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Although acute myocardial infarction (AMI) is a disease predominantly affecting adults60 years of age, a significant proportion of the young population who have different risk profiles, are also affected. We undertook a retrospective analysis using National Inpatient Sample (NIS) 2010 to 2014 to evaluate gender differences in characteristics, treatments, and outcomes in the younger AMI population.The NIS 2010-2014 was used to identify all patient hospitalizations with AMI between 18 to45 years using ICD-9-CM codes. We demonstrated a gender-based difference of in-hospital all-cause mortality, other complications, and revascularization strategies in the overall AMI population and other subgroups of AMI [anterior wall ST-segment elevation MI (STEMI), and non-anterior wall STEMI and non-STEMI (NSTEMI)].A total of 156,018 weighted records of AMI hospitalizations were identified, of which 111,894 were men and 44,124 were women. Young women had a higher prevalence of anemia, chronic lung disease, obesity, peripheral vascular disease, and diabetes. Conversely, young men had a higher prevalence of dyslipidemia, smoking, and alcohol. Among non-traditional risk factors, women had a higher prevalence of depression and rheumatologic/collagen vascular disease. There was no difference in all-cause in-hospital mortality in women compared to men [2.03% vs 1.48%; OR 1.04, CI (0.84-1.29); P = .68], including in subgroup analysis of NSTEMI, anterior wall STEMI, and non-anterior wall STEMI. Women with AMI were less likely to undergo percutaneous coronary intervention [47.13% vs 61.17%; OR 0.66, 95% CI (0.62-0.70; P .001] and coronary artery bypass grafting [5.6% vs 6.0%; OR 0.73, 95% CI 0.64-0.83; P .001] compared to men. Women were also less likely to undergo percutaneous coronary intervention within 24 h of presentation (38.47% vs 51.42%, P .001).Despite higher baseline comorbidities in young women with AMI, there was no difference in in-hospital mortality in women compared to men. Additional studies are needed to evaluate the impact of gender on clinical presentation, treatment patterns, and outcomes of AMI in young patients.

Hyponatremia is a very common electrolyte abnormality, associated with poor short- and long-term outcomes in patients with heart failure (HF). Two opposite processes can result in hyponatremia in this setting: Volume overload with dilutional hypervolemic hyponatremia from congestion, and hypovolemic hyponatremia from excessive use of natriuretics. These two conditions require different therapeutic approaches. While sodium in the form of normal saline can be lifesaving in the second case, the same treatment would exacerbate hyponatremia in the first case. Hypervolemic hyponatremia in HF patients is multifactorial and occurs mainly due to the persistent release of arginine vasopressin (AVP) in the setting of ineffective renal perfusion secondary to low cardiac output. Fluid restriction and loop diuretics remain mainstay treatments for hypervolemic/ dilutional hyponatremia in patients with HF. In recent years, a few strategies, such as AVP antagonists (Tolvaptan, Conivaptan, and Lixivaptan), and hypertonic saline in addition to loop diuretics, have been proposed as potentially promising treatment options for this condition. This review aimed to summarize the current literature on pathogenesis and management of hyponatremia in patients with HF.

Background Studies have suggested that obesity could improve prognosis in patients with heart failure (HF), known as the "obesity paradox." However, the association between bariatric surgery (BS) and HF outcomes is not well established. Objective This study aimed to assess the effects of prior BS on outcomes of HF patients. Setting Inpatient hospital admissions from the Nationwide Inpatient Sample. Methods The Nationwide Inpatient Sample database for years 2006 to 2014 was queried for adults with a primary diagnosis of HF. We performed multivariable regression analyses to compare outcomes including in-hospital mortality, complications, cost, and length of stay between prior BS (body mass index Results Of 164,220 patients with HF, 3617 were with prior BS and 160,603 were diagnosed with morbid obesity. Prior BS patients were younger, tended to be female, and had fewer co-morbidities and complications. Multivariate regression analyses adjusting for baseline patient and hospital characteristics revealed that compared with morbid obesity, prior BS with successful weight loss (body mass index Conclusion Among HF hospitalized patients, prior BS is associated with better in-hospital outcomes, mainly in those who had successful weight loss. Our findings emphasize potential clinical and economic impact of BS on HF patients.

