Figure 9.1
Incidence of CHF in prevalent patients
CKD: point prevalent general Medicare CKD patients (from the 5 percent sample), age 66 & older & enrolled in Medicare for at least one year; adjusted for age, gender, race, & diabetic status. ESRD: point prevalent ESRD patients with Medicare as primary payor; adjusted for age, gender, race, & dialysis vintage.
Figure 9.2
Prevalence of CHF in prevalent patients
CKD: point prevalent general Medicare CKD patients (from the 5 percent sample), age 66 & older & enrolled in Medicare for at least one year; adjusted for age, gender, race, & diabetic status. ESRD: point prevalent ESRD patients with Medicare as primary payor; adjusted for age, gender, race, & dialysis vintage.
Figure 9.3
Demographics & comorbidity of incident patients with incident CHF
CKD: incident general Medicare CKD patients (from the 5 percent sample), age 66 & older, & enrolled in Medicare for at least one year; 2003–2005 combined. ESRD: incident Medicare dialysis & first transplant patients with Medicare as primary payor, 2003–2005 combined.
Figure 9.4
Demographics & comorbidity of prevalent patients with incident CHF
CKD: January 1, 2005, point prevalent general Medicare CKD patients (from the 5 percent sample), age 66 & older & enrolled in Medicare for at least one year. ESRD: January 1, 2005, point prevalent ESRD patients.
Figure 9.5
Probability of CHF in incident patients, overall
CKD: incident general Medicare CKD patients (from the 5 percent sample), age 66 & older, & enrolled in Medicare for at least one year, 2001–2003 combined. ESRD: incident ESRD patients with Medicare as primary payor, age 20 & older, 2001–2003 combined. Patients with CHF at baseline excluded. Overall probabilities unadjusted; in graphs by age, gender, race, & diabetic status, data for one factor adjusted for the remaining three; data by comorbidity adjusted for age, gender, race, & diabetic status.
Figure 9.6
Probability of CHF in incident patients, by age
CKD: incident general Medicare CKD patients (from the 5 percent sample), age 66 & older, & enrolled in Medicare for at least one year, 2001–2003 combined. ESRD: incident ESRD patients with Medicare as primary payor, age 20 & older, 2001–2003 combined. Patients with CHF at baseline excluded. Overall probabilities unadjusted; in graphs by age, gender, race, & diabetic status, data for one factor adjusted for the remaining three; data by comorbidity adjusted for age, gender, race, & diabetic status.
Figure 9.7
Probability of CHF in incident patients, by gender
CKD: incident general Medicare CKD patients (from the 5 percent sample), age 66 & older, & enrolled in Medicare for at least one year, 2001–2003 combined. ESRD: incident ESRD patients with Medicare as primary payor, age 20 & older, 2001–2003 combined. Patients with CHF at baseline excluded. Overall probabilities unadjusted; in graphs by age, gender, race, & diabetic status, data for one factor adjusted for the remaining three; data by comorbidity adjusted for age, gender, race, & diabetic status.
Figure 9.8
Probability of CHF in incident patients, by race
CKD: incident general Medicare CKD patients (from the 5 percent sample), age 66 & older, & enrolled in Medicare for at least one year, 2001–2003 combined. ESRD: incident ESRD patients with Medicare as primary payor, age 20 & older, 2001–2003 combined. Patients with CHF at baseline excluded. Overall probabilities unadjusted; in graphs by age, gender, race, & diabetic status, data for one factor adjusted for the remaining three; data by comorbidity adjusted for age, gender, race, & diabetic status.
Figure 9.9
Probability of CHF in incident patients, by diabetic status
CKD: incident general Medicare CKD patients (from the 5 percent sample), age 66 & older, & enrolled in Medicare for at least one year, 2001–2003 combined. ESRD: incident ESRD patients with Medicare as primary payor, age 20 & older, 2001–2003 combined. Patients with CHF at baseline excluded. Overall probabilities unadjusted; in graphs by age, gender, race, & diabetic status, data for one factor adjusted for the remaining three; data by comorbidity adjusted for age, gender, race, & diabetic status.
Figure 9.10
Probability of CHF in incident patients, by comorbidity
CKD: incident general Medicare CKD patients (from the 5 percent sample), age 66 & older, & enrolled in Medicare for at least one year, 2001–2003 combined. ESRD: incident ESRD patients with Medicare as primary payor, age 20 & older, 2001–2003 combined. Patients with CHF at baseline excluded. Overall probabilities unadjusted; in graphs by age, gender, race, & diabetic status, data for one factor adjusted for the remaining three; data by comorbidity adjusted for age, gender, race, & diabetic status.
Figure 9.11
Probability of CHF in prevalent patients, overall
CKD: January 1, 2003 point prevalent general Medicare CKD patients (from the 5 percent sample), age 66 & older, & enrolled in Medicare for at least one year. ESRD: January 1, 2003 point prevalent Medicare ESRD patients, age 20 & older. Patients with CHF at baseline excluded. Overall probabilities unadjusted; in graphs by age, gender, race, & diabetic status, data for one factor adjusted for the remaining three; data by comorbidity adjusted for age, gender, race, & diabetic status.
Figure 9.12
Probability of CHF in prevalent patients, by age
CKD: January 1, 2003 point prevalent general Medicare CKD patients (from the 5 percent sample), age 66 & older, & enrolled in Medicare for at least one year. ESRD: January 1, 2003 point prevalent Medicare ESRD patients, age 20 & older. Patients with CHF at baseline excluded. Overall probabilities unadjusted; in graphs by age, gender, race, & diabetic status, data for one factor adjusted for the remaining three; data by comorbidity adjusted for age, gender, race, & diabetic status.
Figure 9.13
Probability of CHF in prevalent patients, by gender
