Subir Bhatia

Non–ST‐Segment–Elevation Myocardial Infarction Among Patients With Chronic Kidney Disease: A Propensity Score–Matched Comparison of Percutaneous Coronary Intervention Versus Conservative Management

Background Chronic kidney disease (CKD) remains an independent predictor of cardiovascular morbidity and mortality. CKD complicates referral for percutaneous coronary intervention (PCI) in non–ST‐segment–elevation myocardial infarction (NSTEMI) patients because of the risk for acute kidney injury and the need for dialysis, with American College of Cardiology/American Heart Association guidelines underscoring the limited data on these patients. Methods and Results Using the National Inpatient Sample to analyze hospitalizations in the United States from 2004 to 2014, we sought to assess PCI utilization and in‐hospital outcomes in NSTEMI admissions with CKD. NSTEMI admissions were identified by International Classification of Diseases, Ninth Edition, Clinical Modification (ICD‐9‐CM) code 410.7. CKD admissions were identified by ICD‐9‐CM code 585. Propensity score–matched cohorts of patients with NSTEMI were matched for age, sex, comorbidities, race, median household income, primary payer status, and hospital characteristics. Of 4 488 795 hospitalizations for NSTEMI, 31% underwent PCI. Overall, 89% of admissions had no CKD. In addition, 32% of NSTEMI admissions with no CKD and 23%, 14%, and 22% with CKD stages 3, 4, and 5 underwent PCI, respectively. Hospitalized NSTEMI patients with CKD stages 4 and 5 had 41% and 20% less likelihood, respectively, of undergoing PCI compared with those with no CKD. Among hospitalized NSTEMI patients with no CKD or CKD stage 3, 4, or 5, PCI‐treated groups had 63%, 57%, 39%, and 59% lower likelihood, respectively, of all‐cause, in‐hospital mortality compared with propensity score–matched medically managed groups. Conclusions PCI use decreased among hospitalized NSTEMI patients as CKD severity increased, and all‐cause, in‐hospital mortality was greater for NSTEMI patients admitted with more severe CKD regardless of treatment strategy.

Seasonal Periodicity of Ischemic Heart Disease and Heart Failure

Seasonal variation for ischemic heart disease and heart failure is known. The interplay of environmental, biological, and physiologic changes is fascinating. This article highlights the seasonal periodicity of ischemic heart disease and heart failure and examines some of the potential reasons for these unique observations.

The Arrhythmia Patient in the CCU – Impact of Echocardiography

Echocardiography is an essential tool in patients with cardiac arrhythmias, particularly in the critical care environment. It plays an important role in the etiological assessment, prognosis, and risk stratification of patients with arrhythmias. In this chapter, we discuss the key role of echocardiography in the arrhythmic patient in the coronary care unit.

Atrial Fibrillation: Beyond Rate Control

&NA; Atrial fibrillation is the most common cardiac dysrhythmia encountered in the primary care setting. Although a rate control strategy is pursued by physicians for the initial treatment of atrial fibrillation, the efficacy of a rhythm control approach is often undervalued despite offering effective treatment options. There are many pharmacological therapies available to patients, with drug choice often dictated by safety concerns (toxicities and proarrhythmic adverse effects) as well as patient characteristics and comorbidities. This article presents a simplified approach to understanding the rhythm control strategy, including the advantages and disadvantages of various antiarrhythmic drugs and common drug‐drug interactions encountered in the primary care setting.

