Patients with advanced chronic kidney disease (CKD), including those treated with dialysis, are at high risk for the development of cardiovascular disease (CVD). CVD accounts for 45-50% of deaths among dialysis patients. Therapy of acute and chronic coronary heart disease (CHD) that is effective in the general population is frequently less effective in patients with advanced CKD. Drug therapy in such patients may require dose modification in some cases. Oral anti-platelet drugs are less effective in those with advanced CKD than in persons with normal or near normal renal function. The intravenous antiplatelet drugs eptifibatide and tirofiban both require dose reductions in patients with advanced CKD. Enoxaparin requires dose reduction in early stage CKD and is contraindicated in hemodialysis patients. Unfractionated heparin and warfarin maybe used without dose adjustment in CKD patients. Atenolol, acetbutolol and nadolol may require dose adjustments in CKD. Metoprolol and carvedilol do not. Calcium channel blockers and nitrates do not require dose adjustment, whereas ranolazine does. Angiotensin converting enzyme inhibitors and angiotensin receptor blockers may safely be used in CKD patients with close observation for hyperkalemia. The safety of spironolactone in such patients is questionable. Statins are less effective in reducing cardiovascular complication in CKD patients and their initiation is not recommended in dialysis patients. Coronary artery bypass grafting is associated with higher short-term mortality, but better long-term morbidity and mortality than percutaneous coronary interventions in patients with advanced CKD with non-ST segment ACS and chronic CHD.

Until recently, pharmaceutical options for stroke prevention in atrial fibrillation were restricted to aspirin or vitamin K antagonist therapy. In recent years development has been underway for alternatives. Apixaban, a direct Factor Xa inhibitor, is orally dosed, target selective and has few known drug or food interactions. As such, it is a member of a new generation of anticoagulants expected to revolutionize the way we approach anticoagulation for stroke prevention in atrial fibrillation. Apixaban has been studied in Phase II and Phase III trials for a variety of indications. The AVERROES trial established apixaban as superior to aspirin for stroke reduction in patients with atrial fibrillation for whom vitamin K antagonist therapy is unsuitable. The recent ARISTOTLE trial found apixaban to be superior to warfarin for stroke prevention in a wide range of patients with atrial fibrillation, with significantly lower bleeding risk, and lower risk of all-cause mortality.

A 43-year-old healthy Amish man presented to the emergency department with a history of blunt trauma to the chest following a horse kick. The blunt trauma happened 6 hours before presentation. He also reported loss of consciousness for a brief period of 5 minutes. After regaining consciousness, he experienced constant dull ache in his chest that radiated to his left shoulder. He presented to the emergency department for further evaluation. He was a tobacco user and there was no family history of coronary disease. On examination, he did not have any bruising over his chest. His chest was tender to palpation. Laboratory tests were significant for troponin T of 0.8 ng/mL (normal <0.01 ng/mL). Twelve-lead ECG revealed age indeterminate inferior infarct (Figure 1). Chest radiograph did not reveal any evidence of rib fractures. A preliminary diagnosis of cardiac contusion was made. Cardiac MRI was performed to evaluate for cardiac contusion. Cardiac MRI revealed no evidence of contusion. However, there was inferior, inferoseptal wall akinesis ( Blunt trauma to the chest has cardiac implications. Cardiac contusion, coronary dissection, coronary artery intramural hematoma, epicardial hematoma, and commotio cordis are some disease entities that occur secondary to blunt trauma. 1Myocardial infarction after blunt trauma can be secondary to dissection, intramural hematoma, or extrinsic compression from hematoma. Coronary intramural hematoma is a rare complication after blunt trauma, other causes being iatrogenic during percutaneous coronary intervention, spontaneous and retrograde propagation of aortic dissection. Hemorrhage in the vessel wall occurs because of the rupture of vasa vasorum and leads to hematoma formation in the medial-adventitial layers. This entity is distinguished from coronary dissection by the absence of intimal flap. Intravascular ultrasound is the mainstay modality to diagnose intramural hematomas and to differentiate from dissection.2 The most common coronary artery to be involved in blunt trauma is the left anterior descending artery, followed by right coronary artery 3 and left circumflex artery.3 Very few reports of coronary intramural hematomas secondary to blunt trauma have been published. 4 Our case is unique in that cardiac MRI performed to assess for contusion revealed evidence of transmural infarction in the right coronary artery territory. This prompted emergent coronary angiography. Intravascular ultrasound performed during angiography further characterized the mechanism of myocardial infarction. Elevated cardiac biomarkers can be seen both with contusion, and with vessel injury, as well. Multimodality assessment in patients experiencing blunt trauma can characterize the type of myocardial injury and expedite appropriate therapy. DisclosuresNone. References

Atrial fibrillation (AF) is an increasingly common cardiac arrhythmia, currently affecting more than 5 million Americans. Management of patients with AF can be complex, with key strategies including selecting rhythm control versus heart rate control and reducing the patient's risk of stroke or other systemic embolization. The American Heart Association, American College of Cardiology, and Heart Rhythm Society released 2014 Guideline for the Management of Patients with Atrial Fibrillation, which outlines several new recommendations with important clinical implications. Among these are a new recommendation to use the CHA2DS2-Vasc score for stroke risk assessment, rather than the previously advised CHADS2 score, expansion of anticoagulation options in selected patients, decreased emphasis on the role of aspirin, and an increased emphasis on the role of catheter ablation.

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