CKD: January 1, 2003 point prevalent general Medicare CKD patients (from the 5 percent sample), age 66 & older, & enrolled in Medicare for at least one year. ESRD: January 1, 2003 point prevalent Medicare ESRD patients, age 20 & older. Patients with CHF at baseline excluded. Overall probabilities unadjusted; in graphs by age, gender, race, & diabetic status, data for one factor adjusted for the remaining three; data by comorbidity adjusted for age, gender, race, & diabetic status.
Figure 9.14
Probability of CHF in prevalent patients, by race
CKD: January 1, 2003 point prevalent general Medicare CKD patients (from the 5 percent sample), age 66 & older, & enrolled in Medicare for at least one year. ESRD: January 1, 2003 point prevalent Medicare ESRD patients, age 20 & older. Patients with CHF at baseline excluded. Overall probabilities unadjusted; in graphs by age, gender, race, & diabetic status, data for one factor adjusted for the remaining three; data by comorbidity adjusted for age, gender, race, & diabetic status.
Figure 9.15
Probability of CHF in prevalent patients, by diabetic status
CKD: January 1, 2003 point prevalent general Medicare CKD patients (from the 5 percent sample), age 66 & older, & enrolled in Medicare for at least one year. ESRD: January 1, 2003 point prevalent Medicare ESRD patients, age 20 & older. Patients with CHF at baseline excluded. Overall probabilities unadjusted; in graphs by age, gender, race, & diabetic status, data for one factor adjusted for the remaining three; data by comorbidity adjusted for age, gender, race, & diabetic status.
Figure 9.16
Probability of CHF in prevalent patients, by comorbidity
CKD: January 1, 2003 point prevalent general Medicare CKD patients (from the 5 percent sample), age 66 & older, & enrolled in Medicare for at least one year. ESRD: January 1, 2003 point prevalent Medicare ESRD patients, age 20 & older. Patients with CHF at baseline excluded. Overall probabilities unadjusted; in graphs by age, gender, race, & diabetic status, data for one factor adjusted for the remaining three; data by comorbidity adjusted for age, gender, race, & diabetic status.
Figure 9.17
Cumulative percentage of patients receiving stress tests
Incident CHF patients with Medicare as primary payor. CKD patients: age 66 & older; ESRD patients: age 20 & older.
Figure 9.18
Cumulative percentage of patients receiving coronary angiography
Incident CHF patients with Medicare as primary payor. CKD patients: age 66 & older; ESRD patients: age 20 & older.
Figure 9.19
Cumulative percentage of patients receiving stress tests/coronary angiography
Incident CHF patients with Medicare as primary payor. CKD patients: age 66 & older; ESRD patients: age 20 & older.
Figure 9.20
Cumulative percentage of patients receiving coronary echocardiograms
Incident CHF patients with Medicare as primary payor. CKD patients: age 66 & older; ESRD patients: age 20 & older.
Figure 9.21
Cumulative percentage of patients receiving revascularization: PCI
Incident CHF patients with Medicare as primary payor. CKD patients: age 66 & older; ESRD patients: age 20 & older.
Figure 9.22
Cumulative percentage of patients receiving revascularization: surgical
Incident CHF patients with Medicare as primary payor. CKD patients: age 66 & older; ESRD patients: age 20 & older.
Figure 9.23
Medicare beneficiaries receiving cardiovascular medications, by diabetic status
Patients in the Medicare Current Beneficiary Survey (Cost & Use data file), age 65 & older. See Appendix A for further details.
Figure 9.24
Cumulative percentage of patients receiving ICDs/CRT-Ds
Incident CHF patients with Medicare as primary payor. CKD patients: age 66 & older; ESRD patients: age 20 & older.
Figure 9.25
Survival after CHF in incident patients, overall
CKD: incident general Medicare CKD patients (from the 5 percent sample) with incident CHF, age 66 & older, & enrolled in Medicare for at least one year, 2002. ESRD: incident Medicare dialysis patients & first transplant patients with incident CHF, age 20 & older, with Medicare as primary payor, 2002. Overall probabilities unadjusted; in graphs by age, gender, race, & diabetic status, data for one factor adjusted for the remaining three; data by comorbidity adjusted for age, gender, race, & diabetic status.
Figure 9.26
Survival after CHF in incident patients, by age
CKD: incident general Medicare CKD patients (from the 5 percent sample) with incident CHF, age 66 & older, & enrolled in Medicare for at least one year, 2002. ESRD: incident Medicare dialysis patients & first transplant patients with incident CHF, age 20 & older, with Medicare as primary payor, 2002. Overall probabilities unadjusted; in graphs by age, gender, race, & diabetic status, data for one factor adjusted for the remaining three; data by comorbidity adjusted for age, gender, race, & diabetic status.
Figure 9.27
Survival after CHF in incident patients, by gender
CKD: incident general Medicare CKD patients (from the 5 percent sample) with incident CHF, age 66 & older, & enrolled in Medicare for at least one year, 2002. ESRD: incident Medicare dialysis patients & first transplant patients with incident CHF, age 20 & older, with Medicare as primary payor, 2002. Overall probabilities unadjusted; in graphs by age, gender, race, & diabetic status, data for one factor adjusted for the remaining three; data by comorbidity adjusted for age, gender, race, & diabetic status.
Figure 9.28
Survival after CHF in incident patients, by race
CKD: incident general Medicare CKD patients (from the 5 percent sample) with incident CHF, age 66 & older, & enrolled in Medicare for at least one year, 2002. ESRD: incident Medicare dialysis patients & first transplant patients with incident CHF, age 20 & older, with Medicare as primary payor, 2002. Overall probabilities unadjusted; in graphs by age, gender, race, & diabetic status, data for one factor adjusted for the remaining three; data by comorbidity adjusted for age, gender, race, & diabetic status.
