Differential management of cardiovascular disease in ESRD by nephrologists and cardiologists.

BACKGROUND: Mortality and morbidity from cardiovascular disease are high in patients with end-stage renal disease (ESRD). The cardiovascular profile of patients with ESRD may differ from that of the general population. We examined how nephrologists and cardiologists differ in managing hypertension and cardiovascular disease in patients with ESRD.

METHODS: Seven cases incorporating relevant clinical and echocardiographic findings common to this population were developed based on a chart review of an ESRD population. Each ESRD case incorporated a clinical presentation designed to test for a specific dichotomous response to a common and important clinical problem. Nine nephrology and 7 cardiology faculty members, each paired with a senior clinical fellow from the discipline, were surveyed.

RESULTS: Nephrologists were less likely than cardiologists to initiate beta-blockade in patients with echocardiographic evidence of regional wall motion abnormalities if there was no history of coronary artery disease (CAD; P < 0.01). In patients with known CAD, cardiologists were more likely than nephrologists to intensify antihypertensive therapy, even in the setting of a history of fractures associated with orthostatic hypotension (P < 0.02). Decision making did not differ between subspecialists in the management of left ventricular hypertrophy, congestive heart failure, or diastolic dysfunction.

CONCLUSION: Nephrologists and cardiologists differ in their management of hypertension in the presence of ischemic heart disease in the ESRD population. Only limited data specific to the ESRD population are available to assess which approach is superior. The discipline-driven differential management approaches observed emphasize the need for better evidence-based management strategies for this population.