Managing Blood Pressure and Heart Rate Drops During Dialysis: A Patient's Concern

During dialysis, when blood pressure drops, the heart rate also decreases?

Hello, Doctor.
I have been a dialysis patient for over a year and have hypertension, hyperlipidemia, and coronary artery disease, along with mild arrhythmia.
Last year, I underwent a cardiac catheterization, which revealed that two arteries were 40% and 50% occluded.
The doctor mentioned that intervention is not necessary unless the blockage exceeds 70%, and medication is sufficient.
Recently, over the past month, I experienced two episodes of significant hypotension during dialysis, accompanied by cold sweats, vomiting, and near syncope, with my heart rate dropping as well.
The first episode saw my heart rate drop to 41 beats per minute, and the second even lower to 28 beats per minute.
However, after stopping dialysis and resting, my heart rate returned to normal (typically around 50 to 60 beats per minute due to taking Concor).
I have had a few episodes of low blood pressure over the past year, but this is the first time my heart rate has dropped so significantly.
After a myocardial perfusion scan last week, the doctor recommended another cardiac catheterization, noting myocardial ischemia of 12% (first scan) and 16% (second scan).
I am concerned that if the catheterization again shows less than 70% blockage, there will be no intervention, and I am unsure how to address the issue of my heart rate dropping.

Attached are the reports from last year's cardiac catheterization:
Indication: (Stress Test) TL-201 (SPECT)
Pre-Cath Diagnosis: Chronic CAD
Post-Cath Diagnosis: 1VD-CAD
Intervention: No
Complication: No
Stent: No
Procedure Time: (Start 17:02 Close 17:14 Mins 12)
Contrast: Visipaque: 35 ml
Vascular Access: Artery, Trans-radial (Right)
Intervention Methods: Additional Procedure: None
Hemodynamics: AsAo 130-/70 mmHg
Coronary Angiography:
- Dominant (Right)
- LM - normal
- LAD - 50% stenosis, mid-LAD
- LCX - 40% stenosis
- RCA - Insignificant stenosis
- Ramus -
- Collateral -
- SYNTAX score-
Others (Selective Angiography):
Intervention Procedure:
Recommendation: Medical treatment including risk factor modification
In September last year, I underwent a 24-hour Holter monitor:
1.
Normal sinus rhythm at baseline (51-99 bpm, average = 67 bpm)
2.
Transient T-wave inversion at midnight, cause undetermined
3.
164 isolated VPCs, 13 VPC couplets
4.
No significant tachyarrhythmia and long pauses
In September last year, I also had an echocardiogram:
1.
Dilated LA (42mm) and LV (55, 29mm) chamber sizes; concentric LVH with normal LV systolic wall motion; LVEF: 79%
2.
Mild to moderate aortic regurgitation
3.
Mild mitral regurgitation; reversed MV E/A ratio, suggesting diastolic dysfunction
4.
Minimal pulmonic regurgitation
5.
Mild tricuspid regurgitation with peak pressure gradient 24 mmHg
In October this year, I had another 24-hour Holter monitor:
1.
Normal sinus rhythm at baseline (47-90 bpm, average = 62 bpm)
2.
2 isolated APCs
3.
19 isolated VPCs
4.
No significant tachyarrhythmia and long pauses
In October this year, I also had an echocardiogram:
Poor echo window
Concentric LVH, dilated LA (41mm)
Impaired LV and RV relaxation
Mild PR, trivial TR (PG=21.2 mmHg), mild MR, and mild AR
Adequate LV and RV systolic function (LVEF=72%)
Normal LV and RV wall motion
Additionally, I would like to ask if the decrease in my left ventricular ejection fraction from 79% last year to 72% this year indicates a potential gradual decline towards heart failure.
I apologize for the numerous questions, but I am extremely worried, especially about my heart rate dropping to 28 beats per minute!

Gao Xiansheng, 40~49 year old female. Ask Date: 2023/12/09

Dr. Wu Xueming reply Cardiology

A left ventricular systolic power of over 60% in a cardiac ultrasound is considered normal and should not be a cause for concern.
Regarding the heart rate issue, the 24-hour Holter monitor in October did not show any signs of bradycardia.

Reply Date: 2023/12/09

More Info

Managing blood pressure and heart rate drops during dialysis can be a significant concern, especially for patients with underlying cardiovascular conditions such as coronary artery disease (CAD) and arrhythmias. Your situation, characterized by episodes of severe hypotension and bradycardia during dialysis, warrants careful consideration and management.

Understanding Your Condition
You have a history of hypertension, diabetes, and coronary artery disease, with previous coronary angiography revealing 40-50% stenosis in two coronary arteries. While your doctors have indicated that intervention is not necessary unless stenosis exceeds 70%, the presence of myocardial ischemia (12% and 16% in two separate tests) suggests that your heart is not receiving adequate blood flow during stress, which could be contributing to your symptoms during dialysis.