Figure 9.29
Survival after CHF in incident patients, by diabetic status
CKD: incident general Medicare CKD patients (from the 5 percent sample) with incident CHF, age 66 & older, & enrolled in Medicare for at least one year, 2002. ESRD: incident Medicare dialysis patients & first transplant patients with incident CHF, age 20 & older, with Medicare as primary payor, 2002. Overall probabilities unadjusted; in graphs by age, gender, race, & diabetic status, data for one factor adjusted for the remaining three; data by comorbidity adjusted for age, gender, race, & diabetic status.
Figure 9.30
Survival after CHF in incident patients, by comorbidity
CKD: incident general Medicare CKD patients (from the 5 percent sample) with incident CHF, age 66 & older, & enrolled in Medicare for at least one year, 2002. ESRD: incident Medicare dialysis patients & first transplant patients with incident CHF, age 20 & older, with Medicare as primary payor, 2002. Overall probabilities unadjusted; in graphs by age, gender, race, & diabetic status, data for one factor adjusted for the remaining three; data by comorbidity adjusted for age, gender, race, & diabetic status.
Figure 9.31
Survival after CHF in prevalent patients, overall
CKD: January 1, 2003 point prevalent general Medicare CKD patients (from the 5 percent sample) with incident CHF, age 66 & older, & enrolled in Medicare for at least one year. ESRD: January 1, 2003 point prevalent Medicare ESRD patients with incident CHF, age 20 & older. Overall probabilities unadjusted; in graphs by age, gender, race, & diabetic status, data for one factor adjusted for the remaining three; data by comorbidity adjusted for age, gender, race, & diabetic status.
Figure 9.32
Survival after CHF in prevalent patients, by age
CKD: January 1, 2003 point prevalent general Medicare CKD patients (from the 5 percent sample) with incident CHF, age 66 & older, & enrolled in Medicare for at least one year. ESRD: January 1, 2003 point prevalent Medicare ESRD patients with incident CHF, age 20 & older. Overall probabilities unadjusted; in graphs by age, gender, race, & diabetic status, data for one factor adjusted for the remaining three; data by comorbidity adjusted for age, gender, race, & diabetic status.
Figure 9.33
Survival after CHF in prevalent patients, by gender
CKD: January 1, 2003 point prevalent general Medicare CKD patients (from the 5 percent sample) with incident CHF, age 66 & older, & enrolled in Medicare for at least one year. ESRD: January 1, 2003 point prevalent Medicare ESRD patients with incident CHF, age 20 & older. Overall probabilities unadjusted; in graphs by age, gender, race, & diabetic status, data for one factor adjusted for the remaining three; data by comorbidity adjusted for age, gender, race, & diabetic status.
Figure 9.34
Survival after CHF in prevalent patients, by race
CKD: January 1, 2003 point prevalent general Medicare CKD patients (from the 5 percent sample) with incident CHF, age 66 & older, & enrolled in Medicare for at least one year. ESRD: January 1, 2003 point prevalent Medicare ESRD patients with incident CHF, age 20 & older. Overall probabilities unadjusted; in graphs by age, gender, race, & diabetic status, data for one factor adjusted for the remaining three; data by comorbidity adjusted for age, gender, race, & diabetic status.
Figure 9.35
Survival after CHF in prevalent patients, by diabetic status
CKD: January 1, 2003 point prevalent general Medicare CKD patients (from the 5 percent sample) with incident CHF, age 66 & older, & enrolled in Medicare for at least one year. ESRD: January 1, 2003 point prevalent Medicare ESRD patients with incident CHF, age 20 & older. Overall probabilities unadjusted; in graphs by age, gender, race, & diabetic status, data for one factor adjusted for the remaining three; data by comorbidity adjusted for age, gender, race, & diabetic status.
Figure 9.36
Survival after CHF in prevalent patients, by comorbidity
CKD: January 1, 2003 point prevalent general Medicare CKD patients (from the 5 percent sample) with incident CHF, age 66 & older, & enrolled in Medicare for at least one year. ESRD: January 1, 2003 point prevalent Medicare ESRD patients with incident CHF, age 20 & older. Overall probabilities unadjusted; in graphs by age, gender, race, & diabetic status, data for one factor adjusted for the remaining three; data by comorbidity adjusted for age, gender, race, & diabetic status.
Figure 9.37
Trends in one-year survival after CHF diagnosis in incident patients, overall
CKD: incident general Medicare CKD patients (from the 5 percent sample) with incident CHF, age 66 & older, & enrolled in Medicare for at least one year. ESRD: incident Medicare dialysis patients & first transplant patients with incident CHF, age 20 & older, with Medicare as primary payor. Overall probabilities unadjusted; rates by race adjusted for age, gender, & diabetic status; rates by diabetic status adjusted for age, gender, & race.
Figure 9.38
Trends in one-year survival after CHF diagnosis in incident patients, by race
CKD: incident general Medicare CKD patients (from the 5 percent sample) with incident CHF, age 66 & older, & enrolled in Medicare for at least one year. ESRD: incident Medicare dialysis patients & first transplant patients with incident CHF, age 20 & older, with Medicare as primary payor. Overall probabilities unadjusted; rates by race adjusted for age, gender, & diabetic status; rates by diabetic status adjusted for age, gender, & race.
Figure 9.39
Trends in one-year survival after CHF diagnosis in incident patients, by diabetic status
CKD: incident general Medicare CKD patients (from the 5 percent sample) with incident CHF, age 66 & older, & enrolled in Medicare for at least one year. ESRD: incident Medicare dialysis patients & first transplant patients with incident CHF, age 20 & older, with Medicare as primary payor. Overall probabilities unadjusted; rates by race adjusted for age, gender, & diabetic status; rates by diabetic status adjusted for age, gender, & race.
