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Rali AS, Tran L, Balakrishna A, Senussi M, Kapur NK, Metkus T, Tedford RJ, Lindenfeld J. Guide to Lung-Protective Ventilation in Cardiac Patients. J Card Fail 2024; 30:829-837. [PMID: 38513887 DOI: 10.1016/j.cardfail.2024.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 01/12/2024] [Accepted: 01/16/2024] [Indexed: 03/23/2024]
Abstract
The incidence of acute respiratory insufficiency has continued to increase among patients admitted to modern-day cardiovascular intensive care units. Positive pressure ventilation (PPV) remains the mainstay of treatment for these patients. Alterations in intrathoracic pressure during PPV has distinct effects on both the right and left ventricles, affecting cardiovascular performance. Lung-protective ventilation (LPV) minimizes the risk of further lung injury through ventilator-induced lung injury and, hence, an understanding of LPV and its cardiopulmonary interactions is beneficial for cardiologists.
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Affiliation(s)
- Aniket S Rali
- Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, TN.
| | - Lena Tran
- Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, TN
| | - Aditi Balakrishna
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
| | - Mourad Senussi
- Department of Medicine, Baylor St. Luke's Medical Center, Houston, TX
| | - Navin K Kapur
- Division of Cardiovascular Diseases, Tufts Medical Center, Boston, MA
| | - Thomas Metkus
- Departments of Medicine and Surgery, Divisions of Cardiology and Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ryan J Tedford
- Department of Medicine, Division of Cardiology, Medical University of South Carolina, Charleston, SC
| | - Joann Lindenfeld
- Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, TN
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2
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Papolos AI, Kenigsberg BB, Singam NSV, Berg DD, Guo J, Bohula EA, Katz JN, Diepen SVAN, Morrow DA. Pulmonary Artery Diastolic Pressure as a Surrogate for Pulmonary Capillary Wedge Pressure in Cardiogenic Shock. J Card Fail 2024; 30:853-856. [PMID: 38513886 DOI: 10.1016/j.cardfail.2024.02.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 02/06/2024] [Accepted: 02/16/2024] [Indexed: 03/23/2024]
Abstract
BACKGROUND It is common for clinicians to use the pulmonary artery diastolic pressure (PADP) as a surrogate for the pulmonary capillary wedge pressure (PCWP). Here, we determine the validity of this relationship in patients with various phenotypes of cardiogenic shock (CS). METHODS AND RESULTS In this analysis of the Critical Care Cardiology Trials Network registry, we identified 1225 people admitted with CS who received pulmonary artery catheters. Linear regression, Bland-Altman and receiver operator characteristic analyses were performed to determine the strength of the association between PADP and PCWP in patients with left-, right-, biventricular, and other non-myocardia phenotypes of CS (eg, arrhythmia, valvular stenosis, tamponade). There was a moderately strong correlation between PADP and PCWP in the total population (r = 0.64, n = 1225) and in each CS phenotype, except for right ventricular CS, for which the correlation was weak (r = 0.43, n = 71). Additionally, we found that a PADP ≥ 24 mmHg can be used to infer a PCWP ≥ 18 mmHg with ≥ 90% confidence in all but the right ventricular CS phenotype. CONCLUSIONS This analysis validates the practice of using PADP as a surrogate for PCWP in most patients with CS; however, it should generally be avoided in cases of right ventricular-predominant CS.
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Affiliation(s)
- Alexander I Papolos
- Department of Critical Care and Division of Cardiology, MedStar Washington Hospital Center, Washington, DC, USA.
| | - Benjamin B Kenigsberg
- Department of Critical Care and Division of Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Narayana Sarma V Singam
- Department of Critical Care and Division of Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - David D Berg
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Jianping Guo
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Erin A Bohula
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Jason N Katz
- Department of Medicine, Division of Cardiology, New York University, New York, NY, USA
| | - Sean VAN Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - David A Morrow
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
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3
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Hamzi K, Gall E, Roubille F, Trimaille A, Elbaz M, El Ouahidi A, Noirclerc N, Fard D, Lattuca B, Fauvel C, Goralski M, Alvain S, Chaib A, Piliero N, Schurtz G, Pommier T, Bouleti C, Tron C, Bonnet G, Nhan P, Auvray S, Léquipar A, Dillinger JG, Vicaut E, Henry P, Toupin S, Pezel T. Phenotypic clustering of patients hospitalized in intensive cardiac care units: Insights from the ADDICT-ICCU study. Arch Cardiovasc Dis 2024:S1875-2136(24)00211-0. [PMID: 38834393 DOI: 10.1016/j.acvd.2024.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 03/16/2024] [Accepted: 03/25/2024] [Indexed: 06/06/2024]
Abstract
BACKGROUND Intensive cardiac care units (ICCUs) were created to manage ventricular arrhythmias after acute coronary syndromes, but have diversified to include a more heterogeneous population, the characteristics of which are not well depicted by conventional methods. AIMS To identify ICCU patient subgroups by phenotypic unsupervised clustering integrating clinical, biological, and echocardiographic data to reveal pathophysiological differences. METHODS During 7-22 April 2021, we recruited all consecutive patients admitted to ICCUs in 39 centers. The primary outcome was in-hospital major adverse events (MAEs; death, resuscitated cardiac arrest or cardiogenic shock). A cluster analysis was performed using a Kamila algorithm. RESULTS Of 1499 patients admitted to the ICCU (69.6% male, mean age 63.3±14.9 years), 67 (4.5%) experienced MAEs. Four phenogroups were identified: PG1 (n=535), typically patients with non-ST-segment elevation myocardial infarction; PG2 (n=444), younger smokers with ST-segment elevation myocardial infarction; PG3 (n=273), elderly patients with heart failure with preserved ejection fraction and conduction disturbances; PG4 (n=247), patients with acute heart failure with reduced ejection fraction. Compared to PG1, multivariable analysis revealed a higher risk of MAEs in PG2 (odds ratio [OR] 3.13, 95% confidence interval [CI] 1.16-10.0) and PG3 (OR 3.16, 95% CI 1.02-10.8), with the highest risk in PG4 (OR 20.5, 95% CI 8.7-60.8) (all P<0.05). CONCLUSIONS Cluster analysis of clinical, biological, and echocardiographic variables identified four phenogroups of patients admitted to the ICCU that were associated with distinct prognostic profiles. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT05063097.
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Affiliation(s)
- Kenza Hamzi
- Inserm MASCOT - UMRS 942, Department of Cardiology, University Hospital of Lariboisière, Université Paris-Cité, Assistance publique-Hôpitaux de Paris (AP-HP), 75010 Paris, France; Department of Data Science, Machine Learning and Artificial Intelligence in Health, DATA-TEMPLE Laboratory, University Hospital of Lariboisière (AP-HP), 75010 Paris, France
| | - Emmanuel Gall
- Inserm MASCOT - UMRS 942, Department of Cardiology, University Hospital of Lariboisière, Université Paris-Cité, Assistance publique-Hôpitaux de Paris (AP-HP), 75010 Paris, France; Department of Data Science, Machine Learning and Artificial Intelligence in Health, DATA-TEMPLE Laboratory, University Hospital of Lariboisière (AP-HP), 75010 Paris, France
| | - François Roubille
- Inserm, CNRS, PhyMedExp, Cardiology Department, INI-CRT, Université de Montpellier, CHU de Montpellier, 34295 Montpellier, France
| | - Antonin Trimaille
- Department of Cardiovascular Medicine, Nouvel Hôpital Civil, Strasbourg University Hospital, 67000 Strasbourg, France
| | - Meyer Elbaz
- Intensive Cardiac Care Unit, Rangueil University Hospital, Toulouse, France
| | - Amine El Ouahidi
- Department of Cardiology, University Hospital of Brest, 29609 Brest cedex, France
| | - Nathalie Noirclerc
- Service de Cardiologie, Centre Hospitalier Annecy-Genevois, 74370 Épagny-Metz-Tessy, France
| | - Damien Fard
- Intensive Cardiac Care Unit, University Hospital Henri-Mondor, Créteil, France
| | - Benoit Lattuca
- Department of Cardiology, Nîmes University Hospital, Montpellier University, Nîmes, France
| | - Charles Fauvel
- Inserm U1096, Department of Cardiology, Université de Rouen-Normandie, CHU de Rouen, 76000 Rouen, France
| | - Marc Goralski
- Service de Cardiologie, Centre Hospitalier d'Orleans, Orléans, France
| | - Sean Alvain
- Service de Cardiologie, Centre Hospitalier de Saintes, Saintes, France
| | - Aures Chaib
- Service de Cardiologie, Centre Hospitalier de Montreuil, Montreuil, France
| | - Nicolas Piliero
- Service de Cardiologie, CHU de Grenoble-Alpes, Grenoble, France
| | - Guillaume Schurtz
- Department of Cardiology, University Hospital of Lille, Lille, France
| | - Thibaut Pommier
- Department of Cardiology, University Hospital, Dijon, France
| | - Claire Bouleti
- Department of Cardiology, University Hospital of Poitiers, 86000 Poitiers, France
| | - Christophe Tron
- Inserm U1096, Department of Cardiology, Université de Rouen-Normandie, CHU de Rouen, 76000 Rouen, France
| | - Guillaume Bonnet
- Inserm, Inrae, C2VN, Service de Cardiologie Interventionnelle, Aix-Marseille Université, CHU de Timone, AP-HM, Marseille, France
| | - Pascal Nhan
- Inserm UMR_S 938, Centre de Recherche Saint-Antoine, Institut Hospitalo-Universitaire de Cardiométabolisme et Nutrition (ICAN), Sorbonne Université, Paris, France; Service de Cardiologie, Hôpital Saint-Antoine, Assistance publique-Hôpitaux de Paris, Paris, France
| | - Simon Auvray
- Department of Cardiology, Felix-Guyon University Hospital, Saint-Denis, Reunion
| | - Antoine Léquipar
- Inserm MASCOT - UMRS 942, Department of Cardiology, University Hospital of Lariboisière, Université Paris-Cité, Assistance publique-Hôpitaux de Paris (AP-HP), 75010 Paris, France; Department of Data Science, Machine Learning and Artificial Intelligence in Health, DATA-TEMPLE Laboratory, University Hospital of Lariboisière (AP-HP), 75010 Paris, France
| | - Jean-Guillaume Dillinger
- Inserm MASCOT - UMRS 942, Department of Cardiology, University Hospital of Lariboisière, Université Paris-Cité, Assistance publique-Hôpitaux de Paris (AP-HP), 75010 Paris, France; Department of Data Science, Machine Learning and Artificial Intelligence in Health, DATA-TEMPLE Laboratory, University Hospital of Lariboisière (AP-HP), 75010 Paris, France
| | - Eric Vicaut
- Department of Data Science, Machine Learning and Artificial Intelligence in Health, DATA-TEMPLE Laboratory, University Hospital of Lariboisière (AP-HP), 75010 Paris, France; Unité de Recherche Clinique, Hôpital Fernand-Widal, AP-HP, 75010 Paris, France
| | - Patrick Henry
- Inserm MASCOT - UMRS 942, Department of Cardiology, University Hospital of Lariboisière, Université Paris-Cité, Assistance publique-Hôpitaux de Paris (AP-HP), 75010 Paris, France; Department of Data Science, Machine Learning and Artificial Intelligence in Health, DATA-TEMPLE Laboratory, University Hospital of Lariboisière (AP-HP), 75010 Paris, France
| | - Solenn Toupin
- Inserm MASCOT - UMRS 942, Department of Cardiology, University Hospital of Lariboisière, Université Paris-Cité, Assistance publique-Hôpitaux de Paris (AP-HP), 75010 Paris, France; Department of Data Science, Machine Learning and Artificial Intelligence in Health, DATA-TEMPLE Laboratory, University Hospital of Lariboisière (AP-HP), 75010 Paris, France
| | - Théo Pezel
- Inserm MASCOT - UMRS 942, Department of Cardiology, University Hospital of Lariboisière, Université Paris-Cité, Assistance publique-Hôpitaux de Paris (AP-HP), 75010 Paris, France; Department of Data Science, Machine Learning and Artificial Intelligence in Health, DATA-TEMPLE Laboratory, University Hospital of Lariboisière (AP-HP), 75010 Paris, France.
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Berg DD, Singal S, Palazzolo M, Baird-Zars VM, Bofarrag F, Bohula EA, Chaudhry SP, Dodson MW, Hillerson D, Lawler PR, Liu S, O'Brien CG, Pisani BA, Racharla L, Roswell RO, Shah KS, Solomon MA, Sridharan L, Thompson AD, Diepen SVAN, Katz JN, Morrow DA. Modes of Death in Patients with Cardiogenic Shock in the Cardiac Intensive Care Unit: A Report from the Critical Care Cardiology Trials Network. J Card Fail 2024; 30:728-733. [PMID: 38387758 PMCID: PMC11098678 DOI: 10.1016/j.cardfail.2024.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 01/26/2024] [Indexed: 02/24/2024]
Abstract
BACKGROUND There are limited data on how patients with cardiogenic shock (CS) die. METHODS The Critical Care Cardiology Trials Network is a research network of cardiac intensive care units coordinated by the Thrombolysis In Myocardial Infarction (TIMI) Study Group (Boston, MA). Using standardized definitions, site investigators classified direct modes of in-hospital death for CS admissions (October 2021 to September 2022). Mutually exclusive categories included 4 modes of cardiovascular death and 4 modes of noncardiovascular death. Subgroups defined by CS type, preceding cardiac arrest (CA), use of temporary mechanical circulatory support (tMCS), and transition to comfort measures were evaluated. RESULTS Among 1068 CS cases, 337 (31.6%) died during the index hospitalization. Overall, the mode of death was cardiovascular in 82.2%. Persistent CS was the dominant specific mode of death (66.5%), followed by arrhythmia (12.8%), anoxic brain injury (6.2%), and respiratory failure (4.5%). Patients with preceding CA were more likely to die from anoxic brain injury (17.1% vs 0.9%; P < .001) or arrhythmia (21.6% vs 8.4%; P < .001). Patients managed with tMCS were more likely to die from persistent shock (P < .01), both cardiogenic (73.5% vs 62.0%) and noncardiogenic (6.1% vs 2.9%). CONCLUSIONS Most deaths in CS are related to direct cardiovascular causes, particularly persistent CS. However, there is important heterogeneity across subgroups defined by preceding CA and the use of tMCS.