Recurrent pulmonary alveolar proteinosis in an immunocompromised host

Five months later, he had a recurrence requiring repeat bilateral lung washings with removal of proteinaceous material from the PAP. PAP is a rare cause of hypoxemic respiratory failure that is characterized by abnormal accumulation of surfactant within the alveolar space. Here, we present a unique case of biopsy-proven, recurrent secondary PAP requiring repeated whole lung lavage treatments in an immunocompromised patient who had received a bone marrow transplant (BMT) for AML. PAP is a disorder that is characterized by periodic acid Schiff (PAS)-positive, lipid rich, proteinaceous material deposition in the distal airways in the absence of significant airway inflammation [1]. A diagnosis of PAP is established using a combination of clinical history, imaging findings, cytopathology, and histopathology. This case demonstrates the hallmark CT and pathology findings of PAP, namely the “crazy paving” pattern representing thickening of interlobular septa and PAS-positive proteinaceous material within alveolar macrophages, respectively. This case illustrates a rare complication associated with a common hematologic malignancy and its standard treatment. While pulmonary complications represent the most common cause of death in patients with prior BMT, PAP accounts for only 1% of pulmonary complications [2]. The low prevalence makes prompt recognition of PAP challenging; however, early identification is essential in ensuring prompt management, and health-care providers should look for this disease in a patient presenting with hypoxemic respiratory failure. Whole lung lavage is the mainstay of treatment of PAP; however, similar to our patient, a small subset of patients require repeated lung lavage treatments before achieving clinical resolution [3]. A 52-year-old man presented with a 3-month history of progressive dyspnea on exertion. He had a history of acute myeloid leukemia (AML) status post-allogeneic peripheral blood stem cell transplant 5 years prior. This was complicated by graft-versus-host disease (GVHD) of the skin, mouth, muscles, and lungs. He was prescribed prednisone, sirolimus, cyclophosphamide, mycophenolic acid, and ruxolitinib for management of GVHD. On admission, his oxygen requirement was higher and he was noted to have desaturations with prolonged conversation along with bibasilar crackles. Laboratory workup (reference range) was notable for hemoglobin 7.0 g/dL (13.5–17.5 g/ dL) and leukocytes 9.1 × 109/L (3.5–10.5 × 109/L). A chest X-ray (Fig. 1a) revealed diffuse mixed poorly defined patchy opacities with septal thickening. A computed tomography (CT) scan of the chest (Fig. 1b) demonstrated patchy illdefined diffuse ground-glass opacities with interlobular septal thickening representing “crazy paving”. A bronchoscopy with bronchoalveolar lavage (BAL) and transbronchial biopsies was performed. Both BAL and biopsies illustrated amorphous alveolar casts and pulmonary alveolar proteinosis (PAP). He underwent bilateral lung washings under general anesthesia. A total of 12 L was instilled and drained from both the right (Fig. 1c) and left lungs. Most of the debris was noted in the third to fifth aliquots. He had marked improvement in his dyspnea thereafter and was discharged home with significantly less supplemental oxygen.

His Bundle (Conduction System) Pacing: A Contemporary Appraisal

The His bundle (conduction system) is an attractive target for physiologic pacing because it uses the native conduction system. Although the potential benefits of conduction system pacing were recognized in the 1970s, in the past 2 decades, it has grown in interest as a potentially preferred method of ventricular stimulation in appropriate patients. This review provides an appraisal of conduction system pacing, with focus on anatomy, physiology, tools, and techniques as well as an appraisal of current published data and thoughts on future directions.

PERCUTANEOUS CORONARY INTERVENTION IS ASSOCIATED WITH DECREASED MORTALITY IN NSTEMI PATIENTS WITH ADVANCED CKD

Background: Chronic kidney disease (CKD) remains a significant independent predictor of cardiovascular morbidity and mortality. However, there is an insufficient amount of revascularization data in non-ST-segment elevation myocardial infarction (NSTEMI) patients with CKD, especially at advanced

ATRIAL FIBRILLATION IS ASSOCIATED WITH WORSE OUTCOMES IN PATIENTS WITH CIRRHOSIS

Background: Cardiovascular disease continues to be a major cause of morbidity and mortality in cirrhotic patients. Liver disease is associated with thrombocytopenia and coagulopathy while anticoagulant use for atrial fibrillation (AF) is associated with bleeding risk. However, whether cirrhosis with