Figure 9.40
Trends in one-year survival after CHF diagnosis in prevalent patients, overall
CKD: January 1 point prevalent general Medicare CKD patients (from the 5 percent sample) with incident CHF, age 66 & older, & enrolled in Medicare for at least one year. ESRD: January 1 point prevalent Medicare ESRD patients with incident CHF, age 20 & older. Overall probabilities unadjusted; rates by race adjusted for age, gender, & diabetic status; rates by diabetic status adjusted for age, gender, & race.
Figure 9.41
Trends in one-year survival after CHF diagnosis in prevalent patients, by race
CKD: January 1 point prevalent general Medicare CKD patients (from the 5 percent sample) with incident CHF, age 66 & older, & enrolled in Medicare for at least one year. ESRD: January 1 point prevalent Medicare ESRD patients with incident CHF, age 20 & older. Overall probabilities unadjusted; rates by race adjusted for age, gender, & diabetic status; rates by diabetic status adjusted for age, gender, & race.
Figure 9.42
Trends in one-year survival after CHF diagnosis in prevalent patients, by diabetic status
CKD: January 1 point prevalent general Medicare CKD patients (from the 5 percent sample) with incident CHF, age 66 & older, & enrolled in Medicare for at least one year. ESRD: January 1 point prevalent Medicare ESRD patients with incident CHF, age 20 & older. Overall probabilities unadjusted; rates by race adjusted for age, gender, & diabetic status; rates by diabetic status adjusted for age, gender, & race.
Figure 9.43
Survival after treatment for CHF, by type of treatment
Incident CHF patients, 1996–2003, with Medicare as primary payor & receiving treatment within one year after CHF diagnosis, unadjusted. CKD patients: age 66 & older; ESRD patients: age 20 & older.
Figure 9.44
One-year L-carnitine use in CHF patients
Incident & January 1 point prevalent CHF patients on hemodialysis, age 20 & older, with Medicare as primary payor. L-carnitine use in one year following CHF diagnosis (incident CHF patients) or in each calendar year (point prevalent CHF patients).
Figure 9.45
Survival in CHF patients, by initial (3-month) L-carnitine use
Incident CHF patients on hemodialysis, age 20 & older, 1998–2003, with Medicare as primary payor, unadjusted. L-carnitine use in three months following CHF diagnosis.
Figure 9.46
Patients receiving an implantable cardioverter defibrillator (ICD) or cardiac resynchronization therapy + defibrillator (CRT-D)
CKD & non-CKD: prevalent general Medicare patients (from the 5 percent sample), age 66 & older, & enrolled in Medicare for at least one year prior to January 1 of each year, 1993–2005. ESRD: period prevalent patients, age 20 & older, with Medicare as primary payor.
Figure 9.47
Cardiovascular disease, cerebrovascular disease, & coronary revascularization in patients receiving ICDs/CRT-Ds / first ICD/CRT-D recipients
Recipients of first ICD/CRT-D during 1996–2005, age 66 & older (CKD & non-CKD patients, from the general Medicare 5 percent sample) or 20 & older (ESRD patients) on the date of ICD/CRT-D & with Medicare as primary payor. Survival probabilities are unadjusted. *Age groups for CKD & non-CKD patients: 66–74 & 75+.
Figure 9.48
Demographics & comorbidity of patients receiving ICDs/CRT-Ds / first ICD/CRT-D recipients
Recipients of first ICD/CRT-D during 1996–2005, age 66 & older (CKD & non-CKD patients, from the general Medicare 5 percent sample) or 20 & older (ESRD patients) on the date of ICD/CRT-D & with Medicare as primary payor. Survival probabilities are unadjusted. *Age groups for CKD & non-CKD patients: 66–74 & 75+.
Figure 9.49
Stress testing prior to ICD/CRT-D use / first ICD/CRT-D recipients
Recipients of first ICD/CRT-D during 1996–2005, age 66 & older (CKD & non-CKD patients, from the general Medicare 5 percent sample) or 20 & older (ESRD patients) on the date of ICD/CRT-D & with Medicare as primary payor. Survival probabilities are unadjusted. *Age groups for CKD & non-CKD patients: 66–74 & 75+.
Figure 9.50
Coronary angiography prior to ICD/CRT-D use / first ICD/CRT-D recipients
Recipients of first ICD/CRT-D during 1996–2005, age 66 & older (CKD & non-CKD patients, from the general Medicare 5 percent sample) or 20 & older (ESRD patients) on the date of ICD/CRT-D & with Medicare as primary payor. Survival probabilities are unadjusted. *Age groups for CKD & non-CKD patients: 66–74 & 75+.
Figure 9.51
Stress testing/coronary angiography prior to ICD/CRT-D use / first ICD/CRT-D recipients
Recipients of first ICD/CRT-D during 1996–2005, age 66 & older (CKD & non-CKD patients, from the general Medicare 5 percent sample) or 20 & older (ESRD patients) on the date of ICD/CRT-D & with Medicare as primary payor. Survival probabilities are unadjusted. *Age groups for CKD & non-CKD patients: 66–74 & 75+.
Figure 9.52
Echocardiograms prior to ICD/CRT-D use / first ICD/CRT-D recipients
Recipients of first ICD/CRT-D during 1996–2005, age 66 & older (CKD & non-CKD patients, from the general Medicare 5 percent sample) or 20 & older (ESRD patients) on the date of ICD/CRT-D & with Medicare as primary payor. Survival probabilities are unadjusted. *Age groups for CKD & non-CKD patients: 66–74 & 75+.
Figure 9.53
All-cause survival after implantation of ICD/CRT-D / first ICD/CRT-D recipients
Recipients of first ICD/CRT-D during 1996–2005, age 66 & older (CKD & non-CKD patients, from the general Medicare 5 percent sample) or 20 & older (ESRD patients) on the date of ICD/CRT-D & with Medicare as primary payor. Survival probabilities are unadjusted. *Age groups for CKD & non-CKD patients: 66–74 & 75+.
2007 Anual Data Repot (ADR) Text Based
Atlas of End-Stage Renal Disease in the United States