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Affiliation(s)
- David D Berg
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Sachit Singal
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Michael Palazzolo
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Vivian M Baird-Zars
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Fadel Bofarrag
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Erin A Bohula
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Mark W Dodson
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, Utah
| | - Dustin Hillerson
- Department of Medicine, Division of Cardiovascular Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | | | - Shuangbo Liu
- Section of Cardiology, Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Connor G O'Brien
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Barbara A Pisani
- Section of Cardiovascular Medicine, Department of Internal Medicine, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | | | - Robert O Roswell
- Northwell, Department of Cardiology, Zucker School of Medicine at Hofstra/Northwell. New Hyde Park, NY
| | - Kevin S Shah
- Division of Cardiology, Department of Medicine, University of Utah, Salt Lake City, Utah
| | - Michael A Solomon
- Critical Care Medicine Department, National Institutes of Health Clinical Center and Cardiovascular Branch, National Heart, Lung, Blood Institute of the National Institutes of Health, Bethesda, Maryland
| | - Lakshmi Sridharan
- Division of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Andrea D Thompson
- Division of Cardiovascular Medicine, Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Sean VAN Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Jason N Katz
- NYU Grossman School of Medicine & Bellevue Hospital Center, New York, New York
| | - David A Morrow
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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5
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Koerber DM, Katz JN, Bohula E, Park JG, Dodson MW, Gerber DA, Hillerson D, Liu S, Pierce MJ, Prasad R, Rose SW, Sanchez PA, Shaw J, Wang J, Jentzer JC, Kristin Newby L, Daniels LB, Morrow DA, van Diepen S. Variation in risk-adjusted cardiac intensive care unit (CICU) length of stay and the association with in-hospital mortality: An analysis from the Critical Care Cardiology Trials Network (CCCTN) registry. Am Heart J 2024; 271:28-37. [PMID: 38369218 DOI: 10.1016/j.ahj.2024.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 02/13/2024] [Indexed: 02/20/2024]
Abstract
BACKGROUND Previous studies have suggested that there is wide variability in cardiac intensive care unit (CICU) length of stay (LOS); however, these studies are limited by the absence of detailed risk assessment at the time of admission. Thus, we evaluated inter-hospital differences in CICU LOS, and the association between LOS and in-hospital mortality. METHODS Using data from the Critical Care Cardiology Trials Network (CCCTN) registry, we included 22,862 admissions between 2017 and 2022 from 35 primarily tertiary and quaternary CICUs that captured consecutive admissions in annual 2-month snapshots. The primary analysis compared inter-hospital differences in CICU LOS, as well as the association between CICU LOS and all-cause in-hospital mortality using a Fine and Gray competing risk model. RESULTS The overall median CICU LOS was 2.2 (1.1-4.8) days, and the median hospital LOS was 5.9 (2.8-12.3) days. Admissions in the longest tertile of LOS tended to be younger with higher rates of pre-existing comorbidities, and had higher Sequential Organ Failure Assessment (SOFA) scores, as well as higher rates of mechanical ventilation, intravenous vasopressor use, mechanical circulatory support, and renal replacement therapy. Unadjusted all-cause in-hospital mortality was 9.3%, 6.7%, and 13.4% in the lowest, intermediate, and highest CICU LOS tertiles. In a competing risk analysis, individual patient CICU LOS was correlated (r2 = 0.31) with a higher risk of 30-day in-hospital mortality. The relationship remained significant in admissions with heart failure, ST-elevation myocardial infarction and non-ST segment elevation myocardial infarction. CONCLUSIONS In a large registry of academic CICUs, we observed significant variation in CICU LOS and report that LOS is independently associated with all-cause in-hospital mortality. These findings could potentially be used to improve CICU resource utilization planning and refine risk prognostication in critically ill cardiovascular patients.
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Affiliation(s)
- Daniel M Koerber
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | | | - Erin Bohula
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Jeong-Gun Park
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Mark W Dodson
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT
| | - Daniel A Gerber
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA
| | - Dustin Hillerson
- Department of Medicine, Division of Cardiovascular Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Shuangbo Liu
- Max Rady College of Medicine, St. Boniface Hospital, Winnipeg, Manitoba, Canada
| | - Matthew J Pierce
- North Shore University Hospital, Northwell Health, Manhasset, NY, USA
| | | | - Scott W Rose
- Atrium Health Wake Forest Baptist, Winston-Salem, NC
| | - Pablo A Sanchez
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA
| | - Jeffrey Shaw
- Division of Cardiology, Department of Cardiac Sciences, University of Calgary, Calgary, Alberta, Canada
| | | | - Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - L Kristin Newby
- Division of Cardiology, Department of Medicine, Duke Clinical Research Institute, Durham, NC
| | - Lori B Daniels
- Division of Cardiovascular Medicine, Department of Medicine, University of California, San Diego, La Jolla, CA
| | - David A Morrow
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Sean van Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.
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6
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Patel SM, Berg DD, Bohula EA, Baird-Zars VM, Barsness GW, Chaudhry SP, Chonde MD, Cooper HA, Ginder C, Jentzer JC, Kontos MC, Miller PE, Newby LK, O'Brien CG, Park JG, Pierce MJ, Pisani BA, Potter BJ, Shah KS, Teuteberg JJ, Katz JN, van Diepen S, Morrow DA. Early Serial Assessment of Aggregate Vasoactive Support and Mortality in Cardiogenic Shock: Insights From the Critical Care Cardiology Trials Network Registry. Circ Heart Fail 2024; 17:e011736. [PMID: 38587438 DOI: 10.1161/circheartfailure.124.011736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 03/19/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND Associations of early changes in vasoactive support with cardiogenic shock (CS) mortality remain incompletely defined. METHODS The Critical Care Cardiology Trials Network is a multicenter registry of cardiac intensive care units. Patients admitted with CS (2018-2023) had vasoactive dosing assessed at 4 and 24 hours from cardiac intensive care unit admission and quantified by the vasoactive-inotropic score (VIS). Prognostic associations of VIS at both time points, as well as change in VIS from 4 to 24 hours, were examined. Interaction testing was performed based on mechanical circulatory support status. RESULTS Among 3665 patients, 82% had a change in VIS <10, with 7% and 11% having a ≥10-point increase and decrease from 4 to 24 hours, respectively. The 4 and 24-hour VIS were each associated with cardiac intensive care unit mortality (13%-45% and 11%-73% for VIS <10 to ≥40, respectively; Ptrend <0.0001 for each). Stratifying by the 4-hour VIS, changes in VIS from 4 to 24 hours had a graded association with mortality, ranging from a 2- to >4-fold difference in mortality comparing those with a ≥10-point increase to ≥10-point decrease in VIS (Ptrend <0.0001). The change in VIS alone provided good discrimination of cardiac intensive care unit mortality (C-statistic, 0.72 [95% CI, 0.70-0.75]) and improved discrimination of the 24-hour Sequential Organ Failure Assessment score (0.72 [95% CI, 0.69-0.74] to 0.76 [95% CI, 0.74-0.78]) and the clinician-assessed Society for Cardiovascular Angiography and Interventions shock stage (0.72 [95% CI, 0.70-0.74] to 0.77 [95% CI, 0.75-0.79]). Although present in both groups, the mortality risk associated with VIS was attenuated in patients managed with versus without mechanical circulatory support (odds ratio per 10-point higher 24-hour VIS, 1.36 [95% CI, 1.23-1.49] versus 1.84 [95% CI, 1.69-2.01]; Pinteraction <0.0001). CONCLUSIONS Early changes in the magnitude of vasoactive support in CS are associated with a gradient of risk for mortality. These data suggest that early VIS trajectory may improve CS prognostication, with the potential to be leveraged for clinical decision-making and research applications in CS.
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Affiliation(s)
- Siddharth M Patel
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (S.M.P., D.D.B., E.A.B., V.M.B.-Z., C.G., J.-G.P., D.A.M.)
| | - David D Berg
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (S.M.P., D.D.B., E.A.B., V.M.B.-Z., C.G., J.-G.P., D.A.M.)
| | - Erin A Bohula
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (S.M.P., D.D.B., E.A.B., V.M.B.-Z., C.G., J.-G.P., D.A.M.)
| | - Vivian M Baird-Zars
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (S.M.P., D.D.B., E.A.B., V.M.B.-Z., C.G., J.-G.P., D.A.M.)
| | - Gregory W Barsness
- Department of Cardiovascular Medicine, Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN (G.W.B., J.C.J.)
| | | | - Meshe D Chonde
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (M.D.C.)
| | - Howard A Cooper
- Department of Cardiology, Westchester Medical Center, Valhalla, NY (H.A.C.)
| | - Curtis Ginder
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (S.M.P., D.D.B., E.A.B., V.M.B.-Z., C.G., J.-G.P., D.A.M.)
| | - Jacob C Jentzer
- Department of Cardiovascular Medicine, Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN (G.W.B., J.C.J.)
| | - Michael C Kontos
- Division of Cardiology, Department of Medicine, Virginia Commonwealth University, Richmond (M.C.K.)
| | - P Elliott Miller
- Section of Cardiovascular Medicine, Yale University, New Haven, CT (P.E.M.)
| | - L Kristin Newby
- Division of Cardiology and Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (L.K.N.)
| | - Connor G O'Brien
- Division of Cardiology, Department of Medicine, University of California San Francisco (C.G.O.B.)
| | - Jeong-Gun Park
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (S.M.P., D.D.B., E.A.B., V.M.B.-Z., C.G., J.-G.P., D.A.M.)
| | - Matthew J Pierce
- Department of Cardiology, Northwell Health, Zucker School of Medicine, New Hyde Park, NY (M.J.P.)
| | - Barbara A Pisani
- Section of Cardiovascular Medicine, Department of Internal Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC (B.A.P.)
| | - Brian J Potter
- Cardiology Service, Department of Medicine, Centre Hospitalier de l'Université de Montréal Research Center and Cardiovascular Center, Quebec, QC, Canada (B.J.P.)
| | - Kevin S Shah
- Division of Cardiology, Department of Medicine, University of Utah, Salt Lake City (K.S.S.)
| | - Jeffrey J Teuteberg
- Division of Cardiovascular Medicine, Stanford University School of Medicine, CA (J.J.T.)
| | - Jason N Katz
- Division of Cardiovascular Medicine, Department of Medicine, New York University School of Medicine, New York (J.N.K.)
| | - Sean van Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, AB, Canada (S.v.D.)
| | - David A Morrow
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (S.M.P., D.D.B., E.A.B., V.M.B.-Z., C.G., J.-G.P., D.A.M.)
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7
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Keane RR, Menon V, Cremer PC. Acute Heart Valve Emergencies. Cardiol Clin 2024; 42:237-252. [PMID: 38631792 DOI: 10.1016/j.ccl.2024.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
Within the cardiac intensive care unit, prompt recognition of severe acute valvular lesions is essential because hemodynamic collapse can occur rapidly, especially when cardiac chambers have not had time for compensatory remodeling. Within this context, optimal medical management, considerations for temporary mechanical circulatory support and decisive treatments strategies are addressed. Fundamental concepts include an appreciation for how sudden changes in flow and pressure gradients between cardiac chambers can impact hemodynamic and echocardiographic findings differently compared to similarly severe chronic lesions, as well as understanding the main causes for decompensated heart failure and cardiogenic shock for each valvular abnormality.
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Affiliation(s)
- Ryan R Keane
- Department of Cardiovascular Medicine, Cleveland Clinic Coordinating Center for Clinical Research, Heart Vascular and Thoracic Institute, 9500 Euclid Ave: Desk J1-5, Cleveland, OH 44195, USA
| | - Venu Menon
- Department of Cardiovascular Medicine, Cleveland Clinic Coordinating Center for Clinical Research, Heart Vascular and Thoracic Institute, 9500 Euclid Ave: Desk J1-5, Cleveland, OH 44195, USA
| | - Paul C Cremer
- Department of Cardiovascular Medicine, Cleveland Clinic Coordinating Center for Clinical Research, Heart Vascular and Thoracic Institute, 9500 Euclid Ave: Desk J1-5, Cleveland, OH 44195, USA.
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8
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Lopez MP, Applefeld W, Miller PE, Elliott A, Bennett C, Lee B, Barnett C, Solomon MA, Corradi F, Sionis A, Mireles-Cabodevila E, Tavazzi G, Alviar CL. Complex Heart-Lung Ventilator Emergencies in the CICU. Cardiol Clin 2024; 42:253-271. [PMID: 38631793 DOI: 10.1016/j.ccl.2024.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
This review aims to enhance the comprehension and management of cardiopulmonary interactions in critically ill patients with cardiovascular disease undergoing mechanical ventilation. Highlighting the significance of maintaining a delicate balance, this article emphasizes the crucial role of adjusting ventilation parameters based on both invasive and noninvasive monitoring. It provides recommendations for the induction and liberation from mechanical ventilation. Special attention is given to the identification of auto-PEEP (positive end-expiratory pressure) and other situations that may impact hemodynamics and patients' outcomes.