Cardiovascular disease (CVD) is the most common cause of death worldwide. Cardiac rehabilitation (CR) is increasingly recognised as an essential part of clinical care for patients with CVD. CR is a complex intervention that encompasses a multidisciplinary approach that focuses on health education, modification of cardiovascular risk factors, exercise training, physical activity and stress management. In the current American Heart Association/American College of Cardiology guidelines, cardiac rehabilitation is a class IA recommendation for secondary prevention of acute myocardial infarction, percutaneous coronary intervention and cardiac surgery and Class II recommendation for chronic stable heart failure. Despite proven effectiveness, however, participation in traditional CR remains low. Although the reasons for participation and non-participation in CR have been well described, the use of Twitter to explore public perceptions of CR has not yet been formally reported. To the best of our knowledge, the analysis of Twitter for insights on CR is a novel investigation that is relevant for addressing significant problems related to CR awareness in the digital age.We performed data mining of Twitter to assess patients’ perceptions regarding CR and the reasons for their participation and non-participation in CR between 23 July 2015 and 22 October 2017.We analysed a total of 5515 Twitter messages. Tweets associated with CR were often used to self-report on health status either before or after participating in CR or contained emotional language with positive or negative comments, advertisements or updated news.Twitter users wrote mainly positive comments about CR, suggesting the platform has the potential to disseminate both the benefits of CR and its research to the public on the worldwide scale.

Venous thromboembolism (VTE), the combined syndromes of deep vein thrombosis (DVT) and pulmonary embolism (PE), is currently the third most frequent acute cardiovascular syndrome globally behind myocardial infarction and stroke. PE carries substantial mortality. In the past decade we have seen a remarkable improvement in new diagnostic tools as well as advances in therapeutic options to manage patients with PE. Still, even with recently updated society guidelines, the management of intermediate and high-risk PE requires clinician expertise and judgment. To aid health care providers caring for patients with acute PE, we have developed a novel, comprehensive yet straightforward, pathway for the management of patients with PE. We believe this pathway can be used in many health care systems around the globe. Our pathway for the diagnosis and management of PE is divided into three steps: the diagnosis of PE, the acute management of patients with PE, and recommendations for chronic management. The pathway requires classification of the PE by the risk of mortality and thus leads to the appropriate intensity of initial care, intervention and monitoring. The Pulmonary Embolism Response Team (PERT) is a multispecialty team designed to guide the decision-making for the individual patient with intermediate-high or high-risk PE. The PERT team brings together specialists from different disciplines. The team convenes in real time via a platform such as WhatsApp or texts messages to communicate clinical data, discuss the options and provide consensus for a course of management. The success of this pathway to manage PE depends heavily on developing a collaborative group of specialists dedicated to provide care at each stage to patients with PE.

Background Spontaneous coronary artery dissection (SCAD) is a very rare cause of acute coronary syndromes in young otherwise healthy patients with a striking predilection for the female gender. Unfortunately, SCAD can result in significant morbidities and mortality. The pathological mechanism has not been fully clarified yet but hormonal changes might represent a sufficiently convincing explanation for some patients with SCAD. We hypothesized that gender difference in mortality in SCAD patients. Methods Data for this retrospective cohort study were extracted from the Nationwide Inpatient Sample for 2014 using the 9th revision of the International Classification of Diseases (ICD) 414.12 (spontaneous coronary artery dissection). Demographics, in-hospital mortality, conventional risk factors (diabetes, hypertension, hyperlipidemia, alcohol and tobacco abuse), acute critical illnesses like sepsis, septic shock, stroke, acute respiratory insufficiency, acute renal failure, and chronic conditions (anxiety, depression, malignancy and metastatic diseases) were studied. Univariate and multivariate logistic regression modeling were performed to determine predictors associated with the development of inpatient mortality in SCAD patients. All analyses were conducted using R 3.4.0 and STATA/MP 14.2. All p-values were two-sided, and statistical significance was determined at the level of p Result A total of 270 SCAD patients were identified. Of those SCAD patients, no fibromuscular dysplasia (FMD) or pregnancy were identified. Patients were predominantly women (71%) and the mean age was 53 years. Overall in-hospital mortality was 5.6%, with 6.6% in male and 5.3% in female. Ethnicity, gender, stroke, acute renal failure, anxiety and depression did not predict mortality, length of stay, annual income, total hospital charge (all p>0.05). Multivariate analysis revealed no gender difference in SCAD patients and no independent predictors of mortality were identified. Conclusions This large nationwide study reveals that SCAD may be underdiagnosed but underutilization of work up such as FMD. SCAD is thought to be hormone related likely associated with female gender. Our results showed that no gender difference in mortality. Further large prospective studies are needed to determine gender difference in mortality and other predictors in mortality. Funding Acknowledgement Type of funding source: None

