Ashish Correa

National Trends and Outcomes in Dialysis-Requiring Acute Kidney Injury in Heart Failure: 2002–2013

BACKGROUND Dialysis-requiring acute kidney injury (D-AKI) is a serious complication in hospitalized heart failure (HF) patients. However, data on national trends are lacking after 2002. METHODS We used the Nationwide Inpatient Sample (2002-2013) to identify HF hospitalizations with and without D-AKI. We analyzed trends in incidence, in-hospital mortality, length of stay (LoS), and cost. We calculated adjusted odds ratios (aORs) for predictors of D-AKI and for outcomes including in-hospital mortality and adverse discharge (discharge to skilled nursing facilities, nursing homes, etc). RESULTS We identified 11,205,743 HF hospitalizations. Across 2002-2013, the incidence of D-AKI doubled from 0.51% to 1.09%. We found male sex, younger age, African-American and Hispanic race, and various comorbidities and procedures, such as sepsis and mechanical ventilation, to be independent predictors of D-AKI in HF hospitalizations. D-AKI was associated with higher odds of in-hospital mortality (aOR 2.49, 95% confidence interval [CI] 2.36-2.63; P < .01) and adverse discharge (aOR 2.04, 95% CI 1.95-2.13; P < .01). In-hospital mortality and attributable risk of mortality due to D-AKI decreased across 2002-2013. LoS and cost also decreased across this period. CONCLUSIONS The incidence of D-AKI in HF hospitalizations doubled across 2002-2013. Despite declining in-hospital mortality, LoS, and cost, D-AKI was associated with worse outcomes.

National Trends and Impact of Acute Kidney Injury Requiring Hemodialysis in Hospitalizations With Atrial Fibrillation.

Background Atrial fibrillation (AF) is a common cause for hospitalization, but there are limited data regarding acute kidney injury requiring dialysis (AKI‐D) in AF hospitalizations. We aimed to assess temporal trends and outcomes in AF hospitalizations complicated by AKI‐D utilizing a nationally representative database. Methods and Results Utilizing the Nationwide Inpatient Sample, AF hospitalizations and AKI‐D were identified using diagnostic and procedure codes. Trends were analyzed overall and within subgroups and utilized multivariable logistic regression to generate adjusted odds ratios (aOR) for predictors and outcomes including mortality and adverse discharge. Between 2003 and 2012, 3751 (0.11%) of 3 497 677 AF hospitalizations were complicated by AKI‐D. The trend increased from 0.3/1000 hospitalizations in 2003 to 1.5/1000 hospitalizations in 2012, with higher increases in males and black patients. Temporal changes in demographics and comorbidities explained a substantial proportion but not the entire trend. Significant comorbidities associated with AKI‐D included mechanical ventilation (aOR 13.12; 95% CI 9.88‐17.43); sepsis (aOR 8.20; 95% CI 6.00‐11.20); and liver failure (aOR 3.72; 95% CI 2.92‐4.75). AKI‐D was associated with higher risk of in‐hospital mortality (aOR 3.54; 95% CI 2.81‐4.47) and adverse discharge (aOR 4.01; 95% CI 3.12‐5.17). Although percentage mortality within AKI‐D decreased over the decade, attributable risk percentage mortality remained stable. Conclusions AF hospitalizations complicated by AKI‐D have quintupled over the last decade with differential increase by demographic groups. AKI‐D is associated with significant morbidity and mortality. Without effective AKI‐D therapies, focus should be on early risk stratification and prevention to avoid this devastating complication.

Pharmacological management of hypertension in the elderly and frail populations

ABSTRACT Introduction: Cardiovascular disease is a leading cause of mortality in the elderly. Hypertension is an important modifiable risk factor that contributes to cardiovascular morbidity and mortality. The prevalence of hypertension is known to increase with age, and hypertension has been associated with an increase in risk for cardiovascular disease in the elderly. There is a wealth of evidence that supports aggressive control of blood pressure to lower cardiovascular risk in the general population. However, there are limited data to guide management of hypertension in the elderly and frail patient subgroups. These subgroups are inadequately treated due to lack of clarity regarding blood pressure thresholds, treatment targets, comorbidities, frailty, drug interactions from polypharmacy, and high cost of care. Areas covered: We review the current evidence behind the definition, goals, and treatments for hypertension in the elderly and frail and outline a strategy that can be used to guide antihypertensive pharmacotherapy in this population. Expert commentary: Lower blood pressure to < 130/80 mm Hg in elderly patients if tolerated and promote use of combination therapy if the blood pressure is > 20/10 mm Hg over the goal blood pressure. Antihypertensive treatment regimens must be tailored to each individual based on their comorbidities, risk for adverse effects, and potential drug interactions (Figure 1).

National Landscape of Unplanned 30-Day Readmissions in Patients with Left Ventricular Assist Device Implantation

The number of patients with advanced heart failure receiving left ventricular assist device (LVAD) implantation has increased dramatically over the last decade. There are limited data available about the nationwide trends of complications leading to readmissions after implantation of contemporary devices. Patients who underwent LVAD implantation from January 2013 to December 2013 were identified using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) code 37.66 from the Healthcare Cost and Utilization Projects National Readmission Database. The top causes of unplanned 30-day readmission after LVAD implantation were determined. Survey logistic regression was used to analyze the significant predictors of readmission. In 2013, there were 2,235 patients with an LVAD implantation. Of them, 665 (29.7%) had at least 1 unplanned readmission within 30 days, out of which 289 (43.4%) occurred within 10 days after discharge. Implant complications (14.9%), congestive heart failure (11.7%), and gastrointestinal bleeding (8.4%) were the top 3 diagnoses for the first readmission and accounted for more than a third of all readmissions. Significant predictors of readmissions included a prolonged length of stay during the index admission, Medicare insurance, and discharge to short-term facility. In conclusion, despite increased experience with LVADs, unplanned readmissions within 30 days of implantation remain significantly high.

DOWNSTREAM EFFECTS OF FALSE POSITIVE ACTIVATION OF THE CARDIAC CATHETERIZATION LAB

Background: Time to reperfusion is a major determinant of outcome among patients with ST elevation infarction (STEMI). Unfortunately, efforts to rapidly triage these patients can result in false positive activation (FPA) of the cardiac catheterization laboratory for some patients without true STEMI

ETIOLOGY AND PREDICTORS OF 30-DAY UNPLANNED READMISSION RATES AFTER LEFT VENTRICULAR ASSIST DEVICE PLACEMENT

Background: Mechanical circulatory support with Left Ventricular Assist Device (LVAD) placement is an important therapy for advanced heart failure. Although these patients are likely vulnerable to increased hospitalizations, there are limited data on a national level about incidence and reasons for