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Affiliation(s)
- Mireia Padilla Lopez
- Department of Cardiology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute IIB Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Willard Applefeld
- Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - P. Elliott Miller
- Division of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Andrea Elliott
- Division of Cardiology, University of Minnesota, Minneapolis, MN, USA
| | - Courtney Bennett
- Heart and Vascular Institute, Leigh Valley Health Network, Allentown, PA, USA
| | - Burton Lee
- Department of Critical Care Medicine, National Institutes of Health Clinical Center, Bethesda, MA, USA
| | - Christopher Barnett
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Michael A Solomon
- Clinical Center and Cardiology Branch, Critical Care Medicine Department, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MA, USA
| | - Francesco Corradi
- Department of Surgical, Medical, Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy
| | - Alessandro Sionis
- Department of Cardiology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute IIB Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Eduardo Mireles-Cabodevila
- Respiratory Institute, Cleveland Clinic, Ohio and the Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Guido Tavazzi
- Department of Critical Care Medicine, Intensive Care Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Carlos L Alviar
- The Leon H. Charney Division of Cardiovascular Medicine, New York University School of Medicine, USA.
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9
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Desai R, Mondal A, Patel V, Singh S, Chauhan S, Jain A. Elevated cardiovascular risk and acute events in hospitalized colon cancer survivors: A decade-apart study of two nationwide cohorts. World J Clin Oncol 2024; 15:548-553. [PMID: 38689632 PMCID: PMC11056864 DOI: 10.5306/wjco.v15.i4.548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 03/18/2024] [Accepted: 03/21/2024] [Indexed: 04/22/2024] Open
Abstract
BACKGROUND Over the years, strides in colon cancer detection and treatment have boosted survival rates; yet, post-colon cancer survival entails cardiovascular disease (CVD) risks. Research on CVD risks and acute cardiovascular events in colorectal cancer survivors has been limited. AIM To compare the CVD risk and adverse cardiovascular outcomes in current colon cancer survivors compared to a decade ago. METHODS We analyzed 2007 and 2017 hospitalization data from the National Inpatient Sample, studying two colon cancer survivor groups for CVD risk factors, mortality rates, and major adverse events like pulmonary embolism, arrhythmia, cardiac arrest, and stroke, adjusting for confounders via multivariable regression analysis. RESULTS Of total colon cancer survivors hospitalized in 2007 (n = 177542) and 2017 (n = 178325), the 2017 cohort often consisted of younger (76 vs 77 years), male, African-American, and Hispanic patients admitted non-electively vs the 2007 cohort. Furthermore, the 2017 cohort had higher rates of smoking, alcohol abuse, drug abuse, coagulopathy, liver disease, weight loss, and renal failure. Patients in the 2017 cohort also had higher rates of cardiovascular comorbidities, including hypertension, hyperlipidemia, diabetes, obesity, peripheral vascular disease, congestive heart failure, and at least one traditional CVD (P < 0.001) vs the 2007 cohort. On adjusted multivariable analysis, the 2017 cohort had a significantly higher risk of pulmonary embolism (PE) (OR: 1.47, 95%CI: 1.37-1.48), arrhythmia (OR: 1.41, 95%CI: 1.38-1.43), atrial fibrillation/flutter (OR: 1.61, 95%CI: 1.58-1.64), cardiac arrest including ventricular tachyarrhythmia (OR: 1.63, 95%CI: 1.46-1.82), and stroke (OR: 1.28, 95%CI: 1.22-1.34) with comparable all-cause mortality and fewer routine discharges (48.4% vs 55.0%) (P < 0.001) vs the 2007 cohort. CONCLUSION Colon cancer survivors hospitalized 10 years apart in the United States showed an increased CVD risk with an increased risk of acute cardiovascular events (stroke 28%, PE 47%, arrhythmia 41%, and cardiac arrest 63%). It is vital to regularly screen colon cancer survivors with concomitant CVD risk factors to curtail long-term cardiovascular complications.
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Affiliation(s)
- Rupak Desai
- Independent Researcher, Atlanta, GA 30079, United States
| | - Avilash Mondal
- Department of Internal Medicine, Nazareth Hospital, Philadelphia, PA 19152, United States
| | - Vivek Patel
- Department of Internal Medicine, Nazareth Hospital, Philadelphia, PA 19152, United States
| | - Sandeep Singh
- Department of Clinical Epidemiology, Biostatistics and Bio-informatics, Amsterdam UMC, Amsterdam 7057, Netherlands
| | - Shaylika Chauhan
- Department of Internal Medicine, Geisinger Health System, Wikes-Barre, PA 18702, United States
| | - Akhil Jain
- Division of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX 77079, United States
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10
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Padkins M, Kashani K, Tabi M, Gajic O, Jentzer JC. Association between the shock index on admission and in-hospital mortality in the cardiac intensive care unit. PLoS One 2024; 19:e0298327. [PMID: 38626151 PMCID: PMC11020967 DOI: 10.1371/journal.pone.0298327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 01/22/2024] [Indexed: 04/18/2024] Open
Abstract
BACKGROUND An elevated shock index (SI) predicts worse outcomes in multiple clinical arenas. We aimed to determine whether the SI can aid in mortality risk stratification in unselected cardiac intensive care unit patients. METHODS We included admissions to the Mayo Clinic from 2007 to 2015 and stratified them based on admission SI. The primary outcome was in-hospital mortality, and predictors of in-hospital mortality were analyzed using multivariable logistic regression. RESULTS We included 9,939 unique cardiac intensive care unit patients with available data for SI. Patients were grouped by SI as follows: < 0.6, 3,973 (40%); 0.6-0.99, 4,810 (48%); and ≥ 1.0, 1,156 (12%). After multivariable adjustment, both heart rate (adjusted OR 1.06 per 10 beats per minute higher; CI 1.02-1.10; p-value 0.005) and systolic blood pressure (adjusted OR 0.94 per 10 mmHg higher; CI 0.90-0.97; p-value < 0.001) remained associated with higher in-hospital mortality. As SI increased there was an incremental increase in in-hospital mortality (adjusted OR 1.07 per 0.1 beats per minute/mmHg higher, CI 1.04-1.10, p-Value < 0.001). A higher SI was associated with increased mortality across all examined admission diagnoses. CONCLUSION The SI is a simple and universally available bedside marker that can be used at the time of admission to predict in-hospital mortality in cardiac intensive care unit patients.
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Affiliation(s)
- Mitchell Padkins
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Kianoush Kashani
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Meir Tabi
- Division of Cardiovascular Medicine, Department of Medicine, Jesselson Integrated Heart Center, Jerusalem, Israel
| | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Jacob C. Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
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11
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Nilsson T, Mokhtari A, Sandgren J, Lundager Forberg J, Olsson de Capretz P, Ekelund U. Complications in Emergency Department Patients with Acute Coronary Syndrome with Contemporary Care. Cardiology 2024:1-10. [PMID: 38599184 DOI: 10.1159/000538637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 03/28/2024] [Indexed: 04/12/2024]
Abstract
INTRODUCTION With the implementation of early reperfusion therapy, the number of complications in patients with acute coronary syndrome (ACS) has diminished significantly. However, ACS patients are still routinely admitted to units with high-level monitoring such as the coronary or intensive care unit (CCU/ICU). The cost of these admissions is high and there is often a shortage of beds. The aim of this study was to analyze the complications in contemporary emergency department (ED) patients with ACS and to map patient management. METHODS This observational study was a secondary analysis of data collected in the ESC-TROP trial (NCT03421873) that included 26,545 consecutive chest pain patients ≥18 years at five Swedish EDs. Complications were defined as the following within 30 days: death, cardiac arrest, cardiogenic shock, pulmonary edema, severe ventricular arrhythmia, high-degree atrioventricular (AV) block that required a pacemaker, and mechanical complications such as papillary muscle rupture, cardiac tamponade, or ventricular septum defects (VSDs). Complications were identified via diagnosis and/or intervention codes in the database, and manual chart review was performed in cases with complications. RESULTS Of all 26,545 patients, 2,463 (9.3%) were diagnosed with ACS, and 151 of these (6.1%) suffered any complication within 30 days. Mean age was higher in patients with (79.2 years) than without (69.4 years) complications, and more were female (39.7% vs. 33.0%). Eighty-four (3.4% of all ACS patients) patients died, 33 (1.3%) had cardiac arrest, 22 (0.9%) respiratory failure, 13 (0.5%) high-degree AV block, 10 (0.4%) cardiogenic shock, 12 (0.5%) severe ventricular arrhythmia, and 2 each (<0.1%) had VSD or cardiac tamponade. Almost 30% of the complications were present already at the ED, and 40% of patients with complications were not admitted to the CCU/ICU. Only 80 (53%) of the patients with complications underwent coronary angiography and 62 (41%) were revascularized with percutaneous coronary intervention or coronary artery bypass grafting. CONCLUSION With current care, serious complications occurred in only 6 out of 100 ACS patients, and 2 of these complications were present already at the ED. Four out of 10 ACS patients with complications were not admitted to the CCU/ICU and about half did not undergo coronary angiography. Further research is needed to improve risk assessment in ED ACS patients, which may allow more effective use of cardiac monitoring and hospital resources.
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Affiliation(s)
- Tsvetelina Nilsson
- Department of Emergency Medicine, Skåne University Hospital, Lund University, Lund, Sweden
| | - Arash Mokhtari
- Department of Cardiology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Jenny Sandgren
- Clinical Studies Sweden, Forum South, Skåne University Hospital, Lund, Sweden
| | | | | | - Ulf Ekelund
- Department of Emergency Medicine, Skåne University Hospital, Lund University, Lund, Sweden
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12
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Alviar CL, Li BK, Keller NM, Bohula-May E, Barnett C, Berg DD, Burke JA, Chaudhry SP, Daniels LB, DeFilippis AP, Gerber D, Horowitz J, Jentzer JC, Katrapati P, Keeley E, Lawler PR, Park JG, Sinha SS, Snell J, Solomon MA, Teuteberg J, Katz JN, van Diepen S, Morrow DA. Prognostic performance of the IABP-SHOCK II Risk Score among cardiogenic shock subtypes in the critical care cardiology trials network registry. Am Heart J 2024; 270:1-12. [PMID: 38190931 PMCID: PMC11032171 DOI: 10.1016/j.ahj.2023.12.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 12/27/2023] [Accepted: 12/28/2023] [Indexed: 01/10/2024]
Abstract
BACKGROUND Risk stratification has potential to guide triage and decision-making in cardiogenic shock (CS). We assessed the prognostic performance of the IABP-SHOCK II score, derived in Europe for acute myocardial infarct-related CS (AMI-CS), in a contemporary North American cohort, including different CS phenotypes. METHODS The critical care cardiology trials network (CCCTN) coordinated by the TIMI study group is a multicenter network of cardiac intensive care units (CICU). Participating centers annually contribute ≥2 months of consecutive medical CICU admissions. The IABP-SHOCK II risk score includes age > 73 years, prior stroke, admission glucose > 191 mg/dl, creatinine > 1.5 mg/dl, lactate > 5 mmol/l, and post-PCI TIMI flow grade < 3. We assessed the risk score across various CS etiologies. RESULTS Of 17,852 medical CICU admissions 5,340 patients across 35 sites were admitted with CS. In patients with AMI-CS (n = 912), the IABP-SHOCK II score predicted a >3-fold gradient in in-hospital mortality (low risk = 26.5%, intermediate risk = 52.2%, high risk = 77.5%, P < .0001; c-statistic = 0.67; Hosmer-Lemeshow P = .79). The score showed a similar gradient of in-hospital mortality in patients with non-AMI-related CS (n = 2,517, P < .0001) and mixed shock (n = 923, P < .001), as well as in left ventricular (<0.0001), right ventricular (P = .0163) or biventricular (<0.0001) CS. The correlation between the IABP-SHOCK II score and SOFA was moderate (r2 = 0.17) and the IABP-SHOCK II score revealed a significant risk gradient within each SCAI stage. CONCLUSIONS In an unselected international multicenter registry of patients admitted with CS, the IABP- SHOCK II score only moderately predicted in-hospital mortality in a broad population of CS regardless of etiology or irrespective of right, left, or bi-ventricular involvement.
