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      Detection of Autonomic Dysfunction in Hemodialysis Patients Using the Exercise Treadmill Test: The Role of the Chronotropic Index, Heart Rate Recovery, and R-R Variability

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          Abstract

          Autonomic dysfunction is highly prevalent in hemodialysis patients and has been implicated in their increased risk of cardiovascular mortality.

          Objective

          To evaluate the ability of different parameters of exercise treadmill test to detect autonomic dysfunction in hemodialysis patients.

          Methods

          Cross-sectional study involving hemodialysis patients and a control group. Clinical examination, blood sampling, echocardiogram, 24-hour Holter, and exercise treadmill test were performed. A ramp treadmill protocol symptom-limited with active recovery was employed.

          Results

          Forty-one hemodialysis patients and 41 controls concluded the study. There was significant difference between hemodialysis patients and controls in autonomic function parameters in 24h-Holter and exercise treadmill test. Probability of having autonomic dysfunction in hemodialysis patients compared to controls was 29.7 at the exercise treadmill test and 13.0 in the 24-hour Holter. Chronotropic index, heart rate recovery at the 1st min, and SDNN at exercise were used to develop an autonomic dysfunction score to grade autonomic dysfunction, in which, 83% of hemodialysis patients reached a scoring ≥2 in contrast to 20% of controls. Hemodialysis was independently associated with either altered chronotropic index or autonomic dysfunction scoring ≥2 in every tested model (OR=50.1, P=0.003; and OR=270.9, P=0.002, respectively, model 5).

          Conclusion

          The exercise treadmill test was feasible and useful to diagnose of the autonomic dysfunction in hemodialysis patients. Chronotropic index and autonomic dysfunction scoring ≥2 were the most effective parameters to differentiate between hemodialysis patients and controls suggesting that these variables portrays the best ability to detect autonomic dysfunction in this setting.

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          Most cited references33

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          Are there two types of malnutrition in chronic renal failure? Evidence for relationships between malnutrition, inflammation and atherosclerosis (MIA syndrome).

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            Chronotropic incompetence: causes, consequences, and management.

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              Heart rate recovery: validation and methodologic issues.

              The goal of this study was to validate the prognostic value of the drop in heart rate (HR) after exercise, compare it to other test responses, evaluate its diagnostic value and clarify some of the methodologic issues surrounding its use. Studies have highlighted the value of a new prognostic feature of the treadmill test-rate of recovery of HR after exercise. These studies have had differing as well as controversial results and did not consider diagnostic test characteristics. All patients were referred for evaluation of chest pain at two university-affiliated Veterans Affairs Medical Centers who underwent treadmill tests and coronary angiography between 1987 and 1999 as predicted after a mean seven years of follow-up. All-cause mortality was the end point for follow-up, and coronary angiography was the diagnostic gold standard. There were 2,193 male patients who had treadmill tests and coronary angiography. Heart rate recovery at 2 min after exercise outperformed other time points in prediction of death; a decrease of <22 beats/min had a hazard ratio of 2.6 (2.4 to 2.8 95% confidence interval). This new measurement was ranked similarly to traditional variables including age and metabolic equivalents but failed to have diagnostic power for discriminating those who had angiographic disease. Heart rate at 1 or 2 min of recovery has been validated as a prognostic measurement and should be recorded as part of all treadmill tests. This new measurement does not replace, but is supplemental to, established scores.
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                Author and article information

                Contributors
                Role: Academic Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                4 June 2015
                2015
                : 10
                : 6
                : e0128123
                Affiliations
                [1 ]Department of Medicine, Cardiology Division, Medical School, Universidade Federal Fluminense, Rio de Janeiro, Brazil
                [2 ]Department of Medicine, Nephrology Division, Medical School, Universidade Federal Fluminense, Rio de Janeiro, Brazil
                The University of Manchester, UNITED KINGDOM
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Conceived and designed the experiments: MAMQC ABN FMP MK RCR RRR JSM JRL. Performed the experiments: MAMQC ABN FMP MK RCR RRR JSM JRL. Analyzed the data: MAMQC ABN FMP MK RCR RRR JSM JRL. Contributed reagents/materials/analysis tools: MAMQC ABN FMP MK RCR RRR JSM JRL. Wrote the paper: MAMQC JSM JRL.

                Article
                PONE-D-14-45439
                10.1371/journal.pone.0128123
                4456158
                26042678
                445324ca-c30e-4470-9604-4d5b585a0418
                Copyright @ 2015

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited

                History
                : 17 October 2014
                : 22 April 2015
                Page count
                Figures: 1, Tables: 4, Pages: 11
                Funding
                This research was all supported by Fundação de Apoio à Pesquisa do Estado do Rio de Janeiro (FAPERJ) in doctoral program. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
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