Cardioprotection in the ESRD Population: How Do We Get There?

Cardiovascular mortality for end-stage renal disease (ESRD) patients is about 30 times the risk in the general population. About 30% of ESRD patients have hyperlipidemia. The 1998 National Kidney Foundation Task Force on Cardiovascular Disease recommends implementation of effective measures to prevent and treat cardiovascular disease in this population. Our intent was to evaluate the extent of use of cardioprotective drugs in ESRD patients through a quality improvement project. Twenty-eight dialysis facilities throughout Ohio volunteered for this project. Data regarding use of angiotensin-converting enzyme inhibitors (ACE-I) and angiotensin receptor blockers (ARB) in heart failure, beta-blockers in myocardial infarction (MI), aspirin in coronary artery disease, and 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors (statins) were collected using chart abstraction for the period March through May 2000. The results were compared to Ohio hospital discharges from July through September 2000. This latter population was comprised of non--ESRD patients. Dialysis facilities were visited and interviews were conducted with staff members. Information was gathered regarding facility infrastructure, quality improvement process, and existing protocols. 27% of ESRD patients with a history of heart failure were on ACE-I, compared to 75.7% of non-ESRD patients. 34.8% of ESRD patients with a previous MI were taking beta-blockers, compared with 68.0% of non-ESRD patients with a prior MI. Aspirin use in ESRD patients with a previous MI was 52.8%, compared to 88% in non-ESRD patients with a prior MI. 17.3% of ESRD patients were on statins. Hyperlipidemia is found in 30% to 50% of ESRD patients. The use of cardioprotective drugs in the Medicare ESRD patient is lower than in the Medicare non-dialysis counterpart. Reasons for this are related to fragmentation of health care arising from communication and infrastructure issues. Until these issues are addressed and resolved, efforts at initiation of cardioprotective strategies will be slowed.