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Affiliation(s)
- Carlos L Alviar
- The Leon H. Charney Division of Cardiology, New York University School of Medicine, New York, NY;.
| | - Boyangzi K Li
- Division of Cardiology, University of Miami, Miami, FL
| | - Norma M Keller
- The Leon H. Charney Division of Cardiology, New York University School of Medicine, New York, NY
| | - Erin Bohula-May
- Levine Cardiac Intensive Care Unit, Brigham and Women's Hospital, Boston, MA
| | - Christopher Barnett
- Division of Cardiology, University of California San Francisco, San Francisco, CA
| | - David D Berg
- Levine Cardiac Intensive Care Unit, Brigham and Women's Hospital, Boston, MA
| | - James A Burke
- Division of Cardiology, Lehigh Valley Health Network, Allentown, PA
| | | | - Lori B Daniels
- Division of Cardiovascular Medicine, University of California San Diego, La Jolla, CA
| | | | - Daniel Gerber
- Division of Cardiology, Stanford University, Stanford, CA
| | - James Horowitz
- The Leon H. Charney Division of Cardiology, New York University School of Medicine, New York, NY
| | - Jacob C Jentzer
- Division of Cardiovascular Medicine, Mayo Clinic, Minnesota, CA
| | | | - Ellen Keeley
- Division of Cardiology, University of Florida, Gainesville, FL
| | - Patrick R Lawler
- McGill University Health Centre, Montreal, Quebec, Canada;; Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada
| | - Jeong-Gun Park
- Levine Cardiac Intensive Care Unit, Brigham and Women's Hospital, Boston, MA
| | - Shashank S Sinha
- Inova Fairfax Medical Campus, Inova Heart and Vascular Institute, Falls Church, VA
| | - Jeffrey Snell
- Division of Cardiology, Rush University, Chicago, IL
| | - Michael A Solomon
- Critical Care Medicine Department, National Institutes of Health Clinical Center and Cardiovascular Branch, National Heart, Lung, and Blood Institute of the National Institutes of Health, Bethesda, MD
| | | | - Jason N Katz
- The Leon H. Charney Division of Cardiology, New York University School of Medicine, New York, NY
| | - Sean van Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - David A Morrow
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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13
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Sarma D, Padkins M, Smith R, Bennett CE, Murphy JG, Bell MR, Damluji AA, Anavekar NS, Barsness GW, Jentzer JC. Patients Aged 90 Years and Above With Acute Coronary Syndrome in the Cardiac Intensive Care Unit: Management and Outcomes. Am J Cardiol 2024; 215:19-27. [PMID: 38266797 PMCID: PMC11025344 DOI: 10.1016/j.amjcard.2023.12.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 12/03/2023] [Accepted: 12/24/2023] [Indexed: 01/26/2024]
Abstract
Limited data exist regarding outcomes after coronary angiography (CAG) and percutaneous coronary intervention (PCI) in patients aged ≥90 years admitted to the cardiac intensive care unit (CICU) with acute coronary syndrome (ACS). We studied sequential CICU patients ≥90 years admitted with ACS from 2007 to 2018. Three therapeutic approaches were defined: (1) No CAG; (2) CAG without PCI (CAG/No PCI); and (3) CAG with PCI (CAG/PCI). In-hospital mortality was evaluated using multivariable logistic regression. All-cause 1-year mortality was evaluated using Kaplan-Meier and multivariable Cox proportional hazards analysis. The study included 239 patients with a median age of 92 (range 90 to 100) years (57% females; 45% ST-elevation myocardial infarction; 8% cardiac arrest; 16% shock). The No CAG group had higher Day 1 Sequential Organ Failure Assessment scores, more co-morbidities, worse kidney function, and fewer ST-elevation myocardial infarctions. In-hospital mortality was 20.8% overall and did not differ between the No CAG (n = 103; 21.4%), CAG/No PCI (n = 47; 21.3%), and CAG/PCI (n = 90; 20.0%) groups, before or after adjustment. Overall 1-year mortality was 52.5% and did not differ between groups before or after adjustment. Median survival was 6.9 months overall and 41.2% of hospital survivors died within 1 year of CICU admission. CICU patients aged ≥90 years with ACS have a substantial burden of illness with high in-hospital and 1-year mortality that was not lower in those who underwent CAG or PCI. These results suggest that careful patient selection for invasive coronary procedures is essential in this vulnerable population.
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Affiliation(s)
- Dhruv Sarma
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Mitchell Padkins
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Ryan Smith
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Courtney E Bennett
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota; Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Joseph G Murphy
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Malcolm R Bell
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Abdulla A Damluji
- Inova Center of Outcomes Research, Inova Heart and Vascular Institute, Falls Church, Virginia
| | - Nandan S Anavekar
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Gregory W Barsness
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota; Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota.
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14
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Mehta A, Vavilin I, Nguyen AH, Batchelor WB, Blumer V, Cilia L, Dewanjee A, Desai M, Desai SS, Flanagan MC, Isseh IN, Kennedy JLW, Klein KM, Moukhachen H, Psotka MA, Raja A, Rosner CM, Shah P, Tang DG, Truesdell AG, Tehrani BN, Sinha SS. Contemporary approach to cardiogenic shock care: a state-of-the-art review. Front Cardiovasc Med 2024; 11:1354158. [PMID: 38545346 PMCID: PMC10965643 DOI: 10.3389/fcvm.2024.1354158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 02/13/2024] [Indexed: 05/02/2024] Open
Abstract
Cardiogenic shock (CS) is a time-sensitive and hemodynamically complex syndrome with a broad spectrum of etiologies and clinical presentations. Despite contemporary therapies, CS continues to maintain high morbidity and mortality ranging from 35 to 50%. More recently, burgeoning observational research in this field aimed at enhancing the early recognition and characterization of the shock state through standardized team-based protocols, comprehensive hemodynamic profiling, and tailored and selective utilization of temporary mechanical circulatory support devices has been associated with improved outcomes. In this narrative review, we discuss the pathophysiology of CS, novel phenotypes, evolving definitions and staging systems, currently available pharmacologic and device-based therapies, standardized, team-based management protocols, and regionalized systems-of-care aimed at improving shock outcomes. We also explore opportunities for fertile investigation through randomized and non-randomized studies to address the prevailing knowledge gaps that will be critical to improving long-term outcomes.
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Affiliation(s)
- Aditya Mehta
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Ilan Vavilin
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Andrew H. Nguyen
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Wayne B. Batchelor
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Vanessa Blumer
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Lindsey Cilia
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
- Department of Cardiovascular Disease, Virginia Heart, Falls Church, VA, United States
| | - Aditya Dewanjee
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Mehul Desai
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Shashank S. Desai
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Michael C. Flanagan
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Iyad N. Isseh
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Jamie L. W. Kennedy
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Katherine M. Klein
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Hala Moukhachen
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Mitchell A. Psotka
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Anika Raja
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Carolyn M. Rosner
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Palak Shah
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Daniel G. Tang
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Alexander G. Truesdell
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
- Department of Cardiovascular Disease, Virginia Heart, Falls Church, VA, United States
| | - Behnam N. Tehrani
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Shashank S. Sinha
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
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15
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Gall E, Pezel T, Lattuca B, Hamzi K, Puymirat E, Piliero N, Deney A, Fauvel C, Aboyans V, Schurtz G, Bouleti C, Fabre J, El Ouahidi A, Thuaire C, Millischer D, Noirclerc N, Delmas C, Roubille F, Dillinger JG, Henry P. Profile of patients hospitalized in intensive cardiac care units in France: ADDICT-ICCU registry. Arch Cardiovasc Dis 2024; 117:195-203. [PMID: 38418306 DOI: 10.1016/j.acvd.2023.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 12/12/2023] [Accepted: 12/13/2023] [Indexed: 03/01/2024]
Abstract
BACKGROUND Intensive cardiac care units (ICCU) were initially developed to monitor ventricular arrhythmias after myocardial infarction. In recent decades, ICCU have diversified their activities. AIM To determine the type of patients hospitalized in ICCU in France. METHODS We analysed the characteristics of patients enrolled in the ADDICT-ICCU registry (NCT05063097), a prospective study of consecutive patients admitted to ICCU in 39 centres throughout France from 7th-22nd April 2021. In-hospital major adverse events (MAE) (death, resuscitated cardiac arrest and cardiogenic shock) were recorded. RESULTS Among 1499 patients (median age 65 [interquartile range 54-74] years, 69.6% male, 21.7% diabetes mellitus, 64.7% current or previous smokers), 34.9% had a history of coronary artery disease, 11.7% atrial fibrillation and 5.2% cardiomyopathy. The most frequent reason for admission to ICCU was acute coronary syndromes (ACS; 51.5%), acute heart failure (AHF; 14.1%) and unexplained chest pain (6.8%). An invasive procedure was performed in 36.2%. "Advanced" ICCU therapies were required for 19.9% of patients (intravenous diuretics 18.4%, non-invasive ventilation 6.1%, inotropic drugs 2.3%). No invasive procedures or advanced therapies were required in 44.1%. Cardiac computed tomography or magnetic resonance imaging was carried out in 12.3% of patients. The median length of ICCU hospitalization was 2.0 (interquartile range 1.0-4.0) days. The mean rate of MAE was 4.5%, and was highest in patients with AHF (10.4%). CONCLUSIONS ACS remains the main cause of admissions to ICCU, with most having a low rate of in-hospital MAE. Most patients experience a brief stay in ICCU before being discharged home. AHF is associated with highest death rate and with higher resource consumption.
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Affiliation(s)
- Emmanuel Gall
- Department of Cardiology, hôpital Lariboisière, Assistance publique-Hôpitaux de Paris, University of Paris, Inserm U-942, 10, rue Ambroise-Paré, 75010 Paris, France
| | - Théo Pezel
- Department of Cardiology, hôpital Lariboisière, Assistance publique-Hôpitaux de Paris, University of Paris, Inserm U-942, 10, rue Ambroise-Paré, 75010 Paris, France
| | - Benoît Lattuca
- Department of Cardiology, Nîmes University Hospital, Montpellier University, Nîmes, France
| | - Kenza Hamzi
- Department of Cardiology, hôpital Lariboisière, Assistance publique-Hôpitaux de Paris, University of Paris, Inserm U-942, 10, rue Ambroise-Paré, 75010 Paris, France
| | - Etienne Puymirat
- Department of Cardiology, hôpital européen Georges-Pompidou (HEGP), Paris, France
| | - Nicolas Piliero
- Department of Cardiology, CHU de Grenoble-Alpes, Grenoble, France
| | - Antoine Deney
- Cardiac Care Unit, Rangueil University Hospital, Toulouse, France
| | - Charles Fauvel
- Department of Cardiology, CHU de Rouen, University, UNIROUEN, U1096, 76000 Rouen, France
| | - Victor Aboyans
- Dupuytren University Hospital, Inserm 1094, Limoges, France
| | - Guillaume Schurtz
- Department of Cardiology, University Hospital of Lille, Lille, France
| | | | - Julien Fabre
- Department of Cardiology, University Hospital of Martinique, 97261 Fort-de-France, France
| | - Amine El Ouahidi
- Department of Cardiology, University Hospital of Brest, 29609 Brest cedex, France
| | - Christophe Thuaire
- Department of Cardiology, centre hospitalier de Chartres, 28630 Le Coudray, France
| | - Damien Millischer
- Department of Cardiology, hôpital Montfermeil, 93370 Montfermeil, France
| | - Nathalie Noirclerc
- Department of Cardiology, centre hospitalier Annecy-Genevois, 1, avenue de l'Hôpital, 74370 Epagny Metz-Tessy, France
| | - Clément Delmas
- Intensive Cardiac Care Unit, Rangueil University Hospital, Toulouse, France
| | - François Roubille
- Department of Cardiology, INI-CRT, CHU de Montpellier, PhyMedExp, université de Montpellier, Inserm, CNRS, 3429 Montpellier, France
| | - Jean-Guillaume Dillinger
- Department of Cardiology, hôpital Lariboisière, Assistance publique-Hôpitaux de Paris, University of Paris, Inserm U-942, 10, rue Ambroise-Paré, 75010 Paris, France
| | - Patrick Henry
- Department of Cardiology, hôpital Lariboisière, Assistance publique-Hôpitaux de Paris, University of Paris, Inserm U-942, 10, rue Ambroise-Paré, 75010 Paris, France.
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Sacco A, Pagnesi M, Frea S, Briani M, Dini CS, Bertaina M, Marini M, Trombara F, Villanova L, Ravera A, Tavazzi G, Pappalardo F, Morici N, Potena L. Transitioning to Palliative Care in an Italian Cardiac Intensive Care Unit Network. Am J Crit Care 2024; 33:145-148. [PMID: 38424013 DOI: 10.4037/ajcc2024535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
BACKGROUND Recent data indicate that end-of-life management for patients affected by acute decompensated heart failure in cardiac intensive care units is aggressive, with late or no engagement of palliative care teams. OBJECTIVE To assess current palliative care and end-of-life practices in a contemporary Italian multicenter registry of patients with cardiogenic shock due to acute decompensated heart failure. METHODS A survey-based approach was used to collect data on palliative care and end-of-life management practices. The AltShock-2 registry enrolled patients with cardiogenic shock from 12 participating centers. A subset of 153 patients with cardiogenic shock due to acute decompensated heart failure enrolled between March 2020 and March 2023 was analyzed, with a focus on early engagement of palliative care teams and deactivation of implantable cardioverter-defibrillators (ICDs). RESULTS "Do not resuscitate" orders were documented in patient records in only 5 of 12 centers (42%). Palliative care teams were engaged for 21 of 153 enrolled patients (13.7%). Among the 51 patients with ICDs, 6 of 17 patients who died (35%) had defibrillator deactivation. Of the 17 patients who died, 13 died in the hospital and 4 died within 6 months after discharge; 1 patient had ICD deactivation supported by palliative care services at home. CONCLUSIONS Therapy-limiting practices, including ICD deactivation, are not routine in the Italian centers participating in this study. The results emphasize the importance of integrating palliative care as a simultaneous process with intensive care to address the unmet needs of these patients and their families.