 

9 - Cardiovascular Special Studies

Introduction

The single largest cause of hospitalizations in the U.S. Medicare population is congestive heart failure. CHF is a major cause of morbidity and mortality in elderly patients, and, as we show here, is a key component of cardiovascular morbidity and mortality across the spectrum of renal disease (here including dialysis and transplant patients, and elderly non-ESRD patients with CKD). Figures 9.1 and 9.2 show that the incidence and prevalence of CHF in prevalent patients have been fairly constant over the last decade. Prevalent CHF was reported in 48.1 and 55.8 percent of CKD and hemodialysis patients in 2005. It is noteworthy that the prevalence of CHF in prevalent CKD patients actually exceeds that occurring in some ESRD cohorts. As CHF is a powerful independent predictor of mortality in all patient populations, it should be no surprise that CKD patients are also characterized by high rates of mortality. In some respects, the survival characteristics of an elderly CKD population more closely resemble those of ESRD patients than of other elderly patients without renal disease.
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Figures 9.3 and 9.4 summarize the characteristics of incident and prevalent patients with CHF. In all groups, hypertension is the most common cardiovascular comorbidity. And in each of the prevalent cohorts, more than 50 percent of patients are diabetic, emphasizing the strong known association of diabetes mellitus and CHF in the general population.

We next provide a detailed overview of the likelihood of developing CHF in incident and prevalent patients. The cumulative probability of CHF in the incident population is highest in CKD and hemodialysis patients, at six months reaching 26.8 and 30.3 percent, respectively. At two years it rises to 39.5 percent in CKD patients, and 55.9 percent, 40.8 percent, and 18.2 percent in hemodialysis, peritoneal dialysis, and renal transplant patients. And by three years, approximately two-thirds of incident hemodialysis patients develop CHF.

In each cohort, progressively older age and diabetes are both associated with a higher likelihood of the disease. In the incident peritoneal dialysis population, for example, the three-year probability of CHF is 43.2 percent for non-diabetic patients, but 61.7 percent for those with diabetes. In the prevalent population, the probability of CHF in patients age 20–44 is 41.3 percent for those on hemodialysis and 34.4 percent for those on peritoneal dialysis, but only 10.9 percent for those with a transplant.

In relation to cardiovascular comorbidity, the greatest probability of developing CHF is associated with a history of myocardial infarction—at three years, 60.9 percent for CKD patients, 74.7 percent for those on hemodialysis, and 70.9 and 43.9 percent for those on peritoneal dialysis or with a functioning transplant. Although patients across the spectrum of renal disease are at risk for CHF, those with a history of AMI clearly have a heightened vulnerability. We show similar trends for the prevalent population, though here the overall probability of CHF is greatest for those on hemodialysis—29.4 percent at one year, compared to 20.3 percent for those on peritoneal dialysis, 17.3 percent for those with CKD, and only 5.0 percent in transplant recipients.

Next we examine the diagnostic evaluation of patients and their treatment. One goal of the Cardiovascular Special Studies Center is to monitor the impact of treatment guidelines relating to cardiovascular disease in patients with renal disease. In April, 2005, the National Kidney Foundation published its K/DOQI Clinical Practice Guidelines for Cardiovascular Disease in Dialysis Patients. Guideline 6 recommends that all dialysis patients with diagnosed CHF be evaluated by echocardiography; Guideline 2.1.b recommends evaluation for coronary artery disease in dialysis patients with CHF who are unresponsive to changes in target dry weight. We thus illustrate here trends in the use of echocardiography and evaluation of ischemic heart disease, and look as well at the use of coronary revascularization, cardiovascular medications, and implantable cardioverter defibrillators (ICDs) and cardiac resynchronization therapy + defibrillator (CRT-D).

The fifth spread is a detailed analysis of survival after diagnosis of CHF in both incident and prevalent populations. We focus on temporal trends in one-year survival over more than a decade, and on survival of CHF patients after invasive therapies (coronary revascularization and ICD/CRT-D), and provide a brief overview of a previously unexplored topic, L-carnitine use in hemodialysis patients with CHF.

