Sudden cardiac death and acute myocardial infarction in dialysis patients: perspectives of a cardiologist.

Chronic renal failure is characterized by an increased risk for cardiovascular morbidity and mortality, including acute myocardial infarction (AMI). AMI is associated with poor long-term survival in dialysis patients; the 2-year survival rate of 25% has remained unchanged over the past 2 decades. Although underuse of appropriate therapies likely contributes to adverse outcomes, recent data suggest that dialysis patients with AMI are more likely to have clinical presentations atypical for acute coronary syndrome. The risk for cardiac arrest and in-hospital death are increased in dialysis patients with AMI compared with a nondialysis cohort. The phenomenon of increased AMI mortality in patients with chronic kidney disease is not restricted to end-stage renal disease because there is a gradient of mortality risk related to decreased renal function. Sudden cardiac death is the single largest cause of mortality in dialysis patients. Dialysis patients are vulnerable to sudden cardiac death, and myocardial ischemia likely plays a major role. Nevertheless, after percutaneous and surgical coronary revascularization dialysis patients remain at high risk for sudden cardiac death, implying that other factors besides myocardial ischemia are important. A randomized trial testing the efficacy of implantable cardioverter-defibrillators for the prevention of sudden cardiac death in dialysis patients is warranted.