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Affiliation(s)
- Alice Sacco
- Alice Sacco is a physician, Cardiac Intensive Care Unit, De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Matteo Pagnesi
- Matteo Pagnesi is a physician, Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Simone Frea
- Simone Frea is a physician, Intensive Cardiac Care Unit, Città della Salute e della Scienza di Torino, Turin, Italy
| | - Martina Briani
- Martina Briani is a physician, IRCCS Humanitas Research Hospital Rozzano, Milan, Italy
| | - Carlotta Sorini Dini
- Carlotta Sorini Dini is a physician, Division of Cardiology, Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - Maurizio Bertaina
- Maurizio Bertaina is a physician, Division of Cardiology, San Giovanni Bosco Hospital, ASL Città di Torino, Turin, Italy
| | - Marco Marini
- Marco Marini is a physician, Department of Cardiovascular Sciences, Clinic of Cardiology, Ospedali Riuniti, Ancona, Italy
| | - Filippo Trombara
- Filippo Trombara is a physician, Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | - Luca Villanova
- Luca Villanova is a physician, Cardiac Intensive Care Unit, De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Amelia Ravera
- Amelia Ravera is a physician, Department of Cardiology, "San Giovanni di Dio e Ruggi D'Aragona" Hopital-University, Salerno, Italy
| | - Guido Tavazzi
- Guido Tavazzi is a physician, Department of Clinical-Surgical, Diagnostic and Paediatric Sciences, Unit of Anaesthesia and Intensive Care, University of Pavia Italy Anesthesia and Intensive Care, Fondazione Policlinico San Matteo Hospital IRCCS, Anestesia e Rianimazione I, Pavia, Italy
| | - Federico Pappalardo
- Federico Pappalardo is a physician, Cardiothoracic and Vascular Anesthesia and Intensive Care, Azienda Ospedaliera Nazionale Santi Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Nuccia Morici
- Nuccia Morici is a physician, IRCCS S. Maria Nascente-Fondazione Don Carlo Gnocchi Onlus, Milan, Italy
| | - Luciano Potena
- Luciano Potena is a physician, Heart Failure and Transplant Unit, IRCCS Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy
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Vallabhajosyula S, Mehta A, Bansal M, Jentzer JC, Applefeld WN, Sinha SS, Geller BJ, Gage AE, Rose SW, Barnett CF, Katz JN, Morrow DA, Roswell RO, Solomon MA. Training Paradigms in Critical Care Cardiology: A Scoping Review of Current Literature. JACC. ADVANCES 2024; 3:100850. [PMID: 38352139 PMCID: PMC10861182 DOI: 10.1016/j.jacadv.2024.100850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/16/2024]
Abstract
Background Over the past decade there has been increasing interest in critical care medicine (CCM) training for cardiovascular medicine (CV) physicians either in isolation (separate programs in either order [CV/CCM], integrated critical care cardiology [CCC] training) or hybrid training with interventional cardiology (IC)/heart failure/transplant (HF) with targeted CCC training. Objective To review the contemporary landscape of CV/CCM, CCC, and hybrid training. Methods We reviewed the literature from 2000-2022 for publications discussing training in any combination of internal medicine CV/CCM, CCC, and hybrid training. Information regarding training paradigms, scope of practice and training, duration, sequence, and milestones was collected. Results Of the 2,236 unique citations, 20 articles were included. A majority were opinion/editorial articles whereas two were surveys. The training pathways were classified into - (i) specialty training in both CV (3 years) and CCM (1-2 years) leading to dual American Board of Internal Medicine (ABIM) board certification, or (ii) base specialty training in CV with competencies in IC, HF or CCC leading to a non-ABIM certificate. Total fellowship duration varied between 4-7 years after a three-year internal medicine residency. While multiple articles commented on the ability to integrate the fellowship training pathways into a holistic and seamless training curriculum, few have highlighted how this may be achieved to meet competencies and standards. Conclusions In 20 articles describing CV/CCM, CCC, and hybrid training, there remains significant heterogeneity on the standardized training paradigms to meet training competencies and board certifications, highlighting an unmet need to define CCC competencies.
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Affiliation(s)
- Saraschandra Vallabhajosyula
- Section of Cardiology, Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI
- Lifespan Cardiovascular Institute, Providence, RI
| | - Aryan Mehta
- Department of Medicine, University of Connecticut School of Medicine, Farmington, CT
| | - Mridul Bansal
- Department of Medicine, East Carolina University Brody School of Medicine, Greenville, NC
| | - Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Willard N Applefeld
- Division of Cardiovascular Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Shashank S Sinha
- Inova Fairfax Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA
| | - Bram J Geller
- Department of Cardiovascular Medicine and Department of Cardiovascular Critical Care Services, Maine Medical Center, Portland, ME
| | - Ann E Gage
- Centennial Heart, Centennial Medical Center, Nashville, TN
| | - Scott W Rose
- Division of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC
| | | | - Jason N Katz
- Division of Cardiovascular Medicine, Department of Medicine, New York University School of Medicine, New York, NY
| | - David A Morrow
- Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Robert O Roswell
- Section of Cardiovascular Medicine, Department of Medicine, Zucker School of Medicine at Hofstra/Northwell, New York, NY
| | - Michael A Solomon
- Department of Critical Care Medicine, Clinical Center and Cardiovascular Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
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18
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Kanwar MK, Billia F, Randhawa V, Cowger JA, Barnett CM, Chih S, Ensminger S, Hernandez-Montfort J, Sinha SS, Vorovich E, Proudfoot A, Lim HS, Blumer V, Jennings DL, Reshad Garan A, Renedo MF, Hanff TC, Baran DA. Heart failure related cardiogenic shock: An ISHLT consensus conference content summary. J Heart Lung Transplant 2024; 43:189-203. [PMID: 38069920 DOI: 10.1016/j.healun.2023.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Accepted: 09/25/2023] [Indexed: 12/22/2023] Open
Abstract
In recent years, there have been significant advancements in the understanding, risk-stratification, and treatment of cardiogenic shock (CS). Despite improved pharmacologic and device-based therapies for CS, short-term mortality remains as high as 50%. Most recent efforts in research have focused on CS related to acute myocardial infarction, even though heart failure related CS (HF-CS) accounts for >50% of CS cases. There is a paucity of high-quality evidence to support standardized clinical practices in approach to HF-CS. In addition, there is an unmet need to identify disease-specific diagnostic and risk-stratification strategies upon admission, which might ultimately guide the choice of therapies, and thereby improve outcomes and optimize resource allocation. The heterogeneity in defining CS, patient phenotypes, treatment goals and therapies has resulted in difficulty comparing published reports and standardized treatment algorithms. An International Society for Heart and Lung Transplantation (ISHLT) consensus conference was organized to better define, diagnose, and manage HF-CS. There were 54 participants (advanced heart failure and interventional cardiologists, cardiothoracic surgeons, critical care cardiologists, intensivists, pharmacists, and allied health professionals), with vast clinical and published experience in CS, representing 42 centers worldwide. State-of-the-art HF-CS presentations occurred with subsequent breakout sessions planned in an attempt to reach consensus on various issues, including but not limited to models of CS care delivery, patient presentations in HF-CS, and strategies in HF-CS management. This consensus report summarizes the contemporary literature review on HF-CS presented in the first half of the conference (part 1), while the accompanying document (part 2) covers the breakout sessions where the previously agreed upon clinical issues were discussed with an aim to get to a consensus.
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Affiliation(s)
- Manreet K Kanwar
- Cardiovascular Institute at Allegheny Health Network, Pittsburgh, Pennsylvania.
| | - Filio Billia
- Division of Cardiology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Varinder Randhawa
- Division of Cardiology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jennifer A Cowger
- Department of Cardiology, Henry Ford Health Heart and Vascular Institute, Detroit, Michigan
| | - Christopher M Barnett
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Sharon Chih
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Stephan Ensminger
- Department of Cardiac and Thoracic Vascular Surgery, University Heart Center Lübeck, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Jaime Hernandez-Montfort
- Advanced Heart Disease, Recovery and Replacement Program, Baylor Scott and White Health, Temple, Texas
| | - Shashank S Sinha
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, Virginia
| | - Esther Vorovich
- Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Alastair Proudfoot
- Perioperative Medicine Department, Barts Heart Centre, St Bartholomew's Hospital, London, UK
| | - Hoong S Lim
- Department of Cardiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Vanessa Blumer
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, Virginia
| | - Douglas L Jennings
- Department of Pharmacy, Columbia University Irving Medical Center, New York, New York
| | - A Reshad Garan
- Beth Israel Deaconess Medical Center, Department of Medicine, Division of Cardiology, Harvard Medical School, Boston, Massachusetts
| | - Maria F Renedo
- Department of Heart Failure and Thoracic Transplantation, Fundacion Favaloro, Buenos Aires, Argentina
| | - Thomas C Hanff
- Division of Cardiovascular Medicine, University of Utah Hospital, Salt Lake City, Utah
| | - David A Baran
- Heart, Vascular Thoracic Institute, Cleveland Clinic Florida, Weston, Florida.
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Ko RE, Lee J, Kim S, Ahn JH, Na SJ, Yang JH. Machine learning methods for developing a predictive model of the incidence of delirium in cardiac intensive care units. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2024:S1885-5857(24)00021-5. [PMID: 38237663 DOI: 10.1016/j.rec.2023.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 12/20/2023] [Indexed: 02/10/2024]
Abstract
INTRODUCTION AND OBJECTIVES Delirium, recognized as a crucial prognostic factor in the cardiac intensive care unit (CICU), has evolved in response to the changing demographics among critically ill cardiac patients. This study aimed to create a predictive model for delirium for patients in the CICU. METHODS This study included consecutive patients admitted to the CICU of the Samsung Medical Center. To assess the candidate variables for the model: we applied the following machine learning methods: random forest, extreme gradient boosting, partial least squares, and Plmnet-elastic.net. After selecting relevant variables, we performed a logistic regression analysis to derive the model formula. Internal validation was conducted using 100-repeated hold-out validation. RESULTS We analyzed 2774 patients, 677 (24.4%) of whom developed delirium in the CICU. Machine learning-based models showed good predictive performance. Clinically significant and frequently important predictors were selected to construct a delirium prediction scoring model for CICU patients. The model included albumin level, international normalized ratio, blood urea nitrogen, white blood cell count, C-reactive protein level, age, heart rate, and mechanical ventilation. The model had an area under the receiver operating characteristics curve (AUROC) of 0.861 (95%CI, 0.843-0.879). Similar results were obtained in internal validation with 100-repeated cross-validation (AUROC, 0.854; 95%CI, 0.826-0.883). CONCLUSIONS Using variables frequently ranked as highly important in four machine learning methods, we created a novel delirium prediction model. This model could serve as a useful and simple tool for risk stratification for the occurrence of delirium at the patient's bedside in the CICU.
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Affiliation(s)
- Ryoung-Eun Ko
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jihye Lee
- Division of Pulmonology and Allergy, Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, Republic of Korea
| | - Sungeun Kim
- Division of Cardiology, Department of Internal Medicine, Inje University College of Medicine, Ilsan Paik Hospital, Goyang, Republic of Korea
| | - Joong Hyun Ahn
- Biostatics and Clinical Epidemiology Center, Samsung Medical Center, Seoul, Republic of Korea
| | - Soo Jin Na
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jeong Hoon Yang
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
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20
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Donnelly S, Barnett CF, Bohula EA, Chaudhry SP, Chonde MD, Cooper HA, Daniels LB, Dodson MW, Gerber D, Goldfarb MJ, Guo J, Kontos MC, Liu S, Luk AC, Menon V, O'Brien CG, Papolos AI, Pisani BA, Potter BJ, Prasad R, Schnell G, Shah KS, Sridharan L, So DYF, Teuteberg JJ, Tymchak WJ, Zakaria S, Katz JN, Morrow DA, van Diepen S. Interhospital Variation in Admissions Managed With Critical Care Therapies or Invasive Hemodynamic Monitoring in Tertiary Cardiac Intensive Care Units: An Analysis From the Critical Care Cardiology Trials Network Registry. Circ Cardiovasc Qual Outcomes 2024; 17:e010092. [PMID: 38179787 DOI: 10.1161/circoutcomes.123.010092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 11/14/2023] [Indexed: 01/06/2024]
Abstract
BACKGROUND Wide interhospital variations exist in cardiovascular intensive care unit (CICU) admission practices and the use of critical care restricted therapies (CCRx), but little is known about the differences in patient acuity, CCRx utilization, and the associated outcomes within tertiary centers. METHODS The Critical Care Cardiology Trials Network is a multicenter registry of tertiary and academic CICUs in the United States and Canada that captured consecutive admissions in 2-month periods between 2017 and 2022. This analysis included 17 843 admissions across 34 sites and compared interhospital tertiles of CCRx (eg, mechanical ventilation, mechanical circulatory support, continuous renal replacement therapy) utilization and its adjusted association with in-hospital survival using logistic regression. The Pratt index was used to quantify patient-related and institutional factors associated with CCRx variability. RESULTS The median age of the study population was 66 (56-77) years and 37% were female. CCRx was provided to 62.2% (interhospital range of 21.3%-87.1%) of CICU patients. Admissions to CICUs with the highest tertile of CCRx utilization had a greater burden of comorbidities, had more diagnoses of ST-elevation myocardial infarction, cardiac arrest, or cardiogenic shock, and had higher Sequential Organ Failure Assessment scores. The unadjusted in-hospital mortality (median, 12.7%) was 9.6%, 11.1%, and 18.7% in low, intermediate, and high CCRx tertiles, respectively. No clinically meaningful differences in adjusted mortality were observed across tertiles when admissions were stratified by the provision of CCRx. Baseline patient-level variables and institutional differences accounted for 80% and 5.3% of the observed CCRx variability, respectively. CONCLUSIONS In a large registry of tertiary and academic CICUs, there was a >4-fold interhospital variation in the provision of CCRx that was primarily driven by differences in patient acuity compared with institutional differences. No differences were observed in adjusted mortality between low, intermediate, and high CCRx utilization sites.