The final spread looks back to our chapter in the 2006 ADR, as it focuses on cardiac device therapy: ICDs and CRT-D. As reported previously by the CVSSC, sudden cardiac death is the single largest cause of mortality in dialysis patients, and an important contributor to death in all patients with CKD. In the general population, device therapy has become an increasingly important aspect of the treatment of patients with CHF.

One clinical point of note is the extraordinary difficulty of distinguishing between CHF and circulatory congestion (“volume overload”) in patients with diminished renal function. Particularly in dialysis patients, it can be a Herculean task for practitioners to accurately distinguish between CHF and volume overload, because they may be clinically indistinguishable. Similarly, the accurate identification of dialysis patients with “diastolic heart failure” (versus circulatory congestion) is a daunting challenge.

Characteristics of patients with CHF  Top

Figures 9.3 and 9.4 summarize the characteristics of incident and prevalent CKD and ESRD patients with congestive heart failure (CHF).

Sixty-four and 61 percent, respectively, of incident hemodialysis and peritoneal dialysis patients are age 65 or older, in contrast to the transplant population, in which nearly 72 percent of patients are younger than  65. The incident CKD population studied here is comprised of patients age 66 and older; of these, 73 percent are age 75 and older.

The prevalent dialysis population with CHF tends to be somewhat younger—51 and 44 percent of hemodialysis and peritoneal dialysis patients with CHF, for example, are 65 or older.

In the incident hemodialysis, peritoneal dialysis, and transplant populations with incident CHF, there is a larger proportion of males than of females, at 52.1, 55.2, and 61.0 percent, respectively. In the CKD population, in contrast, the proportion of females is slightly higher, at 52.1 percent. Gender breakdowns in the prevalent populations tend to be similar to those found for incident patients.

Patient distribution by race also differs across populations. Eighty-five percent of incident CKD patients with incident CHF, for instance, are white, compared to just 61.4 percent of their counterparts with a transplant, and 64.6 and 77.2 percent of those on hemodialysis and peritoneal dialysis.

More than half the patients in each of the prevalent cohorts have diabetes, emphasizing the strong known association of diabetes mellitus and CHF in the general population. In the incident CKD cohort, however, the proportion of patients with no diabetes is nearly twice that of those with the disease—62.3 versus 37.7 percent.

 In all groups of patients, the most common cardiovascular comorbid condition is hypertension, with proportions ranging from 75 to 78 percent and 51 to 89 percent, respectively, in the incident and prevalent cohorts.

Peripheral vascular disease (PVD) is the next most common condition, most evident in incident hemodialysis patients at 45.9 percent. The percent of patients with PVD in the incident CKD, peritoneal dialysis, and transplant cohorts is 27.3, 33.9, and 30.1, respectively.

Probability of CHF in incident & prevalent patients  Top

Figures not mentioned in text.

Figures 9.5 - Probability of CHF in incident patients, overall
CKD: incident general Medicare CKD patients (from the 5 percent sample), age 66 & older, & enrolled in Medicare for at least one year, 2001–2003 combined. ESRD: incident ESRD patients with Medicare as primary payor, age 20 & older, 2001–2003 combined. Patients with CHF at baseline excluded. Overall probabilities unadjusted; in graphs by age, gender, race, & diabetic status, data for one factor adjusted for the remaining three; data by comorbidity adjusted for age, gender, race, & diabetic status.

Figures 9.6 - Probability of CHF in incident patients, by age
CKD: incident general Medicare CKD patients (from the 5 percent sample), age 66 & older, & enrolled in Medicare for at least one year, 2001–2003 combined. ESRD: incident ESRD patients with Medicare as primary payor, age 20 & older, 2001–2003 combined. Patients with CHF at baseline excluded. Overall probabilities unadjusted; in graphs by age, gender, race, & diabetic status, data for one factor adjusted for the remaining three; data by comorbidity adjusted for age, gender, race, & diabetic status.

Figures 9.7 - Probability of CHF in incident patients, by gender
CKD: incident general Medicare CKD patients (from the 5 percent sample), age 66 & older, & enrolled in Medicare for at least one year, 2001–2003 combined. ESRD: incident ESRD patients with Medicare as primary payor, age 20 & older, 2001–2003 combined. Patients with CHF at baseline excluded. Overall probabilities unadjusted; in graphs by age, gender, race, & diabetic status, data for one factor adjusted for the remaining three; data by comorbidity adjusted for age, gender, race, & diabetic status.

Figures 9.8 - Probability of CHF in incident patients, by race
CKD: incident general Medicare CKD patients (from the 5 percent sample), age 66 & older, & enrolled in Medicare for at least one year, 2001–2003 combined. ESRD: incident ESRD patients with Medicare as primary payor, age 20 & older, 2001–2003 combined. Patients with CHF at baseline excluded. Overall probabilities unadjusted; in graphs by age, gender, race, & diabetic status, data for one factor adjusted for the remaining three; data by comorbidity adjusted for age, gender, race, & diabetic status.

Figures 9.9 - Probability of CHF in incident patients, by diabetic status
CKD: incident general Medicare CKD patients (from the 5 percent sample), age 66 & older, & enrolled in Medicare for at least one year, 2001–2003 combined. ESRD: incident ESRD patients with Medicare as primary payor, age 20 & older, 2001–2003 combined. Patients with CHF at baseline excluded. Overall probabilities unadjusted; in graphs by age, gender, race, & diabetic status, data for one factor adjusted for the remaining three; data by comorbidity adjusted for age, gender, race, & diabetic status.

