title: Electrophysiologic Substrate and Risk of Mortality in Incident Hemodialysis.
abstract: The single leading cause of mortality on hemodialysis is sudden cardiac death. Whether measures of electrophysiologic substrate independently associate with mortality is unknown. We examined measures of electrophysiologic substrate in a prospective cohort of 571 patients on incident hemodialysis enrolled in the Predictors of Arrhythmic and Cardiovascular Risk in End Stage Renal Disease Study. A total of 358 participants completed both baseline 5-minute and 12-lead electrocardiogram recordings on a nondialysis day. Measures of electrophysiologic substrate included ventricular late potentials by the signal-averaged electrocardiogram and spatial mean QRS-T angle measured on the averaged beat recorded within a median of 106 days (interquartile range, 78-151 days) from dialysis initiation. The cohort was 59% men, and 73% were black, with a mean±SD age of 55±13 years. Transthoracic echocardiography revealed a mean±SD ejection fraction of 65.5%±12.0% and a mean±SD left ventricular mass index of 66.6±22.3 g/m2.7During 864.6 person-years of follow-up, 77 patients died; 35 died from cardiovascular causes, of which 15 were sudden cardiac deaths. By Cox regression analysis, QRS-T angle ≥75° significantly associated with increased risk of cardiovascular mortality (hazard ratio, 2.99; 95% confidence interval, 1.31 to 6.82) and sudden cardiac death (hazard ratio, 4.52; 95% confidence interval, 1.17 to 17.40) after multivariable adjustment for demographic, cardiovascular, and dialysis factors. Abnormal signal-averaged electrocardiogram measures did not associate with mortality. In conclusion, spatial QRS-T angle but not abnormal signal-averaged electrocardiogram significantly associates with cardiovascular mortality and sudden cardiac death independent of traditional risk factors in patients starting hemodialysis.
authors.affiliation: Knight Cardiovascular Institute and.|Division of Cardiology, Department of Medicine.
authors.forename: Larisa G
authors.initials: LG
authors.lastname: Tereshchenko
authors.affiliation: Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada.
authors.forename: Esther D
authors.initials: ED
authors.lastname: Kim
authors.affiliation: Department of Medicine, Oregon Health and Science University, Portland, Oregon.
authors.forename: Andrew
authors.initials: A
authors.lastname: Oehler
authors.affiliation: Departments of Biostatistics and.|Department of Medicine, and.|Welch Center for Prevention, Epidemiology, and Clinical Research, Baltimore, Maryland.
authors.forename: Lucy A
authors.initials: LA
authors.lastname: Meoni
authors.affiliation: Knight Cardiovascular Institute and.
authors.forename: Elyar
authors.initials: E
authors.lastname: Ghafoori
authors.affiliation: Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.
authors.forename: Tejal
authors.initials: T
authors.lastname: Rami
authors.affiliation: Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.
authors.forename: Maggie
authors.initials: M
authors.lastname: Maly
authors.affiliation: Knight Cardiovascular Institute and.
authors.forename: Muammar
authors.initials: M
authors.lastname: Kabir
authors.affiliation: Knight Cardiovascular Institute and.
authors.forename: Lauren
authors.initials: L
authors.lastname: Hawkins
authors.affiliation: Division of Cardiology, Department of Medicine.
authors.forename: Gordon F
authors.initials: GF
authors.lastname: Tomaselli
authors.affiliation: Division of Cardiology, Department of Medicine.
authors.forename: Joao A
authors.initials: JA
authors.lastname: Lima
authors.affiliation: Welch Center for Prevention, Epidemiology, and Clinical Research, Baltimore, Maryland.|Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.|Nephrology Center of Maryland, Baltimore, Maryland; and.|Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Bernard G
authors.initials: BG
authors.lastname: Jaar
authors.affiliation: Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.|Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Stephen M
authors.initials: SM
authors.lastname: Sozio
authors.affiliation: Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Michelle
authors.initials: M
authors.lastname: Estrella
authors.affiliation: Department of Medicine, and.|Welch Center for Prevention, Epidemiology, and Clinical Research, Baltimore, Maryland.|Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.
authors.forename: W H Linda
authors.initials: WH
authors.lastname: Kao
authors.affiliation: Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada; rulan.parekh@sickkids.ca.|Department of Medicine, and.|Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.|Division of Nephrology, Department of Pediatrics and Medicine, The Hospital for Sick Children, University Health Network and University of Toronto, Ontario, Canada.
authors.forename: Rulan S
authors.initials: RS
authors.lastname: Parekh
mesh_terms: D016757:Death, Sudden, Cardiac / Q000453:epidemiology*; D004562:Electrocardiography; D055724:Electrophysiological Phenomena; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D006435:Renal Dialysis / Q000401:mortality*; D012307:Risk Factors
keywords: Arrhythmia; Electrocardiogram; End stage renal disease; QRS-T angle; Sudden cardiac death; mortality