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Affiliation(s)
- Sarah Donnelly
- Division of General Internal Medicine, Department of Medicine (S.D.), University of Alberta, Edmonton, Canada
| | - Christopher F Barnett
- Division of Cardiology, Department of Medicine, University of California, San Francisco (C.F.B., C.G.O.)
| | - Erin A Bohula
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (E.A.B., J.G., D.A.M.)
| | - Sunit-Preet Chaudhry
- Division of Cardiology, Ascension St. Vincent Heart Center, Indianapolis, IN (S.-P.C.)
| | - Meshe D Chonde
- Cedars-Sinai Smidt Heart Institute, Los Angeles, CA (M.D.C.)
| | - Howard A Cooper
- Westchester Medical Center and New York Medical College, Valhalla (H.A.C.)
| | - Lori B Daniels
- Division of Cardiovascular Medicine, Department of Medicine, University of California San Diego, La Jolla (L.B.D.)
| | - Mark W Dodson
- Department of Medicine, Intermountain Medical Center, Murray, UT (M.W.D.)
| | - Daniel Gerber
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, CA (D.G.)
| | - Michael J Goldfarb
- Division of Cardiology, Jewish General Hospital, Montreal, QC, Canada (M.J.G)
| | - Jianping Guo
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (E.A.B., J.G., D.A.M.)
| | - Michael C Kontos
- Division of Cardiology, Virginia Commonwealth University, Richmond (M.C.K.)
| | - Shuangbo Liu
- Max Rady College of Medicine, St. Boniface Hospital, Winnipeg, MB, Canada (S.L.)
| | - Adriana C Luk
- Peter Munk Cardiac Centre at Toronto General Hospital, Division of Cardiology and Interdepartmental Division of Critical Care Medicine, University of Toronto, ON, Canada (A.C.L.)
| | - Venu Menon
- Cardiovascular Medicine, Cleveland Clinic Foundation, OH (V.M.)
| | - Connor G O'Brien
- Division of Cardiology, Department of Medicine, University of California, San Francisco (C.F.B., C.G.O.)
| | - Alexander I Papolos
- Division of Cardiology, Department of Critical Care, MedStar Washington Hospital Center, DC (A.I.P.)
| | | | - Brian J Potter
- Centre Hospitalier de l'Université de Montréal Research Center and Cardiovascular Center, QC, Canada (B.J.P.)
| | | | - Gregory Schnell
- Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Canada (G.S.)
| | - Kevin S Shah
- University of Utah Health Sciences Center, Salt Lake City (K.S.S.)
| | | | - Derek Y F So
- University of Ottawa Heart Institute, ON, Canada (D.Y.F.S.)
| | | | - Wayne J Tymchak
- Department of Critical Care Medicine (W.J.T.), University of Alberta, Edmonton, Canada
- Division of Cardiology, Department of Medicine (W.J.T.), University of Alberta, Edmonton, Canada
| | - Sammy Zakaria
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD (S.Z.)
| | | | - David A Morrow
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (E.A.B., J.G., D.A.M.)
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21
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Salluh JIF, Quintairos A, Dongelmans DA, Aryal D, Bagshaw S, Beane A, Burghi G, López MDPA, Finazzi S, Guidet B, Hashimoto S, Ichihara N, Litton E, Lone NI, Pari V, Sendagire C, Vijayaraghavan BKT, Haniffa R, Pisani L, Pilcher D. National ICU Registries as Enablers of Clinical Research and Quality Improvement. Crit Care Med 2024; 52:125-135. [PMID: 37698452 DOI: 10.1097/ccm.0000000000006050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2023]
Abstract
OBJECTIVES Clinical quality registries (CQRs) have been implemented worldwide by several medical specialties aiming to generate a better characterization of epidemiology, treatments, and outcomes of patients. National ICU registries were created almost 3 decades ago to improve the understanding of case-mix, resource use, and outcomes of critically ill patients. This narrative review describes the challenges, proposed solutions, and evidence generated by National ICU registries as facilitators for research and quality improvement. DATA SOURCES English language articles were identified in PubMed using phrases related to ICU registries, CQRs, outcomes, and case-mix. STUDY SELECTION Original research, review articles, letters, and commentaries, were considered. DATA EXTRACTION Data from relevant literature were identified, reviewed, and integrated into a concise narrative review. DATA SYNTHESIS CQRs have been implemented worldwide by several medical specialties aiming to generate a better characterization of epidemiology, treatments, and outcomes of patients. National ICU registries were created almost 3 decades ago to improve the understanding of case-mix, resource use, and outcomes of critically ill patients. The initial experience in European countries and in Oceania ensured that through locally generated data, ICUs could assess their performances by using risk-adjusted measures and compare their results through fair and validated benchmarking metrics with other ICUs contributing to the CQR. The accomplishment of these initiatives, coupled with the increasing adoption of information technology, resulted in a broad geographic expansion of CQRs as well as their use in quality improvement studies, clinical trials as well as international comparisons, and benchmarking for ICUs. CONCLUSIONS ICU registries have provided increased knowledge of case-mix and outcomes of ICU patients based on real-world data and contributed to improve care delivery through quality improvement initiatives and trials. Recent increases in adoption of new technologies (i.e., cloud-based structures, artificial intelligence, machine learning) will ensure a broader and better use of data for epidemiology, healthcare policies, quality improvement, and clinical trials.
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Affiliation(s)
- Jorge I F Salluh
- D'Or Institute for Research and Education, Rio de Janeiro, Brazil
- Post-Graduation Program, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Amanda Quintairos
- D'Or Institute for Research and Education, Rio de Janeiro, Brazil
- Department of Critical and Intensive Care Medicine, Academic Hospital Fundación Santa Fe de Bogota, Bogota, Colombia
| | - Dave A Dongelmans
- Amsterdam UMC location University of Amsterdam, Department of Intensive Care Medicine, Amsterdam, The Netherlands
- National Intensive Care Evaluation (NICE) Foundation, Amsterdam, The Netherlands
| | - Diptesh Aryal
- National Coordinator, Nepal Intensive Care Research Foundation, Kathmandu, Nepal
| | - Sean Bagshaw
- Department of Medicine, Faculty of Medicine and Dentistry (Ling, Bagshaw), University of Alberta and Alberta Health Services, Edmonton, AB, Canada
- Division of Internal Medicine (Villeneuve), Department of Critical Care Medicine, Faculty of Medicine and Dentistry and School of Public Health, University of Alberta and Grey Nuns Hospitals, Edmonton, AB, Canada
| | - Abigail Beane
- Critical Care, Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | | | - Maria Del Pilar Arias López
- Argentine Society of Intensive Care (SATI). SATI-Q Program, Buenos Aires, Argentina
- Intermediate Care Unit, Hospital de Niños Ricardo Gutierrez, Buenos Aires, Argentina
| | - Stefano Finazzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Ranica, Italy
- Associazione GiViTI, c/o Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Bertrand Guidet
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Saint-Antoine, service de réanimation, Paris, France
| | - Satoru Hashimoto
- Division of Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Nao Ichihara
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Edward Litton
- Fiona Stanley Hospital, Perth, WA
- The University of Western Australia, Perth, WA
| | - Nazir I Lone
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
- Scottish Intensive Care Society Audit Group, United Kingdom
| | - Vrindha Pari
- Chennai Critical Care Consultants, Pvt Ltd, Chennai, India
| | - Cornelius Sendagire
- D'Or Institute for Research and Education, Rio de Janeiro, Brazil
- Anesthesia and Critical Care, Makerere University College of Health Sciences, Kampala, Uganda
| | | | - Rashan Haniffa
- Critical Care, Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
- Crit Care Asia, Network for Improving Critical Care Systems and Training, Colombo, Sri Lanka
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Luigi Pisani
- Critical Care, Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - David Pilcher
- University College Hospital, London, United Kingdom
- Department of Intensive Care, Alfred Health, Prahran, VIC, Australia
- The Australian and New Zealand Intensive Care Society (ANZICS) Centre for Outcome and Resource Evaluation, Camberwell, Australia
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22
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Li L, Ding L, Zheng L, Wu L, Hu Z, Liu L, Zhang Z, Zhou L, Yao Y. U-shaped association between stress hyperglycemia ratio and risk of all-cause mortality in cardiac ICU. Diabetes Metab Syndr 2024; 18:102932. [PMID: 38147811 DOI: 10.1016/j.dsx.2023.102932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 11/28/2023] [Accepted: 12/17/2023] [Indexed: 12/28/2023]
Abstract
BACKGROUND Stress hyperglycemia has been associated with poor prognosis in patients admitted to the cardiac intensive care unit (ICU). Recently, the stress hyperglycemia ratio (SHR) has been proposed to reflect true acute hyperglycemic. This study aimed to investigate the relationship between SHR and prognosis of patients in the cardiac ICU. METHODS A retrospective analysis was conducted on a cohort of 5,564 patients admitted to the cardiac ICU. The participants were divided into seven groups based on their SHR levels. SHR was calculated as admission blood glucose/[(28.7 × HbA1c %) - 46.7]. The primary outcomes of this study were 28-day all-cause mortality. RESULTS During the follow-up period, 349 (6.3%) patients succumbed within 28 days. A U-shaped correlation between SHR and mortality persisted, even after adjusting for other confounding variables, with a discernible inflection point at 0.95. When SHR surpassed 0.95, each standard deviation (SD) increase corresponded to a 1.41-fold elevation in the risk of mortality (odds ratio [OR]: 1.41, 95% CI: 1.25 to 1.59). In contrast, when SHR fell below 0.95, each SD increment correlated with a significantly reduced risk of mortality (OR: 0.56, 95% CI: 0.34 to 0.91). CONCLUSION There was a U-shaped association between SHR and short -term mortality in patients in the cardiac ICU. The inflection point of SHR for poor prognosis was identified at an SHR value of 0.95.
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Affiliation(s)
- Le Li
- Chinese Academy of Medical Sciences, Peking Union Medical College, National Center for Cardiovascular Diseases, Fuwai Hospital, Beijing, China
| | - Ligang Ding
- Chinese Academy of Medical Sciences, Peking Union Medical College, National Center for Cardiovascular Diseases, Fuwai Hospital, Beijing, China
| | - Lihui Zheng
- Chinese Academy of Medical Sciences, Peking Union Medical College, National Center for Cardiovascular Diseases, Fuwai Hospital, Beijing, China
| | - Lingmin Wu
- Chinese Academy of Medical Sciences, Peking Union Medical College, National Center for Cardiovascular Diseases, Fuwai Hospital, Beijing, China
| | - Zhicheng Hu
- Chinese Academy of Medical Sciences, Peking Union Medical College, National Center for Cardiovascular Diseases, Fuwai Hospital, Beijing, China
| | - Limin Liu
- Chinese Academy of Medical Sciences, Peking Union Medical College, National Center for Cardiovascular Diseases, Fuwai Hospital, Beijing, China
| | - Zhuxin Zhang
- Chinese Academy of Medical Sciences, Peking Union Medical College, National Center for Cardiovascular Diseases, Fuwai Hospital, Beijing, China
| | - Likun Zhou
- Chinese Academy of Medical Sciences, Peking Union Medical College, National Center for Cardiovascular Diseases, Fuwai Hospital, Beijing, China
| | - Yan Yao
- Chinese Academy of Medical Sciences, Peking Union Medical College, National Center for Cardiovascular Diseases, Fuwai Hospital, Beijing, China.
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23
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Sarma D, Jentzer JC. Cardiogenic Shock: Pathogenesis, Classification, and Management. Crit Care Clin 2024; 40:37-56. [PMID: 37973356 DOI: 10.1016/j.ccc.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
Cardiogenic shock (CS) is a life-threatening circulatory failure syndrome which can progress rapidly to irreversible multiorgan failure through self-perpetuating pathophysiological processes. Recent developments in CS classification have highlighted its etiologic, mechanistic, and hemodynamic heterogeneity. Optimal CS management depends on early recognition, rapid reversal of the underlying cause, and prompt initiation of hemodynamic support.
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Affiliation(s)
- Dhruv Sarma
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA.
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24
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Kaur G, Berg DD. The Changing Epidemiology of the Cardiac Intensive Care Unit. Crit Care Clin 2024; 40:1-13. [PMID: 37973347 DOI: 10.1016/j.ccc.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
Coronary care units (CCUs) were originally designed to monitor and treat peri-infarction ventricular arrhythmias but have evolved into highly specialized cardiac intensive care units (CICUs) that provide care to a patient population that is increasingly heterogeneous and complex. Paralleling broader epidemiologic trends, patients admitted to contemporary CICUs are older and have a greater burden of cardiovascular and non-cardiovascular comorbidities. Moreover, contemporary CICU patients have high illness severity and often present with acute noncardiac organ dysfunction. In addition to these shifting demographic patterns, there have been important epidemiologic changes in CICU technologies, multidisciplinary systems of care, and physician staffing and training.
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Affiliation(s)
- Gurleen Kaur
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - David D Berg
- Department of Medicine, Levine Cardiac Intensive Care Unit, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, TIMI Study Group, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA.
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25
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Pierce JB, Applefeld WN, Senman B, Loriaux DB, Lawler PR, Katz JN. Design and Execution of Clinical Trials in the Cardiac Intensive Care Unit. Crit Care Clin 2024; 40:193-209. [PMID: 37973354 DOI: 10.1016/j.ccc.2023.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
Clinical practice in the contemporary cardiac intensive care unit (CICU) has evolved significantly over the last several decades. With more frequent multisystem organ failure, increasing use of advanced respiratory support, and the advent of new mechanical circulatory support platforms, clinicians in the CICU are increasingly managing patients with complex comorbid disease in addition to their high-acuity cardiovascular illnesses. Here, the authors discuss challenges associated with traditional trial design in the CICU setting and review novel clinical trial designs that may facilitate better evidence generation in the CICU.
