021
13) . . . have a negative influence in 🫀 health. In the presence of CKD, two additional risks come into play: vascular calcification and inflammation. pic.twitter.com/bTYyuRKPpD
— cardio-met (@cardiomet_CE) October 11, 2021
15) In the presence of CKD, there is a ceaseless activation of the renin-angiotensin-aldosterone system (#RAAS). Elevated levels of both angiotensin II and aldosterone can induce myocardial fibrosis, resulting in more LVH. pic.twitter.com/WjHXRDmzqC
— cardio-met (@cardiomet_CE) October 11, 2021
… promote cardiac dysfunction. More data are needed. pic.twitter.com/f6IXfgjkSj
— cardio-met (@cardiomet_CE) October 11, 2021
18) Aside from these purported pathophysiologic mechanisms, cardiac dysfunction is promoted by increases in afterload and preload. Stiffer arteries result in higher systolic blood pressures and greater arterial resistance.
— cardio-met (@cardiomet_CE) October 11, 2021
20) So, if we are evaluating for heart disease in pts with #CKD, which diagnostic test might be the best first step?
— cardio-met (@cardiomet_CE) October 11, 2021
22) Welcome back to this #tweetorial on renal function & its complex interrelationships with other #cardiovascular disease. The kidneys can be seen as the “canary in the coal mine.” I am @nephondemand and it’s great that you have joined @cardiomet_CE. Please follow us for CE/#CME
— cardio-met (@cardiomet_CE) October 12, 2021
24) A 12-lead ECG is often used as an early diagnostic test for CV disease. Its utility tho is limited because over half of all patients with CKD have an abnl ECG at baseline. That’s not to say that one shouldn’t obtain an ECG, but interp should be based on comp with prior ECGs.
— cardio-met (@cardiomet_CE) October 12, 2021
26) Exercise stress testing isn’t reliable in CKD or ESRD patients because of the baseline abnormal ECG that many of these patients already have (see tweet 24). Moreover, many dialysis patients aren’t able to reach the necessary heart rate for this test to be conducted.
— cardio-met (@cardiomet_CE) October 12, 2021
28) #Coronaryangiography is at the top of the list of valuable diagnostic testing, so why don’t more advanced #CKD/#ESRD patients receive it? In two words…contrast nephropathy. pic.twitter.com/u5GxBaavEK
— cardio-met (@cardiomet_CE) October 12, 2021
30) Cardiac MRI is another useful test to elucidate structural changes in and around the heart. Many fear the contrast used in the MRI can precipitate nephrogenic systemic fibrosis, but this seems to be . . .
— cardio-met (@cardiomet_CE) October 12, 2021
32) CT coronary angiography (#CTCA) offers valuable diagnostic information in a less invasive manner than the standard diagnostic cardiac catheterization. It results in a calcium score which can be followed over time.
— cardio-met (@cardiomet_CE) October 12, 2021
34) And finally cardiac biomarkers: TnI, TnT, BNP, N-terminal pro-B-type natriuretic peptide, hrCRP, and dimethylarginine. All are elevated in ESRD patients at baseline and it is still unclear if early intervention based on these markers alters one’s cardiac prognosis.
— cardio-met (@cardiomet_CE) October 12, 2021
36) So how do we mitigate cardiac dysfunction in CKD? There are multiple approaches, but the best is to limit progression of CKD to ESRD. For that, early referral to a nephrologist is🔑. If that’s not possible (or if referral was delayed), here are some steps one can take.
— cardio-met (@cardiomet_CE) October 12, 2021
38) Cholesterol: interestingly, cholesterol-lowering therapies haven’t shown to be as effective in the CKD population. Perhaps because the main driver of cardiac disease is *not* atherosclerosis (tweet 16).