IntroductionAtrial fibrillation (AF) is the most common arrhythmia encountered in clinical practice and is a significant risk factor for ischemic stroke and death. Digitalis has been used for more than 200 years to treat heart conditions, including AF, and its use remains controversial due to uncertain long-term morbidity and mortality.MethodsWe conducted a cohort study of hospitalized patients with AF assessing the effects of digoxin on longterm all-cause mortality. Patients were divided into two groups: with and without heart failure (HF). We performed multivariable Cox regression analysis to assess hazard ratios (HR) for all-cause mortality depending on digoxin treatment and used propensity score matching to adjust for differences in background characteristics between treatment groups.ResultsAmong 2179 consecutive patients hospitalized with AF, the median age was 73 ± 14, and 52.5% of patients were male, 49% had HF, and 18.8% were discharged on digoxin. Median left ventricular ejection fraction in the whole cohort was 60 (IQR 40-65). Among patients with HF, 34.5% had preserved, 17.3% had mid-range and 48.1% had reduced left ventricular ejection fraction. The mean follow-up time was 3 ± 2.05 years. In patients without HF there was a statistically significant increased mortality in the digoxin subgroup after propensity score matching (HR = 2.23, 95% CI 1.42-3.51, p < 0.001). In contrast, in patients with HF, there was no difference in mortality between the treatment groups (p = 0.92).ConclusionsDigoxin use in our study was associated with increased mortality in patients with AF and without concomitant HF.

Purpose: To determine the relationship between obesity and thirty-days readmission, mortality, morbidity, and health care resource utilization in patients who underwent cardiopulmonary resuscitation (CPR) during their hospitalization in the in the United States. Method: A retrospective study was conducted using the AHRQ-HCUP NRD for the year 2014. Adults (≥ 18 years) with a primary diagnosis of CPR (1), along with a secondary diagnosis of obesity were identified using ICD-9 codes as described in the literature (2). The primary outcome was the rate of all-cause readmission within 30 days of discharge. Secondary outcomes were reasons for readmission, readmission mortality rate, morbidity, and resource use. Propensity score (PS) using the 1:1 nearest neighbor matching without replacement was utilized to adjust for confounders (3). Results: 113,394 hospital admissions among adults with a primary and secondary diagnosis of CPR were identified, of which 14.8% were obese. 1:1 PS matching was performed based on demographic and clinical characteristics. The 30-day rate of readmission among obese and non-obese with CPR were 4.94% and 2.82% (p Conclusion: In this study, obese patients admitted with CPR have a higher 30 days of readmission rate, total hospital cost, and in-hospital mortality (p

Introduction: Cardiovascular disease is a leading cause of morbidity and mortality in human immunodeficiency virus (HIV) infected adults, and should be managed more aggressively.Prior studies highlighted treatment disparities for Acute Coronary Syndrome (ACS) among HIV patients. This study aims at examining these disparities with the latest large cohort data. Hypothesis: HIV patient with ACS are as likely to receive cardiac revascularization related procedures compared to control group. Methods: We reviewed the Nationwide Inpatient Sample from 2013 to 2016 to identify patients with diagnosis of ACS (ST-elevation and non ST-elevation myocardial infarction, and unstable angina) to compare rates of cardiac procedures (Catheterization, Percutaneous Coronary Intervention - PCI - and Coronary Artery Bypass Graft - CABG) among groups of population of interest (control, asymptomatic HIV, symptomatic HIV). Results: Overall, 515,016 patients with primary diagnosis of ACS where identified and among them 2066 (0.40%) of ACS patients had diagnosis of HIV (asymptomatic and symptomatic). Multivariate regression analysis showed statistically significant lower procedural rates for catheterization (OR: 0.62, 95% CI: [0.52, 0.73]), PCI (OR: 0.80, 95% CI: [0.67, 0.96]) and CABG (OR: 0.70, 95% CI: [0.52, 0.93]) in symptomatic HIV compared to control group. For asymptomatic HIV patient group, no significant change of procedural rates were found compared to control group for catheterization, PCI and CABG (respectively OR: 0.90, 95% CI: [0.78, 1.05], OR: 1.13, 95% CI: [1.00, 1.26] and OR: OR: 0.87, 95% CI: [0.72, 1.04]). Conclusions: Analysis shows a treatment disparity for ACS for symptomatic HIV patients only as symptomatic HIV affected patients received less aggressive catheterization and revascularization management after ACS, compared to control group. However, this effect was not present for the asymptomatic HIV patient group.