Figures 9.10 - Probability of CHF in incident patients, by comorbidity
CKD: incident general Medicare CKD patients (from the 5 percent sample), age 66 & older, & enrolled in Medicare for at least one year, 2001–2003 combined. ESRD: incident ESRD patients with Medicare as primary payor, age 20 & older, 2001–2003 combined. Patients with CHF at baseline excluded. Overall probabilities unadjusted; in graphs by age, gender, race, & diabetic status, data for one factor adjusted for the remaining three; data by comorbidity adjusted for age, gender, race, & diabetic status.

Figures 9.11 - Probability of CHF in prevalent patients, overall
CKD: January 1, 2003 point prevalent general Medicare CKD patients (from the 5 percent sample), age 66 & older, & enrolled in Medicare for at least one year. ESRD: January 1, 2003 point prevalent Medicare ESRD patients, age 20 & older. Patients with CHF at baseline excluded. Overall probabilities unadjusted; in graphs by age, gender, race, & diabetic status, data for one factor adjusted for the remaining three; data by comorbidity adjusted for age, gender, race, & diabetic status.

Figures 9.12 - Probability of CHF in prevalent patients, by age
CKD: January 1, 2003 point prevalent general Medicare CKD patients (from the 5 percent sample), age 66 & older, & enrolled in Medicare for at least one year. ESRD: January 1, 2003 point prevalent Medicare ESRD patients, age 20 & older. Patients with CHF at baseline excluded. Overall probabilities unadjusted; in graphs by age, gender, race, & diabetic status, data for one factor adjusted for the remaining three; data by comorbidity adjusted for age, gender, race, & diabetic status.

Figures 9.13 - Probability of CHF in prevalent patients, by gender
CKD: January 1, 2003 point prevalent general Medicare CKD patients (from the 5 percent sample), age 66 & older, & enrolled in Medicare for at least one year. ESRD: January 1, 2003 point prevalent Medicare ESRD patients, age 20 & older. Patients with CHF at baseline excluded. Overall probabilities unadjusted; in graphs by age, gender, race, & diabetic status, data for one factor adjusted for the remaining three; data by comorbidity adjusted for age, gender, race, & diabetic status.

Figures 9.14 - Probability of CHF in prevalent patients, by race
CKD: January 1, 2003 point prevalent general Medicare CKD patients (from the 5 percent sample), age 66 & older, & enrolled in Medicare for at least one year. ESRD: January 1, 2003 point prevalent Medicare ESRD patients, age 20 & older. Patients with CHF at baseline excluded. Overall probabilities unadjusted; in graphs by age, gender, race, & diabetic status, data for one factor adjusted for the remaining three; data by comorbidity adjusted for age, gender, race, & diabetic status.

Figures 9.15 - Probability of CHF in prevalent patients, by diabetic status
CKD: January 1, 2003 point prevalent general Medicare CKD patients (from the 5 percent sample), age 66 & older, & enrolled in Medicare for at least one year. ESRD: January 1, 2003 point prevalent Medicare ESRD patients, age 20 & older. Patients with CHF at baseline excluded. Overall probabilities unadjusted; in graphs by age, gender, race, & diabetic status, data for one factor adjusted for the remaining three; data by comorbidity adjusted for age, gender, race, & diabetic status.

Figures 9.16 - Probability of CHF in prevalent patients, by comorbidity
CKD: January 1, 2003 point prevalent general Medicare CKD patients (from the 5 percent sample), age 66 & older, & enrolled in Medicare for at least one year. ESRD: January 1, 2003 point prevalent Medicare ESRD patients, age 20 & older. Patients with CHF at baseline excluded. Overall probabilities unadjusted; in graphs by age, gender, race, & diabetic status, data for one factor adjusted for the remaining three; data by comorbidity adjusted for age, gender, race, & diabetic status.

Diagnosis & treatment of CHF  Top

The use of non-invasive stress tests and invasive coronary angiography in patients with incident congestive heart failure has increased (Figures 9.17, 9.18, 9.19, and 9.20). In 2004, for example, 26 percent of CKD patients with incident CHF received an evaluation for ischemic heart disease within one year of diagnosis, up from 18.7 percent in 1996; in the hemodialysis population, the percentage rose from 26.3 to 40.7. The lowest rates of testing are those for coronary angiography in CKD patients, a finding likely related to fears of contrast nephropathy as a complication. We suspect that efforts to ameliorate this result will be paralleled by increased use of diagnostic procedures employing radiocontrast media.

Paralleling this increased evaluation for ischemic heart disease is a rising use of coronary revascularization in CHF patients with CKD and ESRD (Figures 9.21 and 9.22). Reflecting national trends in the general population, the use of percutaneous versus surgical revascularization has grown. The cumulative percentage of hemodialysis patients receiving PCI in the first three years, for example, has nearly doubled, from 4.4 percent in the 1996 cohort to 8.4 percent in 2002 patients, while use of surgical revascularization has grown just from 4.2 to 5.2 percent.

Medicare Current Beneficiary Survey data provide a snapshot of the use of potentially cardioprotective medications in diabetic and non-diabetic beneficiaries (Figure 9.23). The largest changes have occurred in the prescription of ACE-Is/ARBs and lipid lowering agents to diabetic patients, between 1992 and 2003 rising from 25.9 to 63.3 percent and 11.0 to 51.0 percent, respectively.

