Parameters of Systolic and Diastolic Dysfunction in Patients with Intradialytic Hypertension

Intradialytic hypertension (IH) is associated with elevated ambulatory blood pressure (BP), volume overload, and endothelial dysfunction, which may contribute to its increased morbidity/mortality. There is a paucity of data on cardiac structural and functional abnormalities in IH patients.

In a cross-sectional analysis among 83 Veterans on maintenance hemodialysis with transthoracic echocardiograms (TTEs), we analyzed all intradialytic BP measurements from 3 treatments before and 3 treatments after the TTE and defined IH as an intradialytic BP slope >0 mm Hg/min averaged over these treatments. We compared systolic and diastolic dysfunction prevalence, ejection fraction (EF), left ventricular mass index (LVMI), left atrial volume index (LAVI), and early transmitral flow velocity to early diastolic mitral annular velocity ratio (E/e') and used logistic regression to determine if IH is independently associated with E/e' >14, a key criteria for diagnosing diastolic dysfunction and assessing elevated filling pressure.

Mean age was 67.4 (±9.2) years. Most were men (n = 81), and 71% had diabetes. IH was present in 25 patients (30%), and they had higher prevalence of systolic dysfunction (52% vs. 17%, p = 0.003) and grade III diastolic dysfunction (16% vs. 2%, p = 0.03) reported on TTE compared to non-IH patients. IH patients had higher E/e' (18.5 [14-24] vs. 15.5 [11-19], p = 0.03), greater LVMI (137 [43] vs. 113 [38] mg/m2, p = 0.009), greater LAVI (52.7 [39-59] vs. 41.0 (33-48] mL/m2, p = 0.005), and lower EF (45.6% [17] vs. 55.7% [11], p = 0.002). IH associated with E/e' >14 in multiple models controlling for demographics, EF, mean intradialytic BP or CV comorbidities (OR 3.59-3.85, p < 0.05 for all); but in the model with LVMI, the association was blunted (OR 2.86, p = 0.1).

IH patients had a higher prevalence of TTE-reported systolic dysfunction and more severe diastolic dysfunction with more abnormalities than those without IH. IH independently associated with E/e' >14, even controlling for EF, intradialytic BP burden, and comorbid CV disease. Clinicians should consider TTE in IH patients to evaluate these abnormalities and optimize dialysis prescriptions and preventative pharmacologic therapies.