Rapid Hydration

Prevention of CIN in CKD

DR RAJESH PONNADA
CARDIOLOGY RESIDENT
APOLLO HOSPITAL, VISAKHAPATNAM
BACKGROUND Patients with chronic kidney disease (CKD) undergoing coronary
angiography (CAG) are at high risk of contrast-associated acute kidney injury (CA-
AKI) and mortality. Therefore, there is a clinical need to explore safe, convenient, and
effective strategies for preventing CA-AKI.
Patients with chronic kidney disease (CKD) undergoing coronary angiography(CAG)

• High risk of contrast-associated acute kidney injury (CA-AKI)

• 3-fold increased risk of mortality.

• Usually older in age with H/o T2DM, HTN, CHF

Standard Hydration (EACTS) guidelines

12 hours before to 24 hours after the procedure, ( at a rate of 1 mL/ kg/h )

Influences feasibility and is time-consuming.

Introduction

Syndrome of no obstructed
symptoms and coronary arteries
signs

INOCA

prognosis that is
clearly not Women >Men
benign
PREDICTORS OF ADVERSE OUTCOMES

Smoking Old Age

Increased

Mortality Risk
Mortality Risk
Non No Evident

Mortality Risk
Obstructive CAD
Diabetes Hypertension CAD
PATHOPHYSIOLOGY

Hypertension • Arterial stiffness is known to predict cardiovascular

Severe Aortic Stenosis events beyond traditional risk factors
Severe Anaemia
Type II MI
Shunt Lesions • The best markers of subclinical large artery stiffening were
Drugs aortic arch distensibility in younger individuals and aortic
arch pulse wave velocity after age 50
Heart Failure or Cardiogenic Shock
Prinzmetal Variant Angina(Coronary Spasm)
Myocardial Diseases
Congenital Heart Disease
Coronary Anamolies
Myocardial Bridging
 Atherosclerosis Pathophysiology

chronic inflammatory
lipid storage disease process
flow-limiting plaque
with large lipid pool periods of minor
resulting in vessel
thin fibrous cap plaque rupture,
occlusion
atheroma erosion, distal
embolism

• Almost all patients with INOCA with chronic angina studied by intravascular ultrasound
(IVUS) to date have some coronary atherosclerosis
 Coronary endothelial
dysfunction

Ectopic fat deposition
in cardiomyocytes
• Mitochondrial
functions
Impairments in
Dyslipidemia ventricular relaxation • Reactive oxygen
species signaling,

• Apoptosis

Metabolic shift Lower diastolic

away from free circumferential
fatty acids strain rate
Cardiac Autonomic Nervous System

Normal INOCA Symptoms

Abnormal vascular response to Sympathetically mediated
acetylcholine vasoconstriction
β-adrenergic induces
Vasodilation,
Defective bioavailable nitric experiencing mental stress–
oxide, prostacyclin induced angina,
exposure to cold triggers
α-adrenergic angina, rest angina, or
Increased smooth
vasoconstriction, early morning angina.
muscle cell sensitivity to
muscarinic
Muscarinic
vasoconstriction
Platelet Dysfunction or Other Coagulopathy

INOCA Increases Platelet

Receptor expression,
Increased leucocyte Platelet
Aggregate

Platelet reactivity

Exercise Reduced
Platelet Receptor
expression, Increased
leucocyte Platelet
Aggregate
 Mechanisms of Coronary Flow Regulation

Metabolite Vascular Smooth Coronary Blood

production Muscle Flow

Voltage-gated potassium channels (Kv1.5) are critical in

coupling myocardial blood flow to myocardial metabolism
 Coronary Microvascular Dysfunction • Coronary vasomotor dysfunction, even without flow-limiting stenosis,
identifies patients at risk for cardiac death

Epicardial, Microvascular Detected as reduced

endothelial, or coronary flow reserve Limits myocardial
nonendothelial perfusion
dysfunction (CFR)

Limited correlation between anatomic CAD severity and functional

impairment, as reflected in the CFR.
Coronary reactivity testing

• To diagnose CMD

• Defined as an invasive Doppler time-averaged peak hyperemic coronary flow

velocity/resting flow velocity <2.32,

• CFR was a continuous predictor of MACE

MACE Rate
CFRPET CFR <2.0 increased at
3 Years
WISE Study
CFR 5-year MACE CFR Annualized MACE rate
rate
Women Men
<2.32 27% <2 7.8% 5.6%
≥2.32 9.3%
≥2 3.3% 1.7%
Angiographic measures with increased risk for adverse outcomes

• number of major vessels involved

• WISE-CAD Severity Score

progressive, near-linear increases for each WISE CAD severity score range of 5, 5.1 to
10, 10.1 to 20, 20.1 to 50, and >50.
Cumulative 10-year
Normal Coronary Nonobstructive Cumulative 10-year
6.7% 12.8% Cumulative 10-year

• TIMI frame counts

DIAGNOSIS

Measurement of coronary vascular function

• CBF Exercise, pacing-induced tachycardia, cold pressor test,

and mental stress have also been used to elicit abnormalities in CBF

• Epicardial coronary artery diameter with endothelium-dependent probes—

acetylcholine, bradykinin, substance-P, and shear stress—and predominantly
endothelium-independent probes, adenosine and sodium nitroprusside.
Noninvasive Testing
Transthoracic Echo Cardiac Magnetic
Position Emission Doppler Resonance Imaging
Tomography
Coronary flow Failure of
PET is a highly velocity
subendocardial perfusion
accurate,reproduci By pulsed wave
ble Doppler of the LAD to increase appropriately
Evaluation of at rest and after in response to stress can
CBF,including dipyridamole, 26%
perfusion, left be detected by CMR
had coronary flow
ventricular imaging among subjects
function, and CFR velocity reserve
<2.0 with INOCA
MANAGEMENT

Statins,
Angiotensin-Converting Enzyme Antianginal Agents
Inhibitors,

INOCA

Non Pharmocological
Exercise
Antiplatelet Agents CBT
Transcendental Meditation
TENS
Thank you…..