As shown in Figure 9.24, the use of cardiac device therapy has increased, but, even in the most recent cohort year of 2004, relatively few patients with CHF and diminished renal function received either ICD or CRT-D devices. In that year, within one year of CHF diagnosis, 1.0 percent of CKD patients, 1.2 percent of hemodialysis patients, 2.1 percent of peritoneal dialysis patients, and 0.7 percent of transplant recipients received an ICD/CRT-D.

Survival after diagnosis of CHF  Top

Figures not mentioned in text.

Figures 9.25 - Survival after CHF in incident patients, overall
CKD: incident general Medicare CKD patients (from the 5 percent sample) with incident CHF, age 66 & older, & enrolled in Medicare for at least one year, 2002. ESRD: incident Medicare dialysis patients & first transplant patients with incident CHF, age 20 & older, with Medicare as primary payor, 2002. Overall probabilities unadjusted; in graphs by age, gender, race, & diabetic status, data for one factor adjusted for the remaining three; data by comorbidity adjusted for age, gender, race, & diabetic status.

Figures 9.26 - Survival after CHF in incident patients, by age
CKD: incident general Medicare CKD patients (from the 5 percent sample) with incident CHF, age 66 & older, & enrolled in Medicare for at least one year, 2002. ESRD: incident Medicare dialysis patients & first transplant patients with incident CHF, age 20 & older, with Medicare as primary payor, 2002. Overall probabilities unadjusted; in graphs by age, gender, race, & diabetic status, data for one factor adjusted for the remaining three; data by comorbidity adjusted for age, gender, race, & diabetic status.

Figures 9.27 - Survival after CHF in incident patients, by gender
CKD: incident general Medicare CKD patients (from the 5 percent sample) with incident CHF, age 66 & older, & enrolled in Medicare for at least one year, 2002. ESRD: incident Medicare dialysis patients & first transplant patients with incident CHF, age 20 & older, with Medicare as primary payor, 2002. Overall probabilities unadjusted; in graphs by age, gender, race, & diabetic status, data for one factor adjusted for the remaining three; data by comorbidity adjusted for age, gender, race, & diabetic status.

Figures 9.28 - Survival after CHF in incident patients, by race
CKD: incident general Medicare CKD patients (from the 5 percent sample) with incident CHF, age 66 & older, & enrolled in Medicare for at least one year, 2002. ESRD: incident Medicare dialysis patients & first transplant patients with incident CHF, age 20 & older, with Medicare as primary payor, 2002. Overall probabilities unadjusted; in graphs by age, gender, race, & diabetic status, data for one factor adjusted for the remaining three; data by comorbidity adjusted for age, gender, race, & diabetic status.

Figures 9.29 - Survival after CHF in incident patients, by diabetic status
CKD: incident general Medicare CKD patients (from the 5 percent sample) with incident CHF, age 66 & older, & enrolled in Medicare for at least one year, 2002. ESRD: incident Medicare dialysis patients & first transplant patients with incident CHF, age 20 & older, with Medicare as primary payor, 2002. Overall probabilities unadjusted; in graphs by age, gender, race, & diabetic status, data for one factor adjusted for the remaining three; data by comorbidity adjusted for age, gender, race, & diabetic status.

Figures 9.30 - Survival after CHF in incident patients, by comorbidity
CKD: incident general Medicare CKD patients (from the 5 percent sample) with incident CHF, age 66 & older, & enrolled in Medicare for at least one year, 2002. ESRD: incident Medicare dialysis patients & first transplant patients with incident CHF, age 20 & older, with Medicare as primary payor, 2002. Overall probabilities unadjusted; in graphs by age, gender, race, & diabetic status, data for one factor adjusted for the remaining three; data by comorbidity adjusted for age, gender, race, & diabetic status.

Figures 9.31 - Survival after CHF in prevalent patients, overall
CKD: January 1, 2003 point prevalent general Medicare CKD patients (from the 5 percent sample) with incident CHF, age 66 & older, & enrolled in Medicare for at least one year. ESRD: January 1, 2003 point prevalent Medicare ESRD patients with incident CHF, age 20 & older. Overall probabilities unadjusted; in graphs by age, gender, race, & diabetic status, data for one factor adjusted for the remaining three; data by comorbidity adjusted for age, gender, race, & diabetic status.

Figures 9.32 - Survival after CHF in prevalent patients, by age
CKD: January 1, 2003 point prevalent general Medicare CKD patients (from the 5 percent sample) with incident CHF, age 66 & older, & enrolled in Medicare for at least one year. ESRD: January 1, 2003 point prevalent Medicare ESRD patients with incident CHF, age 20 & older. Overall probabilities unadjusted; in graphs by age, gender, race, & diabetic status, data for one factor adjusted for the remaining three; data by comorbidity adjusted for age, gender, race, & diabetic status.

Figures 9.33 - Survival after CHF in prevalent patients, by gender
CKD: January 1, 2003 point prevalent general Medicare CKD patients (from the 5 percent sample) with incident CHF, age 66 & older, & enrolled in Medicare for at least one year. ESRD: January 1, 2003 point prevalent Medicare ESRD patients with incident CHF, age 20 & older. Overall probabilities unadjusted; in graphs by age, gender, race, & diabetic status, data for one factor adjusted for the remaining three; data by comorbidity adjusted for age, gender, race, & diabetic status.

Figures 9.34 - Survival after CHF in prevalent patients, by race
CKD: January 1, 2003 point prevalent general Medicare CKD patients (from the 5 percent sample) with incident CHF, age 66 & older, & enrolled in Medicare for at least one year. ESRD: January 1, 2003 point prevalent Medicare E