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Azithromycin is an antibiotic with QT-prolonging potential commonly prescribed to individuals receiving hemodialysis. Hemodialysis patients have a high prevalence of clinical conditions, such as structural heart disease, that can enhance the pro-arrhythmic effects azithromycin, but were excluded from prior investigations evaluating the cardiac safety of azithromycin. Using data from the United States Renal Data System (2007-2017), we conducted two cohort studies to examine the cardiac safety of azithromycin relative to amoxicillin-based antibiotics (amoxicillin, amoxicillin/clavulanic acid) and levofloxacin (a fluoroquinolone antibiotic known to prolong the QT-interval) in the hemodialysis population. The primary outcome was five-day sudden cardiac death. Using inverse probability of treatment weighted survival models, we estimated hazard ratios, risk differences, and 95% confidence intervals. The azithromycin vs. amoxicillin-based antibiotic cohort included 282,899 patients and 725,431 treatment episodes (381,306 azithromycin and 344,125 amoxicillin-based episodes). Azithromycin vs. amoxicillin-based antibiotic treatment was associated with higher relative and absolute risks of sudden cardiac death, weighted hazard ratio of 1.70 (95% Confidence Interval, 1.36 to 2.11) and weighted risk difference per 100,000 treatment episodes of 25.0 (15.5 to 36.5). The azithromycin vs. levofloxacin cohort included 245,143 patients and 554,557 treatment episodes (387,382 azithromycin and 167,175 levofloxacin episodes). Azithromycin vs. levofloxacin treatment was associated with lower relative and absolute risks of sudden cardiac death, weighted hazard ratio of 0.79 (0.64 to 0.96) and weighted risk difference per 100,000 treatment episodes of -18.9 (-35.5 to -3.8). Thus, when selecting among azithromycin, levofloxacin, and amoxicillin-based antibiotics, clinicians should weigh the relative antimicrobial benefits of these drugs against their potential cardiac risks.

IMPORTANCE: Respiratory fluoroquinolone antibiotics are some of the most common medications with QT interval–prolonging potential prescribed to patients with hemodialysis-dependent kidney failure—individuals who have a very high risk of sudden cardiac death (SCD). To date, there have been no large-scale, population-specific studies evaluating the cardiac safety of respiratory fluoroquinolones in the hemodialysis population. OBJECTIVE: To investigate the cardiac safety of respiratory fluoroquinolones among individuals with hemodialysis-dependent kidney failure. DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort study examining safety using an active comparator new-user design was conducted using administrative claims data from a US-wide kidney failure registry from January 1, 2007, to December 31, 2016, including 264 968 Medicare beneficiaries receiving in-center maintenance hemodialysis. Data analysis was performed from January 4 to August 16, 2021. EXPOSURES: Respiratory fluoroquinolone (levofloxacin or moxifloxacin) vs amoxicillin-based (amoxicillin or amoxicillin with clavulanic acid) antibiotic treatment. MAIN OUTCOMES AND MEASURES: Sudden cardiac death within 5 days of outpatient initiation of a study antibiotic. Inverse probability of treatment-weighted survival models to estimate hazard ratios (HRs), risk differences (RDs), and corresponding 95% CIs. Death due to a cause other than SCD was treated as a competing event. Fracture was considered as a negative control outcome. RESULTS: The study cohort included 264 968 unique in-center hemodialysis patients and 626 322 study antibiotic treatment episodes: 251 726 respiratory fluoroquinolone treatment episodes (40.2%) and 374 596 amoxicillin-based treatment episodes (59.8%). Of the 264 968 patients, 135 236 (51.0%) were men, and the mean (SD) age was 61 (15) years. Respiratory fluoroquinolone vs amoxicillin-based antibiotic treatment was associated with a higher relative and absolute 5-day risk of SCD (weighted HR, 1.95; 95% CI, 1.57-2.41; and weighted RD per 100 000 treatment episodes, 44.0; 95% CI, 31.0-59.2). Respiratory fluoroquinolone vs amoxicillin-based antibiotic treatment was not associated with the 5-day risk of fracture. CONCLUSIONS AND RELEVANCE: In this study, compared with amoxicillin-based antibiotic treatment, respiratory fluoroquinolone treatment was associated with a higher short-term risk of SCD among patients with hemodialysis-dependent kidney failure. This finding suggests that decisions between the use of respiratory fluoroquinolones and amoxicillin-based antibiotics should be individualized, with prescribers considering both the clinical benefits and potential cardiac risks.

Hemodialysis patients carry a large burden of cardiovascular disease; most onerous is the high risk for sudden cardiac death. Defining sudden cardiac death among hemodialysis patients and understanding its pathogenesis are challenging, but inferences from the existing literature reveal differences between sudden cardiac death among hemodialysis patients and the general population. Vascular calcifications and left ventricular hypertrophy may play a role in the pathophysiology of sudden cardiac death, whereas traditional cardiovascular risk factors seem to have a more muted effect. Arrhythmic triggers also differ in this group as compared to the general population, with some arising uniquely from the hemodialysis procedure. Combined, these factors may alter the types of terminal arrhythmias that lead to sudden cardiac death among hemodialysis patients, having important implications for prevention strategies. This review highlights current knowledge on the epidemiology, pathophysiology, and risk factors for sudden cardiac death among hemodialysis patients. We then examine strategies for prevention, including the use of specific cardiac medications and device-based therapies such as implantable defibrillators. We also discuss dialysis-specific prevention strategies, including minimizing exposure to low potassium and calcium dialysate concentrations, extending dialysis treatment times or adding sessions to avoid rapid ultrafiltration, and lowering dialysate temperature.

