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

When blood pressure drops during dialysis and heart rate also decreases, how should it be managed?

Hello, Doctor Wu: I have been a dialysis patient for over a year and have hypertension, hyperlipidemia, and diabetes.
I also have coronary artery disease and mild arrhythmia.
Last year, I underwent a cardiac catheterization, which revealed that two arteries were 40% and 50% blocked.
The doctor said that as long as the blockage is less than 70%, it is generally not treated, and medication is sufficient.
Recently, over the past month, I experienced two episodes of hypotension during dialysis, with symptoms including cold sweats, vomiting, and near fainting.
My heart rate dropped to 41 beats per minute during the first episode and even to 28 beats per minute during the second episode.
However, after stopping dialysis and resting, my heart rate returned to normal (usually, due to taking Concor, my heart rate is not fast, around 50 to 60 beats per minute).
After the first drop in heart rate, I stopped taking Concor, but the second episode still occurred, and the heart rate dropped even lower.
Over the past year, I have had a few instances of hypotension but had not experienced a drop in heart rate until these two episodes in the last month.
I am currently concerned about the drop in heart rate, as the doctor mentioned that hypotension typically does not lead to bradycardia.
I asked the nurse, and she said she had not seen such a situation before.
Last week, after a myocardial perfusion scan, the doctor recommended another cardiac catheterization, stating that there was 12% ischemia during the first test and 16% during the second test.
I am worried that if the catheterization is performed again and they still decide not to intervene, how should the issue of bradycardia be addressed? The cardiologist suspects that there may be right coronary artery stenosis (as this artery affects heart rate), but during last year's catheterization, the only artery that was not narrowed was the right coronary artery.
There is also no aging of the heart.
At the beginning of this month, a cardiac ultrasound showed an ejection fraction of 72%.
I would like to ask the doctor what the underlying issue might be.
Attached are some reports related to heart examinations:
Last year's catheterization report:
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 factors modification
October this year cardiac ultrasound:
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
October this year 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 pause

Gao Xiansheng, 40~49 year old female. Ask Date: 2023/12/11

Dr. Wu Hongjie reply Internal Medicine

For heart-related issues, please consult a cardiologist.
In cases of hypotension during dialysis, the on-site nephrologist should provide immediate feedback.
Each situation is different, so please respond according to the circumstances at that time.
Common management strategies include: reducing the volume of fluid removal, slowing the dialysis flow rate, administering blood transfusions to prevent anemia, avoiding food intake during dialysis, and using high-concentration glucose, among others.
Wishing you safety and well-being.

Reply Date: 2023/12/11

More Info

Managing blood pressure and heart rate drops during dialysis is a critical concern for patients, especially those with underlying cardiovascular conditions such as coronary artery disease (CAD) and arrhythmias. Given your history of hypertension, diabetes, and coronary artery disease, along with the recent episodes of significant hypotension and bradycardia during dialysis, it is essential to address these issues comprehensively.

Understanding the Risks
Dialysis can lead to fluctuations in blood pressure and heart rate due to various factors, including fluid shifts, electrolyte imbalances, and the removal of waste products. In patients with CAD, these fluctuations can be more pronounced and may lead to symptoms such as cold sweats, nausea, and fainting, as you've experienced. The episodes of your heart rate dropping to 41 and 28 beats per minute are concerning, especially since they are accompanied by significant hypotension and symptoms of near-syncope.

Possible Causes
1. Fluid Removal: Rapid removal of fluid during dialysis can lead to hypotension. This is particularly true if the patient is volume-depleted or if the ultrafiltration rate is too high.

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

3. Autonomic Dysfunction: Patients with chronic kidney disease often have autonomic dysfunction, which can impair the body's ability to regulate heart rate and blood pressure during dialysis.

4. Cardiac Ischemia: Given your history of CAD and the recent myocardial perfusion imaging results indicating ischemia, it is possible that the heart is not receiving adequate blood flow during dialysis, particularly if the right coronary artery is involved.

Recommendations
1. Monitoring: Continuous monitoring of blood pressure and heart rate during dialysis is crucial. If significant drops occur, the dialysis nurse should be alerted immediately to adjust the treatment.

2. Adjusting Dialysis Parameters: Discuss with your nephrologist the possibility of adjusting the ultrafiltration rate or the dialysis schedule to minimize fluid shifts. Slower dialysis sessions may help maintain hemodynamic stability.

3. Medication Review: Review your current medications with your healthcare provider. Some antihypertensive medications may need to be adjusted or temporarily held on dialysis days to prevent hypotension.

4. Electrolyte Management: Regular monitoring of electrolytes before and after dialysis can help identify imbalances that may contribute to your symptoms. If imbalances are found, your dialysis prescription may need to be adjusted.

5. Cardiology Consultation: Given the episodes of bradycardia and your history of CAD, a thorough evaluation by a cardiologist is warranted. This may include repeat coronary angiography to assess for any changes in coronary artery status, particularly in the right coronary artery, which was previously noted as having no significant stenosis.

6. Consideration of Pacemaker: If bradycardia persists and is symptomatic, a cardiologist may consider the placement of a pacemaker, especially if it is determined that the heart's conduction system is compromised.

Conclusion
Your symptoms during dialysis are significant and warrant a comprehensive approach involving both your nephrologist and cardiologist. It is essential to address the underlying causes of your blood pressure and heart rate drops to ensure your safety during dialysis and to optimize your overall cardiovascular health. Regular follow-ups and open communication with your healthcare team will be vital in managing your condition effectively.

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