Symptoms During Dialysis
The symptoms you describe—cold sweats, vomiting, and near-fainting—are concerning, especially with heart rates dropping to 28 beats per minute. These symptoms can be indicative of several issues:
1. Hypotension: Dialysis can lead to fluid shifts and changes in blood volume, which may cause blood pressure to drop significantly. This is particularly true if there is excessive fluid removal or if the patient is not adequately hydrated prior to the procedure.

2. Bradycardia: A heart rate of 28 beats per minute is dangerously low and can lead to inadequate perfusion of vital organs. This could be due to autonomic dysfunction, electrolyte imbalances (common in dialysis patients), or the effects of medications.

3. Electrolyte Imbalances: Dialysis can alter levels of potassium, calcium, and magnesium, which are crucial for maintaining normal heart rhythm and function. An imbalance can lead to arrhythmias or bradycardia.

Recommendations for Management
1. Monitoring and Adjustment of Dialysis Protocol: It is essential to work closely with your nephrologist to adjust your dialysis prescription. This may include modifying the ultrafiltration rate (the rate at which fluid is removed) or ensuring that you are adequately hydrated before starting dialysis.

2. Medication Review: Review your current medications with your healthcare provider. Some antihypertensive medications may need to be adjusted, especially if they contribute to hypotension during dialysis.

3. Electrolyte Monitoring: Regular monitoring of electrolytes before and after dialysis can help identify any imbalances that may be contributing to your symptoms. If imbalances are found, your treatment plan can be adjusted accordingly.

4. Cardiology Consultation: Given your history of CAD and the recent episodes of bradycardia, a follow-up with a cardiologist is crucial. They may recommend further evaluation, including repeat cardiac catheterization or advanced imaging studies, to assess the current state of your coronary arteries and heart function.

5. Lifestyle Modifications: While managing your medical conditions, consider lifestyle changes that can improve your overall cardiovascular health. This includes a heart-healthy diet, regular physical activity (as tolerated), and stress management techniques.

Concerns About Heart Function
Regarding your concern about the decrease in left ventricular ejection fraction (LVEF) from 79% to 72%, it is essential to understand that while a decline in LVEF can indicate worsening heart function, it does not automatically mean you will progress to heart failure. Continuous monitoring and management of your cardiovascular risk factors are crucial. Regular follow-ups with your cardiologist can help track your heart function and make timely interventions if necessary.

Conclusion
Your symptoms during dialysis are serious and should not be taken lightly. It is crucial to communicate openly with your healthcare team about your experiences and concerns. They can help tailor your treatment plan to ensure your safety and improve your quality of life. Regular monitoring, medication adjustments, and lifestyle changes can significantly impact your overall health and well-being.

Similar Q&A

Managing Blood Pressure and Heart Rate Drops During Dialysis: A Patient's Guide

Hello, doctor. I have been a dialysis patient for over a year and have hypertension, diabetes, and coronary artery disease, along with mild arrhythmia. Last year, I underwent a cardiac catheterization, which revealed that two of my coronary arteries were 40% and 50% blocked. The ...

Dr. Cai Guiqin reply Cardiology
I recommend that you: 1. Discuss the above situation further with your attending physician. 2. Alternatively, seek consultation at a medical center. Wishing you good health. Thank you!

Managing Blood Pressure Issues in Hemodialysis Patients: Key Insights and Solutions

Hello Doctor: 1. I would like to ask you two questions. If a patient undergoing hemodialysis for 10 years has a history of hypertension but, for some unknown reason, their blood pressure has dropped to around 100 without taking any antihypertensive medication, resulting in dizz...

Dr. Wang Yiming reply Internal Medicine
Hello Ms. Wdvrdx: Your question is very profound and is a common topic among dialysis physicians. The most frequent issue faced by patients undergoing hemodialysis is fluctuations in blood pressure, particularly during standard dialysis sessions. The most significant factors infl...

Understanding Blood Pressure Drops and Nausea During Dialysis

The links provided lead to recent blood test reports. I would like to ask the doctor why my grandmother often experiences a drop in blood pressure, confusion, and nausea during the dialysis process. When we asked her attending physician, the doctor only advised us to control her ...

Dr. Wu Hongjie reply Internal Medicine
Hello: There are many causes of intradialytic hypotension (IDH) during dialysis: excessive weight gain between dialysis sessions (> 5%), heart failure, malnutrition, female gender, autonomic nervous system dysfunction, etc., are common causes. 1. If there is excessive weight...

Managing Heart Rhythm Issues During Dialysis: Key Considerations

Hello Doctor: I would like to consult with you regarding my father, who is currently undergoing hemodialysis and taking one tablet of Dronedarone in the morning and evening to treat his arrhythmia. Recently, his heart rate has been around 40-50 beats per minute. The nephrologist ...

Dr. Huang Yinghe reply Cardiology
Hello, Dronedarone is a medication used to treat arrhythmias, primarily effective in slowing down the heart rate. If the heart rate frequently drops below 50 beats per minute, it is necessary to consider reducing the dosage or discontinuing the medication. Generally, a gradual ta...