Black patients and those with diabetes or reduced kidney function experience a disproportionate burden of acute kidney injury (AKI) and cardiovascular events. However, whether these factors modify the association between AKI and cardiovascular events following percutaneous coronary intervention (PCI) is unknown and was the focus of this study.

Introduction:Over the last two decades, publicly accessible AEDs have become available in communities across the US, allowing bystanders to rapidly intervene during OHCA. The impact of static AEDs on rates of bystander AED application and OHCA outcomes is poorly understood.Methods:We created a static AED registry for Forsyth County, NC (mixed rural-urban county with population ~ 380,000)primarily through phone-based surveys of businesses. These data were linked to the Cardiac Arrest Registry to Enhance Survival and geocoded to calculate proximity between OHCA and nearest static AED. The AHA recommends that publicly accessible AEDs be placed to achieve bystander retrieval within 100 meters (m) of OHCA. Multivariable logistic regression modeling examined the relationship between AED proximity and survival to hospital discharge.Results:Included were 2078 patients >18 years old with OHCA between 2013-2019 and 573 businesses with at least one AED. There were 219 (10.5%), 190 (9.1%), 1669 (80.3%) OHCAs with an AED within <100m, 100-200m, and >200m, respectively. OHCA incidence was highest where static AEDs were closest. Static AEDs within 100m of OHCA were primarily at residential facilities (41.1%), health care clinics (26.5%), churches (9.1%), and schools (6.8%). Among OHCAs with nearest AED >200m, AEDs were primarily owned by schools (32.2%), healthcare facilities (15%), industrial facilities (10.6%), and churches (10.4%). Bystander CPR was highest for OHCAs in closest proximity to an AED (<100m: 61.2%; 100-200m: 51.6%; >200m: 39.5%, p<0.001). Bystander AED application was highest where static AEDs were closest to OHCA (28.3%, 14.2%, and 3.8% at <100m, 100-200m, and >200m, respectively, p<0.001). Among patients who were defibrillated, bystander defibrillation was 18.1%, 20%, and 3.9% (p<0.001). There was no difference for survival to hospital discharge (<100m: 15.1%; 100-200m: 15.3%; >200m: 13.1%, p=0.54), even after adjustment (aOR 1.002, 95% CI 0.995-1.008 per 10m decrease).Conclusion:Only 10% of OHCAs in Forsyth County were within 100 meters of a static AED. Bystander CPR and AED application were highest where static AEDs were <100m from OHCA. Despite this, there was no association between AED proximity and survival to hospital discharge.

Introduction:In North Carolina (NC), 911-dispatch centers are accelerating treatment to OHCA by notifying bystanders of nearby public AEDs. This system depends on a comprehensive registry of AED locations. State law requires registration of AEDs with the NC Office of EMS (NC OEMS), but adherence to this legislation is unknown. The purpose of this study was to determine the registration status of public AEDs in a large county in NC.Methods:Using structured phone surveys, we determined the AED status and information for businesses in Forsyth County, NC. Using a national business database, we identified all registered large businesses (>20 employees) and select small businesses (1-19 employees) most likely to have an AED: healthcare, government, childcare, educational, and religious organizations. In addition, AED lists were elicited from large organizations (e.g non-hospital health clinics, universities, and county government) (n=293 AEDs), NC OEMS (n=336), and 911-dispatch center (n=73).Results:Between 1/2/22-5/7/22, we contacted 1,702 businesses (response rate =79.1%). Of these, 411 (30.5%) businesses reported >= 1 AEDs. Additionally, 106 unique AED locations were identified from large organizations; 22 from the 911-dispatch; and 34 from the NC OEMS registry. The final AED list contained 963 AEDs at 573 unique locations (Table). Identified AEDs were most frequently located at health clinics, schools, colleges, offices, industrial facilities, and churches. A majority of AEDs (65.1% [627/963]) were not previously registered in the NC OEMS AED registry. Few business AEDs (11.8% [114/963]) were listed in the county dispatch agency’s geolocation software system.Conclusion:Most businesses and organizations in our survey canvas had AEDs that were unregistered in a state-mandated AED registry. Structured strategies to increase reporting of publicly available AEDs to NC OEMS and transfer of that information to county 911-dispatch systems are needed.

CKD patients face an increased risk of cardiovascular disease mortality, and the risk of sudden cardiac death (SCD) increases as kidney function declines. Risk factors for SCD are poorly understood and understudied among CKD patients. In the general population, coronary heart disease-associated risk factors are the most important determinants of SCD risk, but among CKD patients, there is evidence that these factors play a much smaller role. Complex relationships between CKD-specific risk factors, structural heart disease, and arrhythmic triggers contribute to the high risk of SCD and ventricular arrhythmias and modulate the effectiveness of available therapies. This review examines recent data on the epidemiology, pathophysiology, and mechanisms of SCD among CKD patients and examines current evidence regarding the use of pharmacologic and device-based therapies for management of SCD risk.

Guidelines recommend that implantable cardioverter-defibrillator (ICD) candidates have an estimated longevity of ≥1 year. Longevity can be affected by chronic kidney disease (CKD).

The benefit of a primary prevention implantable cardioverter-defibrillator (ICD) among patients with chronic kidney disease is uncertain.