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Affiliation(s)
- Jacob B Pierce
- Department of Internal Medicine, Duke University School of Medicine, Durham, NC, USA.
| | - Willard N Applefeld
- Division of Cardiology, Department of Internal Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Balimkiz Senman
- Division of Cardiology, Department of Internal Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Daniel B Loriaux
- Division of Cardiology, Department of Internal Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Patrick R Lawler
- McGill University Health Centre, Montreal, Quebec, Canada; Peter Munk Cardiac Centre at University Health Network, Toronto, Canada
| | - Jason N Katz
- Division of Cardiology, Department of Internal Medicine, Duke University School of Medicine, Durham, NC, USA
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26
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Jentzer JC, Van Diepen S, Patel PC, Henry TD, Morrow DA, Baran DA, Kashani KB. Serial Assessment of Shock Severity in Cardiac Intensive Care Unit Patients. J Am Heart Assoc 2023; 12:e032748. [PMID: 37930059 PMCID: PMC10727310 DOI: 10.1161/jaha.123.032748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 10/24/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND One-time assessment of the Society for Cardiovascular Angiography and Interventions (SCAI) shock classification robustly predicts mortality in the cardiac intensive care unit (CICU). We sought to determine whether serial SCAI shock classification could improve risk stratification. METHODS AND RESULTS Unique admissions to a single academic level 1 CICU from 2015 to 2018 were included in this retrospective cohort study. Electronic health record data were used to assign the SCAI shock stage during 4-hour blocks of the first 24 hours of CICU admission. Shock was defined as hypoperfusion (SCAI shock stage C, D, or E). In-hospital death was evaluated using logistic regression. Among 2918 unique CICU patients, 1537 (52.7%) met criteria for shock during ≥1 block, and 266 (9.1%) died in the hospital. The SCAI shock stage on admission was: A, 37.6%; B, 31.5%; C, 25.9%; D, 1.8%; and E, 3.3%. Patients who met SCAI criteria for shock on admission (first 4 hours) and those with worsening SCAI shock stage after admission were at higher risk for in-hospital death. Each higher admission (adjusted odds ratio, 1.36 [95% CI, 1.18-1.56]; area under the receiver operating characteristic curve, 0.70), maximum (adjusted odds ratio, 1.59 [95% CI, 1.37-1.85]; area under the receiver operating characteristic curve, 0.73) and mean (adjusted odds ratio, 2.42 [95% CI, 1.99-2.95]; area under the receiver operating characteristic curve, 0.78) SCAI shock stage was incrementally associated with a higher in-hospital mortality rate. Discrimination was highest for the mean SCAI shock stage (P<0.05). Each additional 4-hour block meeting SCAI criteria for shock predicted a higher mortality rate (adjusted odds ratio, 1.15 [95% CI, 1.07-1.24]). CONCLUSIONS Dynamic assessment of shock using serial SCAI shock classification assignment can improve mortality risk stratification in CICU patients by quantifying the magnitude and duration of shock.
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Affiliation(s)
| | - Sean Van Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of MedicineUniversity of Alberta HospitalEdmontonAlbertaCanada
| | - Parag C. Patel
- Department of Cardiovascular MedicineMayo Clinic FloridaJacksonvilleFLUSA
| | - Timothy D. Henry
- The Carl and Edyth Lindner Center for Research and Education at The Christ Hospital and The Christ Hospital Heart and Vascular InstituteCincinnatiOHUSA
| | - David A. Morrow
- TIMI Study Group, Cardiovascular DivisionBrigham and Women’s Hospital and Harvard Medical SchoolBostonMAUSA
| | - David A. Baran
- Department of Cardiovascular MedicineCleveland Clinic FloridaWestonFLUSA
| | - Kianoush B. Kashani
- Division of Pulmonary and Critical Care Medicine, Division of Nephrology and Hypertension, Department of MedicineMayo Clinic RochesterRochesterMNUSA
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27
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Berg DD, Kaur G, Bohula EA, Baird-Zars VM, Alviar CL, Barnett CF, Barsness GW, Burke JA, Chaudhry SP, Chonde M, Cooper HA, Daniels LB, Dodson MW, Gerber DA, Ghafghazi S, Gidwani UK, Goldfarb MJ, Guo J, Hillerson D, Kenigsberg BB, Kochar A, Kontos MC, Kwon Y, Lopes MS, Loriaux DB, Miller PE, O’Brien CG, Papolos AI, Patel SM, Pisani BA, Potter BJ, Prasad R, Roswell RO, Shah KS, Sinha SS, Smith TD, Solomon MA, Teuteberg JJ, Thompson AD, Zakaria S, Katz JN, van Diepen S, Morrow DA. Prognostic significance of haemodynamic parameters in patients with cardiogenic shock. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2023; 12:651-660. [PMID: 37640029 PMCID: PMC10599641 DOI: 10.1093/ehjacc/zuad095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Revised: 07/17/2023] [Accepted: 08/06/2023] [Indexed: 08/31/2023]
Abstract
AIMS Invasive haemodynamic assessment with a pulmonary artery catheter is often used to guide the management of patients with cardiogenic shock (CS) and may provide important prognostic information. We aimed to assess prognostic associations and relationships to end-organ dysfunction of presenting haemodynamic parameters in CS. METHODS AND RESULTS The Critical Care Cardiology Trials Network is an investigator-initiated multicenter registry of cardiac intensive care units (CICUs) in North America coordinated by the TIMI Study Group. Patients with CS (2018-2022) who underwent invasive haemodynamic assessment within 24 h of CICU admission were included. Associations of haemodynamic parameters with in-hospital mortality were assessed using logistic regression, and associations with presenting serum lactate were assessed using least squares means regression. Sensitivity analyses were performed excluding patients on temporary mechanical circulatory support and adjusted for vasoactive-inotropic score. Among the 3603 admissions with CS, 1473 had haemodynamic data collected within 24 h of CICU admission. The median cardiac index was 1.9 (25th-75th percentile, 1.6-2.4) L/min/m2 and mean arterial pressure (MAP) was 74 (66-86) mmHg. Parameters associated with mortality included low MAP, low systolic blood pressure, low systemic vascular resistance, elevated right atrial pressure (RAP), elevated RAP/pulmonary capillary wedge pressure ratio, and low pulmonary artery pulsatility index. These associations were generally consistent when controlling for the intensity of background pharmacologic and mechanical haemodynamic support. These parameters were also associated with higher presenting serum lactate. CONCLUSION In a contemporary CS population, presenting haemodynamic parameters reflecting decreased systemic arterial tone and right ventricular dysfunction are associated with adverse outcomes and systemic hypoperfusion.
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Affiliation(s)
- David D Berg
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA
| | - Gurleen Kaur
- Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Erin A Bohula
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA
| | - Vivian M Baird-Zars
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA
| | - Carlos L Alviar
- Leon H Charney Division of Cardiology, Bellevue Hospital Center, New York University School of Medicine, New York, NY, USA
| | - Christopher F Barnett
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | | | - James A Burke
- Division of Cardiology, Lehigh Valley Heart Network, Allentown, PA, USA
| | | | - Meshe Chonde
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Howard A Cooper
- Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Lori B Daniels
- Division of Cardiovascular Medicine, Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Mark W Dodson
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT, USA
| | - Daniel A Gerber
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Shahab Ghafghazi
- Cardiovascular Medicine, University of Louisville, Louisville, KY, USA
| | - Umesh K Gidwani
- Division of Cardiology, Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Michael J Goldfarb
- Division of Cardiology, Jewish General Hospital, McGill University, Montreal, QC, Canada
| | - Jianping Guo
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA
| | - Dustin Hillerson
- Department of Medicine, Division of Cardiovascular Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Benjamin B Kenigsberg
- Departments of Cardiology and Critical Care, MedStar Washington Hospital Center, Washington, DC, USA
| | - Ajar Kochar
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA
| | - Michael C Kontos
- Division of Cardiology, Department of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Younghoon Kwon
- Division of Cardiology, University of Washington, Seattle, WA, USA
| | - Mathew S Lopes
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA
| | - Daniel B Loriaux
- Division of Cardiology, Department of Medicine, Duke University, Durham, NC, USA
| | - P Elliott Miller
- Section of Cardiovascular Medicine, Yale University, New Haven, CT, USA
| | - Connor G O’Brien
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Alexander I Papolos
- Departments of Cardiology and Critical Care, MedStar Washington Hospital Center, Washington, DC, USA
| | - Siddharth M Patel
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA
| | - Barbara A Pisani
- Section of Cardiovascular Medicine, Department of Internal Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| | - Brian J Potter
- Cardiology Service, Department of Medicine, Centre Hospitalier de l'Université de Montréal (CHUM) Research Center and Cardiovascular Center, Montreal, QC, Canada
| | - Rajnish Prasad
- Division of Cardiology, Wellstar Health System, Marietta, GA, USA
| | - Robert O Roswell
- Division of Cardiology, Lenox Hill Hospital, Northwell Health, Zucker School of Medicine, New York, NY, USA
| | - Kevin S Shah
- Division of Cardiology, Department of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Shashank S Sinha
- Inova Heart and Vascular Institute, Inova Fairfax Medical Center, Falls Church, VA, USA
| | - Timothy D Smith
- Lindner Center for Research and Education, The Christ Hospital, Cincinnati, OH, USA
| | - Michael A Solomon
- Critical Care Medicine Department, National Institutes of Health Clinical Center and Cardiovascular Branch, National Heart, Lung, and Blood Institute of the National Institutes of Health, Bethesda, MD, USA
| | - Jeffrey J Teuteberg
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Andrea D Thompson
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Sammy Zakaria
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jason N Katz
- Division of Cardiology, Department of Medicine, Duke University, Durham, NC, USA
| | - Sean van Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - David A Morrow
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA
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Fraccaro C, Karam N, Möllmann H, Bleiziffer S, Bonaros N, Teles RC, Carrilho Ferreira P, Chieffo A, Czerny M, Donal E, Dudek D, Dumonteil N, Esposito G, Fournier S, Hassager C, Kim WK, Krychtiuk KA, Mehilli J, Pręgowski J, Stefanini GG, Ternacle J, Thiele H, Thielmann M, Vincent F, von Bardeleben RS, Tarantini G. Transcatheter interventions for left-sided valvular heart disease complicated by cardiogenic shock: a consensus statement from the European Association of Percutaneous Cardiovascular Interventions (EAPCI) in collaboration with the Association for Acute Cardiovascular Care (ACVC) and the ESC Working Group on Cardiovascular Surgery. EUROINTERVENTION 2023; 19:634-651. [PMID: 37624587 PMCID: PMC10587846 DOI: 10.4244/eij-d-23-00473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 08/07/2023] [Indexed: 08/26/2023]
Abstract
Valvular heart disease (VHD) is one of the most frequent causes of heart failure (HF) and is associated with poor prognosis, particularly among patients with conservative management. The development and improvement of catheter-based VHD interventions have broadened the indications for transcatheter valve interventions from inoperable/high-risk patients to younger/lower-risk patients. Cardiogenic shock (CS) associated with severe VHD is a clinical condition with a very high risk of mortality for which surgical treatment is often deemed a prohibitive risk. Transcatheter valve interventions might be a promising alternative in this setting given that they are less invasive. However, supportive scientific evidence is scarce and often limited to small case series. Current guidelines on VHD do not contain specific recommendations on how to manage patients with both VHD and CS. The purpose of this clinical consensus statement, developed by a group of international experts invited by the European Association of Percutaneous Cardiovascular Interventions (EAPCI) Scientific Documents and Initiatives Committee, is to perform a review of the available scientific evidence on the management of CS associated with left-sided VHD and to provide a rationale and practical approach for the application of transcatheter valve interventions in this specific clinical setting.
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Affiliation(s)
- Chiara Fraccaro
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Nicole Karam
- Heart Valves Unit, Georges Pompidou European Hospital, Université Paris Cité, INSERM, Paris, France
| | - Helge Möllmann
- Department of Cardiology, St. Johannes Hospital, Dortmund, Germany
| | | | - Nikolaos Bonaros
- Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Rui Campante Teles
- Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental (HSC), Carnaxide, Portugal and Comprehensive Health Research Center (CHRC), Nova Medical School, Lisbon, Portugal
| | - Pedro Carrilho Ferreira
- Cardiology Department, Santa Maria University Hospital, CHULN, CAML, CCUL, Faculty of Medicine, University of Lisbon, Lisbon, Portugal
| | - Alaide Chieffo
- Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Martin Czerny
- Department of Cardiovascular Surgery, University Heart Centre, Freiburg University, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Erwan Donal
- Service de Cardiologie, CCP CHU de Rennes, University of Rennes, INSERM, LTSI-UMR 1099, Rennes, France
| | - Dariusz Dudek
- Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | | | - Giovanni Esposito
- Divisions of Cardiology and Cardiothoracic Surgery, Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | - Stephane Fournier
- Service of Cardiology, Lausanne University Hospital, Lausanne, Switzerland and University of Lausanne, Lausanne, Switzerland
| | - Christian Hassager
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Won-Keun Kim
- Department of Cardiology, St. Johannes Hospital, Dortmund, Germany
| | - Konstantin A Krychtiuk
- Duke Clinical Research Institute, Durham, NC, USA
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Julinda Mehilli
- Department of Cardiology, German Centre for Cardiovascular Research (DZHK), Ludwig Maximilian University of Munich, Partner Site Munich Heart Alliance, Munich, Germany
- Medizinische Klinik I, Landshut-Achdorf Hospital, Landshut, Germany
| | - Jerzy Pręgowski
- Department of Interventional Cardiology and Angiology, National Institute of Cardiology, Warszawa, Poland
| | - Giulio G Stefanini
- Department of Biomedical Sciences Humanitas University, Pieve Emanuele, Italy
- Humanitas Research Hospital IRCCS Rozzano, Milan, Italy
| | - Julien Ternacle
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC, Canada and Université Laval, Quebec, QC, Canada
- Haut-Leveque Cardiology Hospital, Bordeaux University, Pessac, France
| | - Holger Thiele
- Department of Internal Medicine/Cardiology, Heart Center Leipzig, Leipzig, Germany and University of Leipzig, Leipzig, Germany
| | - Matthias Thielmann
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University Hospital Essen, Essen, Germany
| | - Flavien Vincent
- Service de Cardiologie, Centre Hospitalier Universitaire de Lille, Lille, France
| | | | - Giuseppe Tarantini
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
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Kiyeng J, Akwanalo C, Sugut W, Barasa F, Mwangi A, Njuguna B, Siika A, Vedanthan R. Types and Outcomes of Arrhythmias in a Cardiac Care Unit in Western Kenya: A Prospective Study. Glob Heart 2023; 18:50. [PMID: 37744209 PMCID: PMC10516140 DOI: 10.5334/gh.1261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 08/08/2023] [Indexed: 09/26/2023] Open
Abstract
Background Sustained arrhythmias are frequently encountered in cardiac care units (CCU), but their types and outcomes in Africa are unknown. Studies from high-income countries suggest arrhythmias are associated with worse outcomes. Objectives To determine the types and proportion of cardiac arrhythmias among patients admitted to the CCU at Moi Teaching and Referral Hospital (MTRH), and to compare 30-day outcomes between patients with and without arrhythmias at the time of CCU admission. Methods We conducted a prospective study of a cohort of all patients admitted to MTRH-CCU between March and December 2021. They were stratified on the presence or absence of arrhythmia at the time of CCU admission, irrespective of whether it was the primary indication for CCU care or not. Clinical characteristics were collected using a structured questionnaire. Participants were followed up for 30 days. The primary outcome of interest was 30-day all-cause mortality. Secondary outcomes were 30-day all-cause readmission and length of hospital stay. The 30-day outcomes were compared between the patients with and without arrhythmia, with a p value < 0.05 being considered statistically significant. Results We enrolled 160 participants. The median age was 46 years (IQR 31, 68), and 95 (59.4%) were female. Seventy (43.8%) had a diagnosis of arrhythmia at admission, of whom 62 (88.6%) had supraventricular tachyarrhythmias, five (7.1%) had ventricular tachyarrhythmias, and three (4.3%) had bradyarrhythmia. Atrial fibrillation was the most common supraventricular tachyarrhythmia (82.3%). There was no statistically significant difference in the primary outcome of 30-day mortality between those who had arrhythmia at admission versus those without: 32.9% versus 30.0%, respectively (p = 0.64). Conclusion Supraventricular tachyarrhythmias were common in critically hospitalized cardiac patients in Western Kenya, with atrial fibrillation being the most common. Thirty-day all-cause mortality did not differ significantly between the group admitted with a diagnosis of arrhythmia and those without.