Background The aim of the study is to compare in‐hospital outcomes of acute ST‐segment‐elevation myocardial infarction (STEMI) between China and the United States. Methods and Results Urban teaching hospitals were queried for adult patients with a primary diagnosis of acute STEMI during 2007–2010. The primary outcome was in‐hospital mortality, and the secondary outcome was length of stay. Multivariable analyses adjusting for potential confounders were conducted for comparison between countries. Subgroup analysis was performed in acute STEMI patients receiving revascularization. In total, 32 228 patients in China and 76 117 patients in the United States were included. Overall in‐hospital mortality was 8.23% in China and 7.96% in the United States ( P CI , 0.87–1.09; P =0.59), whereas China had lower 3‐day mortality (odds ratio, 0.78; 95% CI , 0.70–0.89; P CI , 1.85–3.07; P CI , 1.78–3.20; P STEMI patients, acute STEMI patients receiving percutaneous coronary intervention and coronary artery bypass grafting, median length of stay in China and the United States were 10 versus 3, 9 versus 3, and 25 versus 9 days, respectively (all P Conclusions Overall in‐hospital mortality in acute STEMI patients was comparable among urban teaching hospitals between China and the United States during 2007–2010. In addition, 3‐day mortality was lower in China. However, worse outcomes in patients undergoing early revascularization and longer length of stay in China need to be given more attention.

Background: Depression poses a major health challenge to patients with cardiovascular disease. But little is known about its impact on Non-ST-elevation myocardial infarction (NSTEMI). Methods: Using the data from the 2016 National Inpatient Sample database, we identified hospitalization with a principal diagnosis of NSTEMI with or without medical history of depression. Prevalence and baseline characteristic of NSTEMI patient with or without depression was delineated. Mortality, catheterization rate, length of stay, time to catheterization were compared using multivariate linear regression with adjustment for age, sex, race, region, hospital size, Charlson Comorbidity Index, tobacco, heart failure, diabetes, and stable coronary heart disease. Results: Depression was found in 42,914 (9.11%) of total NSTEMI admission of 470,933. A higher percentage of female and a higher prevalence of hypertension, hyperlipidemia, diabetes, and smoking (table 1) was observed in the depression group. No significant association between depression and in-hospital mortality in NSTEMI patient can be found after adjustment for confounders (odds ratio 0.88, p=0.08). However, having depression was associated with lower catheterization rate (odds ratio 0.91, p Conclusion: Depression is associated with decreased catheterization rate, increased length of stay and delayed catheterization in NSTEMI patient. Further investigation of the impact of depression on NSTEMI patient is warranted.

Background: Myocarditis of different etiologies can either present with different types of already existing arrhythmias or be the cause of subsequent arrhythmias. Literature have shown that both scenarios hold worse prognosis and outcomes. Methods: We conducted a retrospective cohort study based on the 2016 National Inpatient Sample of adults (>18 years) hospitalized for acute myocarditis of any kind as the primary admitting diagnosis and atrial fibrillation (AF) as a secondary concomitant diagnosis based on ICD-10 codes. All-cause mortality was our primary outcome while length of stay, in-hospital arrhythmia of any kind requiring DCCV, acute respiratory failure, the rate of endotracheal intubation, ICD device insertion and VAD placement during the same hospital stay were our secondary outcomes. We used multivariate regression adjusted for age, sex, race, history of coronary artery disease, history of congestive heart failure, Charlson comorbidity index, hospital region, size and teaching status. STATA-15 was used for statistical analysis. Results: In 2016, there were 8,110 admissions for myocarditis (37.9% females), out of whom 315 (3.9%) had concomitant AF. Mean age was 40y (39.5y without AF, 59y with AF). Our results, table 1, showed that myocarditis with AF significantly increased all-cause mortality (6.3% [20 of 315] vs 1.6% [130 of 7,760], OR 8.28, p Conclusion: Atrial fibrillation appears to be an independent risk factor for higher all-cause mortality rate in myocarditis and is also associated with higher rate of ICD device and VAD implantation during the same hospital stay. Thus, patients with AF who are hospitalized for myocarditis mostly have worse in-hospital outcomes.