— cardio-met (@cardiomet_CE) October 12, 2021
— cardio-met (@cardiomet_CE) October 12, 2021
41) . . . (though the latter is often up to physician discretion). ISCHEMIA-CKD showed relatively little improvement in mortality or hospitalizations when performing a catheterization versus medical management in CKD patients. pic.twitter.com/P0360jjkQY
— cardio-met (@cardiomet_CE) October 12, 2021
43) MRAs: the DOHAS trial showed that mineralocorticoid receptor antagonists reduce mortality from CHF in advanced CKD patients. Of course, many of us are fearful of the resulting hyperkalemia, which is why a K-binding agent should be co-prescribed (AMBER trial). pic.twitter.com/iq8ZQGKr5G
— cardio-met (@cardiomet_CE) October 12, 2021
— cardio-met (@cardiomet_CE) October 12, 2021
44) While the AMBER and DIAMOND trials showed patiromer to be an effective K-binder with MRA use, don’t forget that sodium zirconium silicate (SZC) is also an option.
— cardio-met (@cardiomet_CE) October 12, 2021
46) For more on this important topic–the use of newer potassium binders to facilitate #RAASi therapy–go to our prior #tweetorials, still available for credit, at https://t.co/GbhudEBEVh for programs by expert authors @ErinMichos @edgarvlermamd @md_pollack
— cardio-met (@cardiomet_CE) October 12, 2021
— cardio-met (@cardiomet_CE) October 12, 2021
49) Ivarbradine: I’ll confess I had not heard of this med & have yet to see my cardiology colleagues use it. It is a sinus node inhibitor & in the SHIFT trial improved mortality in #heartfailure: https://t.co/LR2nVn4L14. A great person to ask/follow about this is @GiuseppeGalati_
— cardio-met (@cardiomet_CE) October 12, 2021
51) Perhaps the biggest player in the cardio-nephrology world is the #SGLT2i. Name the trial, it is likely to be positive: EMPEROR-Preserved/Reduced, DAPA-HF & -CKD, CANVAS. How impressive are SGLT2i’s? #Flozinators facetiously advocate adding it to the municipal water supply! pic.twitter.com/uME7pbDkK9
— cardio-met (@cardiomet_CE) October 12, 2021
53) Mark your answer and return tomorrow for wrap-up, CE/#CME credit grab, and my look at what we need to do going forward in the #CKD–#CV world! #FOAMed @DraNefrona @mpneph @dhekidney @JMTeakell @acssjr @DrRulanParekh @TxPharmD @mala_sachdeva @anuja_java @SumitMohanMD
— cardio-met (@cardiomet_CE) October 12, 2021
55) So re yesterday's poll: 37) In the McGuire meta-analysis, #SGLT2i were associated with ⬇️risk of MACE but significant heterogeneity for CV death. The largest benefit across the class was ⬇️ in risk for HHF & kidney outcomes . . .
— cardio-met (@cardiomet_CE) October 13, 2021
57) So what comes next? There’s lot of excitement at the intersection of cardiology and nephrology. First, though, we must address the elephant in the room. Why don’t we have answers to many questions regarding cardiac disease in CKD patients? In a word…exclusion. pic.twitter.com/96N5Pok7hk
— cardio-met (@cardiomet_CE) October 13, 2021
59) So whatever the future holds, we must ensure that CKD and ESRD patients are *included* in clinical trials. https://t.co/qTgHYhwVwy
— cardio-met (@cardiomet_CE) October 13, 2021
61) Finally, we have two new players in the game: #SGLT2i & non-steroidal MRAs. Both are being touted as game-changing medications, which begs the question…after RAASi, which should come next? This is a great *problem* to have but one with implications for patients and pharma.
— cardio-met (@cardiomet_CE) October 13, 2021
63) And many thanks to my #NephTwitter and #CardioTwitter colleagues. For connection to this tweetorial or if want more information, you can search for scientific tweets in Nephrology and Cardiology at https://t.co/o7hcEGYQCB. It’s completely free.
— cardio-met (@cardiomet_CE) October 13, 2021
64) So now, go claim your 0.75h CE/#CME credit! Just click on https://t.co/dlFNTj0isl, and you'll have your certificate in 3 minutes or less. All free, all accredited, all expert authors, all the time . . . here at @cardiomet_CE. I am @nephondemand. Thanks for joining us! pic.twitter.com/yjVwQSErBb
— cardio-met (@cardiomet_CE) October 13, 2021