Background: Obstructive sleep apnea (OSA) is present in almost 60% of patients with cerebrovascular disease and it is an independent predictor of ischemic stroke. Yet, the impact of OSA on outcomes of ischemic stroke is unclear. Some, small cohort studies indicate increased short-term mortality, whereas larger studies, with more complex logistic regression models, show decreased in-hospital mortality. Lower mortality could be attributed to chronic intermittent episodes of hypoxia affecting the remodeling of cerebral collateral circulation. We thought to investigate outcomes in a large unselected population of patients presenting with acute ischemic stroke. Methods: In a retrospective cohort study, using the 2014 Nationwide Inpatient Sample (NIS), we analyzed adult patients with acute ischemic stroke and OSA. We performed univariate analysis of age, sex, race, hospital location, hospital teaching status, insurance type, hospital bed size, Charlson Comorbidity Index and other relevant comorbidities and we included variables with p Results: A total of 95282 patients with acute ischemic stroke were identified. Patients with the associated diagnosis of OSA (5%) had a mean age of 66+/_0.2, vs 71+/_0.1, p Conclusion: Patients with OSA and ischemic stroke have a higher number of cardiovascular comorbidities. After adjustment with a complex multivariate regression model in a large population of patients, they have lower in-hospital mortality and lower incidence of hemiplegia. We also uncovered underdiagnosing of obstructive sleep apnea in National Inpatient Sample registry, which is a limitation of the study.

Pulmonary hypertension (PH) is a chronic pulmonary vascular disorder that can be caused by a variety of pathophysiological states. Five groups of PH sharing similar hemodynamics, and management were identified: 1) pulmonary arterial hypertension (Group 1); 2) PH due to left heart disease (Group 2); 3) PH due to chronic lung disease (Group 3); 4) chronic thromboembolic PH (Group 4); and 5) miscellaneous mechanisms (Group 5) [1]. Physiologically, PH is defined as mean pulmonary artery pressure (mPAP) ≥ 25 mm Hg at rest or >30 mm Hg with exercise. Clinically, PH leads to right heart ventricular failure and cardiac death [2,3]. Group 2 PH is found commonly and is reported in >60% of heart failure patients [4]. Patients with chronic left heart failure often have other atrial arrhythmias. Atrial fibrillation (AF) is commonly encountered in >3 million people in the United States [5]. Heart failure patients are 5 to 10 times more likely to develop AF than healthy patients [6,7]. AF portends a worse long-term prognosis attributable to the loss of atrial kick, loss of atrioventricular synchrony, and the increased risk of stroke [8,9]. Similarly, the prevalence of Group 2 PH related AF is as high as 57%, and 23% in other forms of PH [10]. The cornerstone of surgical treatment of AF has been AF ablation. Haussaiguarre et al. first reported that AF initiates in the posterior wall of the left atrium near the ostium of pulmonary veins [11]. AF ablation is achieved either radio-frequency (electrocautery) or cryoablation. To date, limited data are available regarding the impact of PH on patients undergoing AF ablation. Therefore, we have demonstrated the effect of PH in patients getting AF ablation in this National Inpatient Sample (NIS) analysis.

Exercise induced dyspnea in patients with valvular surgical replacement has a broad differential, requiring extensive history combined with cardiac imaging. A 64-year-old male with medical history of rheumatic aortic valve stenosis with surgical stentless bioprosthetic aortic (Sorin SOLO) valve

Despite a low pre-test probability of coronary artery disease (CAD) in women of childbearing age, Spontaneous Coronary Artery Dissection (SCAD) remains the most common cause of acute coronary syndrome (ACS) in the gravid patient. A 39 year old female G1P1, pregnancy complicated by pre-eclampsia and

Acute coronary syndrome (ACS) is a leading cause of mortality among patients with non-dialytic end stage renal disease, also known as CKD Stage V (CKD V), and end-stage renal disease requiring hemodialysis (ESRD) and should be managed aggressively. Prior studies highlighted treatment disparities for

Hypertensive crisis is a serious medical condition defined as severely elevated blood pressure; typically the systolic blood pressure is above 180 mmHg, and/or the diastolic blood pressure is above 120 mmHg. Hypertensive crises are divided into two categories: hypertensive urgency and hypertensive emergency. Hypertensive urgency is asymptomatic while hypertensive emergency presents with end-organ damage requiring more aggressive blood-pressure lowering. The common presentations for neurological end-organ dysfunction in conjunction with hypertensive emergency include ischemic strokes, intracranial hemorrhage, subarachnoid hemorrhage, head trauma, and hypertensive encephalopathy. The occurrence of acute spontaneous subdural hematoma (SDH) as a neurological end-organ damage complicating hypertensive crisis is rare and should receive tight blood-pressure lowering to prevent further bleeding. We present a case of hypertensive emergency complicated with acute spontaneous SDH. .

Ventricular assist device (VAD) implantation has improved quality of life and short-term survival for advanced heart failure patients. There are limited data from single-center studies addressing the characteristics and etiologies of 30 day readmissions after VAD implant. We used the Nationwide Readmissions Database (NRD) 2014 to identify insertion of implantable heart assist system during index admission. Primary and secondary outcomes were 30 day readmissions and leading etiologies, respectively. We analyzed 1,481 patients who received VAD during the primary admission of whom 1,315 patients survived to hospital discharge (mortality rate 11.2%), and 60.6% were discharged to a nursing facility. One hundred and thirty-one (10.0%) patients were readmitted within 30 days of primary hospitalization. Leading etiologies of 30 day readmission were bleeding (24%), heart failure (18%), and device complications (14%). Mean length of stay during readmission was 13.8 days with a mortality rate of 2.1%. Fifty percent of 30 day readmissions were readmitted from day 22 to 30. Variables for predictors of 30 day readmissions were not statistically significant. By identifying gastrointestinal bleeding, heart failure, and device complications as leading etiologies of 30 day readmission post-VAD implantation, providers can potentially modify practices to prevent hospital readmissions, decreasing cost of care, and improving the quality of life of patients.

Takotsubo syndrome, initially described in the 1990s by Sato, has been increasingly recognized around the world. Pathophysiology is directed towards central role of catecholamine surge , but other aspects like microvascular endothelial dysfunction and vasospasm have also been described. Dyspnea and chest pain are most common manifestations, but syncope can also be seen. Right ventricular involvement is not uncommon, and left ventricular outflow tract obstruction is a frequent complication. EKG can differentiate between Takotsubo syndrome and myocardial infarction, but coronary angiography should always be performed. Although treatment has been angiotensin converting enzyme inhibitors and betablockers, recent evidence from nonrandomized studies shows no benefit on betablockers regarding outcomes.

Suboptimal echocardiograms are common in critically ill patients. The obstacles that interfere with optimal echocardiographic imaging in cardiac care unit patients include suboptimal positioning, obesity, hyperinflated lungs due to mechanical ventilation, lung disease, subcutaneous emphysema, surgical incisions, chest tubes, bandages, and crowded quarters. It is well known that use of contrast in echocardiography significantly improves the image quality, but despite that, contrast echocardiography is widely underused. The current chapter outlines the basics of contrast echocardiography as it applies to critical care.

The field of critical care cardiology has evolved considerably over the past few decades. Cardiac units in the 1970s and the 1980s were practically coronary care units, where the units most frequently were populated by patients with acute and often uncomplicated myocardial infarction or unstable angina. Detection and rapid treatment of arrhythmias were the primary goals of therapy. Contemporary cardiac care units (CCU) have transformed into Cardiac intensive care units (CICU) where the focus has since shifted towards the management of patients with multisystem diseases, advanced hemodynamics compromise, complex ventricular arrhythmias, and established or incipient multi-organ failure. The two most common clinical scenarios leading to acute chest pain syndrome in CCU patients are acute coronary syndrome and acute aortic syndrome.

Echocardiography is essential in evaluating patients with acute and subacute dyspnea. Depending on the urgency and severity of patient’s condition the applications of echocardiography can range from immediate point-of-care ultrasound to assess for gross abnormalities (such as pericardial effusion) to detailed evaluation of underlying structural heart disease. We present a structured approach to evaluation of patients with acute and subacute dyspnea utilizing a wide range of echocardiographic techniques.

Point-of-care cardiac ultrasound (POCUS) is becoming more commonly used in the assessment of patients as an adjunct to the physical examination, particularly in critically ill patients. Improving technology has made these devices smaller and portable with improved ease of use by cardiologists, as well as critical care and emergency room physicians. The use of cardiac POCUS can improve diagnostic accuracy and provide valuable diagnostic information that can significantly impact medical management.

Current guidelines recommend against revascularization of the noninfarct artery during the index percutaneous coronary intervention (PCI) in hemodynamically stable patients with ST-segment elevation myocardial infarction (STEMI). This was based largely on observational studies with few data coming from randomized controlled trials (RCTs). Recently, several small-to-moderate sized RCTs have provided data, suggesting that a multivessel revascularization approach may be appropriate. We performed a meta-analysis of RCTs comparing multivessel percutaneous coronary intervention (MV PCI) versus culprit vessel-only revascularization (COR) during primary PCI in patients with STEMI and multivessel coronary disease (MVCD). We searched Medline, PubMed, and Scopus databases for RCTs comparing MV PCI versus COR in patients with STEMI and MVCD. The incidence of all-cause death, cardiac death, recurrent myocardial infarction, and revascularization during follow-up were extracted. Four RCTs fit our primary selection criteria. Among these, 566 patients underwent MV PCI (either at the time of the primary PCI or as a staged procedure) and 478 patients underwent COR. During long-term follow-up (range 1 to 2.5 years), combined data indicated a significant reduction in all-cause mortality (relative risk [RR] 0.57, 95% confidence interval [CI] 0.36 to 0.92, p = 0.02) and in cardiac death (RR 0.38, 95% CI 0.20 to 0.73, p = 0.004) with MV PCI. In addition, there was a significantly lower risk of recurrent myocardial infarction (RR 0.41, 95% CI 0.23 to 0.75; p = 0.004) and future revascularization (RR 0.37, 95% CI 0.27 to 0.52; p0.00001). In conclusion, from the RCT data, MV PCI appears to improve outcomes in patients with STEMI and MVCD.

Inpatient hyperglycemia has been associated with increased morbidity and mortality in critically ill patients. Optimal control of blood glucose (BG) levels using insulin infusion protocols has been shown to improve clinical outcomes. Protocols have been developed to prescribe a safe and effective rate of insulin infusion for optimal control of BG levels; however, a major obstacle in their implementation is their complexity. We have revised and updated our previously published pathway for the management of hyperglycemia, which introduces the "wheel" concept for insulin dosing. The "wheel" serves as a treatment guide. It is made up of 6 concentric circles. The core circle represents the goal of BG in critically ill patients, with inner circle showing the actual BG range of the patient. The 4 outer circles correspond to increasing rates of insulin infusion from tier 1 to tier 4. Simple guidelines are provided to facilitate conversion from insulin infusion to a subcutaneous insulin-delivery regimen in preparation for transfer from the cardiac care unit (CCU) setting. Our protocols also provide guidelines for management of diabetic ketoacidosis and hyperosmolar hyperglycemic states while at the same time creates a flowchart for activation of diabetes care team and their involvement in the multidisciplinary care of a patient in CCU with hyperglycemia and/or diabetes mellitus. This pathway provides a comprehensive and detailed, yet simple and practical algorithm for management of hyperglycemia in the CCU.

Sleep-disordered breathing is a highly prevalent medical condition, which if undiagnosed leads to increased morbidity and mortality, particularly related to increased incidence of cardiovascular events. It is therefore imperative that we identify patient population at high risk for sleep apnea and refer them to the appropriate therapy as early as possible. Up-to-date there is no management guideline specifically geared towards cardiac patients. Thus, we propose a (SAP) Sleep Apnea Pathway to correctly identify and triage these patients to the appropriate therapy.

Atrial fibrillation (AF) is the most common cardiac rhythm disturbance encountered in clinical practice, and its prevalence is increasing as the population ages. The American College of Cardiology, the American Heart Association, and the European Society of Cardiology established guidelines for the management of patients with AF. Atrial flutter (Afl) is less common and is often associated with or preceded by AF or occurs in an isolated pattern. A major limitation of the currently published guidelines for the management of patients with AF and Afl is their complexity, the fact that official guidelines are published separately for each of these arrhythmias, and that they were published several years ago. To address these deficiencies, we have developed a novel pathway for the management of AF and Afl. The pathway has been designated with the acronym RACE, which reflects the 4 main components in patient management: rate control, anticoagulation therapy, cardioversion, and electrophysiology/antiarrhythmic medication. This pathway is an attempt to incorporate, in a user-friendly format, the key concepts of the initial diagnosis and management of these prevalent arrhythmias. This is followed by a comprehensive guideline for therapy using the RACE acronym.

Lamotrigine overdose usually follows a benign pattern, and the majority of cases reported involve a co-ingestant. Prior reports have suggested the possible use of intravenous lipid emulsion in cases of severe sodium channel blockade. We describe the electrocardiographic changes in a massive lamotrigine overdose treated with intravenous lipid emulsion. A 36-year-old male with bipolar disorder ingested 13.5 g of lamotrigine in a suicidal attempt. The lamotrigine level was 78.0 μg/mL. Comprehensive drug screen was negative for all screened compounds. The electrocardiogram demonstrated a prolonged QRS complex and signs suggestive of sodium channel blockade. Refractory to treatment with sodium bicarbonate was treated with intravenous lipid emulsion, with immediate resolution of the electrocardiographic changes. Lamotrigine inhibits the voltage-gated sodium channel opening, attenuating the release of excitatory neurotransmitters. Cardiac intraventricular conduction could be delayed in cases of lamotrigine overdose resulting in QRS and QTc prolongation and R waves >3 mm in leads I and aVR. A potential role for intravenous lipid emulsion therapy has been described in patients with toxic levels of lamotrigine and electrocardiographic changes refractory to the treatment with sodium bicarbonate. Intravenous lipid emulsion has been successfully used in the treatment of lamotrigine cardiac toxicity.

Background Recent reports suggest altered antithrombotic efficacy and higher risk of bleeding with new oral anticoagulants (NOACs) in patients with renal insufficiency. A meta-analysis was performed to evaluate the efficacy and safety with recommended doses of NOAC compared with conventional treatment in patients with renal insufficiency. Methods PubMed, Cochrane Library, EMBASE, EBSCO, Web of Science, and CINAHL databases were searched from January 1, 2001 through March 23, 2014. Randomized controlled trials that compared NOACs (rivaroxaban, apixaban, and dabigatran) with comparators (vitamin K antagonist/warfarin, low molecular weight heparin, aspirin, placebo) were selected. We defined moderate renal insufficiency as creatinine clearance (estimated glomerular filtration rate [eGFR]) of 30-49 mL/min, and mild renal insufficiency as eGFR 50-79 mL/min. Results There were 40,693 patients with renal insufficiency in 10 trials. Compared with other anticoagulants in patients with mild renal insufficiency there was significantly less major or clinically relevant nonmajor bleeding (odds ratio [OR], 0.81; 95% confidence interval [CI], 0.72-0.90) and stroke or systemic embolism (OR, 0.70; 95% CI, 0.54-0.92) with NOACs. Using random effects meta-analysis, there was significantly less stroke or systemic embolism (OR, 0.72; 95% CI, 0.57-0.92) and a trend toward less major or clinically relevant nonmajor bleeding (OR, 0.82; 95% CI, 0.59-1.14) with the NOACs among patients with moderate renal insufficiency, and this became statistically significant when evaluated using a fixed effects model. NOACs showed efficiency comparable with conventional anticoagulants for prevention of venous thromboembolism or related mortality. Conclusions In patients with renal insufficiency, recommended doses of novel anticoagulants are noninferior and relatively safe compared with conventional anticoagulants.