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Affiliation(s)
- Joan Kiyeng
- Department of Cardiology, Moi Teaching and Referral Hospital, Eldoret, KE
- Department of Medicine, Moi University School of Medicine, Eldoret, KE
| | | | - Wilson Sugut
- Department of Cardiology, Moi Teaching and Referral Hospital, Eldoret, KE
| | - Felix Barasa
- Department of Cardiology, Moi Teaching and Referral Hospital, Eldoret, KE
| | - Ann Mwangi
- Department of Math, Physics and Computing, Moi University, Eldoret, KE
| | - Benson Njuguna
- Department of Clinical Pharmacy & Practice, Moi Teaching and Referral Hospital, KE
| | - Abraham Siika
- Department of Medicine, Moi University School of Medicine, Eldoret, KE
| | - Rajesh Vedanthan
- Department of Population Health and Department of Medicine, NYU Grossman School of Medicine, New York, USA
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30
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Wolfe JD, Waken RJ, Fanous E, Fox DK, May AM, Maddox KEJ. Variation in the Use of Targeted Temperature Management for Cardiac Arrest. Am J Cardiol 2023; 201:25-33. [PMID: 37352661 PMCID: PMC10960656 DOI: 10.1016/j.amjcard.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 05/27/2023] [Accepted: 06/01/2023] [Indexed: 06/25/2023]
Abstract
Targeted temperature management (TTM) is recommended for patients who do not respond after return of spontaneous circulation after cardiac arrest. However, the degree to which patients with cardiac arrest have access to this therapy on a national level is not known. Understanding hospital- and patient-level factors associated with receipt of TTM could inform interventions to improve access to this treatment among appropriate patients. Therefore, we performed a retrospective analysis using National Inpatient Sample data from 2016 to 2019. We used International Classification of Diseases, Tenth Edition diagnosis and procedure codes to identify adult patients with in-hospital and out-of-hospital cardiac arrest and receipt of TTM. We evaluated patient and hospital factors associated with receiving TTM. We identified 478,419 patients with cardiac arrest. Of those, 4,088 (0.85%) received TTM. Hospital use of TTM was driven by large, nonprofit, urban, teaching hospitals, with less use at other hospital types. There was significant regional variation in TTM capabilities, with the proportion of hospitals providing TTM ranging from >21% in the Mid-Atlantic region to <11% in the East and West South Central and Mountain regions. At the patient level, age >74 years (odds ratio [OR] 0.54, p <0.001), female gender (OR 0.89, p >0.001), and Hispanic ethnicity (OR 0.74, p <0.001) were all associated with decreased odds of receiving TTM. Patients with Medicare (OR 0.75, p <0.001) and Medicaid (OR 0.89, p = 0.027) were less likely than patients with private insurance to receive TTM. Part of these differences was driven by inequitable access to TTM-capable hospitals. In conclusion, TTM is rarely used after cardiac arrest. Hospital use of TTM is predominately limited to a subset of academic hospitals with substantial regional variation. Older age, female gender, Hispanic ethnicity, and Medicare or Medicaid insurance are all associated with a decreased likelihood of receiving TTM.
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Affiliation(s)
| | - R J Waken
- Division of Cardiology, Department of Medicine
| | | | | | - Adam M May
- Division of Cardiology, Department of Medicine
| | - Karen E Joynt Maddox
- Center for Health Economics and Policy, Institute for Public Health, Washington University in St Louis, St. Louis, Missouri.
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31
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Kadosh BS, Berg DD, Bohula EA, Park JG, Baird-Zars VM, Alviar C, Alzate J, Barnett CF, Barsness GW, Burke J, Chaudhry SP, Daniels LB, DeFilippis A, Delicce A, Fordyce CB, Ghafghazi S, Gidwani U, Goldfarb M, Katz JN, Keeley EC, Kenigsberg B, Kontos MC, Lawler PR, Leibner E, Menon V, Metkus TS, Miller PE, O'Brien CG, Papolos AI, Prasad R, Shah KS, Sinha SS, Snell RJ, So D, Solomon MA, Ternus BW, Teuteberg JJ, Toole J, van Diepen S, Morrow DA, Roswell RO. Pulmonary Artery Catheter Use and Mortality in the Cardiac Intensive Care Unit. JACC. HEART FAILURE 2023; 11:903-914. [PMID: 37318422 PMCID: PMC10527413 DOI: 10.1016/j.jchf.2023.04.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 04/04/2023] [Accepted: 04/11/2023] [Indexed: 06/16/2023]
Abstract
BACKGROUND The appropriate use of pulmonary artery catheters (PACs) in critically ill cardiac patients remains debated. OBJECTIVES The authors aimed to characterize the current use of PACs in cardiac intensive care units (CICUs) with attention to patient-level and institutional factors influencing their application and explore the association with in-hospital mortality. METHODS The Critical Care Cardiology Trials Network is a multicenter network of CICUs in North America. Between 2017 and 2021, participating centers contributed annual 2-month snapshots of consecutive CICU admissions. Admission diagnoses, clinical and demographic data, use of PACs, and in-hospital mortality were captured. RESULTS Among 13,618 admissions at 34 sites, 3,827 were diagnosed with shock, with 2,583 of cardiogenic etiology. The use of mechanical circulatory support and heart failure were the patient-level factors most strongly associated with a greater likelihood of the use of a PAC (OR: 5.99 [95% CI: 5.15-6.98]; P < 0.001 and OR: 3.33 [95% CI: 2.91-3.81]; P < 0.001, respectively). The proportion of shock admissions with a PAC varied significantly by study center ranging from 8% to 73%. In analyses adjusted for factors associated with their placement, PAC use was associated with lower mortality in all shock patients admitted to a CICU (OR: 0.79 [95% CI: 0.66-0.96]; P = 0.017). CONCLUSIONS There is wide variation in the use of PACs that is not fully explained by patient level-factors and appears driven in part by institutional tendency. PAC use was associated with higher survival in cardiac patients with shock presenting to CICUs. Randomized trials are needed to guide the appropriate use of PACs in cardiac critical care.
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Affiliation(s)
- Bernard S Kadosh
- Leon H. Charney Division of Cardiology, New York University Grossman School of Medicine, New York University Langone Health, New York, New York, USA; Lenox Hospital, Northwell Health, New York, New York, USA.
| | - David D Berg
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Erin A Bohula
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Jeong-Gun Park
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Vivian M Baird-Zars
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Carlos Alviar
- Department of Medicine at New York University Grossman School of Medicine, Bellevue Hospital, New York, New York, USA
| | - James Alzate
- Lenox Hospital, Northwell Health, New York, New York, USA
| | - Christopher F Barnett
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Gregory W Barsness
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - James Burke
- Lehigh Valley Heart Institute, Allentown, Pennsylvania, USA
| | | | - Lori B Daniels
- Division of Cardiovascular Medicine, Department of Medicine, University of California, San Diego, La Jolla, California, USA
| | | | | | - Christopher B Fordyce
- University of British Columbia, University of British Columbia Centre for Cardiovascular Innovation, Cardiovascular Health Program, University of British Columbia Centre for Health Evaluation and Outcomes Sciences, Vancouver, British Columbia, Canada
| | - Shahab Ghafghazi
- Division of Cardiovascular Medicine, University of Louisville, Louisville, Kentucky, USA
| | - Umesh Gidwani
- Department of Critical Care Medicine, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, New York, New York, USA
| | - Michael Goldfarb
- Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Jason N Katz
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Ellen C Keeley
- Division of Cardiology, Department of Medicine, University of Florida, Gainesville, Florida, USA
| | - Benjamin Kenigsberg
- Departments of Cardiology and Critical Care Medicine, MedStar Washington Hospital Center, Washington, DC, USA
| | - Michael C Kontos
- Division of Cardiology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Patrick R Lawler
- Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Ontario, Canada
| | - Evan Leibner
- Department of Critical Care Medicine, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, New York, New York, USA; Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, New York, New York, USA
| | - Venu Menon
- Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Thomas S Metkus
- Divisions of Cardiology and Cardiac Surgery, Departments of Medicine and Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - P Elliott Miller
- Department of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Connor G O'Brien
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Alexander I Papolos
- Departments of Cardiology and Critical Care Medicine, MedStar Washington Hospital Center, Washington, DC, USA
| | - Rajnish Prasad
- Wellstar Cardiovascular Medicine, Marietta, Georgia, USA
| | - Kevin S Shah
- University of Utah Health Sciences Center, Salt Lake City, Utah, USA
| | - Shashank S Sinha
- Inova Heart and Vascular Institute, Inova Fairfax Medical Center, Falls Church, Virginia, USA
| | | | - Derek So
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Michael A Solomon
- Critical Care Medicine Department, National Institutes of Health Clinical Center and Cardiovascular Branch, National Heart, Lung, and Blood Institute of the National Institutes of Health, Bethesda, Maryland, USA
| | - Bradley W Ternus
- Division of Cardiology, Department of Internal Medicine, University of Wisconsin, Madison, Wisconsin, USA
| | - Jeffrey J Teuteberg
- Division of Cardiovascular Medicine, Stanford University Medical Center, Palo Alto, California, USA
| | - Joseph Toole
- Lenox Hospital, Northwell Health, New York, New York, USA
| | - Sean van Diepen
- Division of Cardiology, Department of Critical Care Medicine, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - David A Morrow
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
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Jyotsna F, Ahmed A, Kumar K, Kaur P, Chaudhary MH, Kumar S, Khan E, Khanam B, Shah SU, Varrassi G, Khatri M, Kumar S, Kakadiya KA. Exploring the Complex Connection Between Diabetes and Cardiovascular Disease: Analyzing Approaches to Mitigate Cardiovascular Risk in Patients With Diabetes. Cureus 2023; 15:e43882. [PMID: 37746454 PMCID: PMC10511351 DOI: 10.7759/cureus.43882] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 08/21/2023] [Indexed: 09/26/2023] Open
Abstract
Cardiovascular disease (CVD) is the primary cause of morbidity and mortality in individuals diagnosed with diabetes mellitus. This narrative review offers a comprehensive examination of the complex correlation between diabetes and cardiovascular complications. The objective of this review is to analyze the most recent evidence on preventive measures and treatment options for mitigating cardiovascular risk in patients with diabetes, by synthesizing existing literature. Insulin resistance plays a crucial role in connecting diabetes and CVD, leading to the development of dyslipidemia and atherogenesis. As a result, the risk of cardiovascular events in individuals with diabetes is significantly elevated. Moreover, the presence of hyperglycemia-induced oxidative stress and inflammation serves to intensify endothelial dysfunction and vascular damage, thereby exacerbating the risk of cardiovascular complications. The interaction between diabetes and CVD frequently speeds up the development of atherosclerotic plaque, making the plaque more prone to rupture. This can lead to severe cardiovascular events such as myocardial infarction and stroke. It is crucial to comprehend the intricate relationship between diabetes and CVD in order to formulate effective strategies aimed at enhancing patient outcomes and mitigating the burden associated with these interconnected chronic conditions. Healthcare practitioners can enhance the quality of life and reduce mortality rates associated with CVD in diabetic patients by thoroughly examining evidence-based preventive measures and treatment options. This approach allows them to make informed decisions when managing cardiovascular risk. In summary, this narrative review provides a valuable resource for healthcare professionals and researchers, presenting a comprehensive analysis of the complex relationship between diabetes and CVD. By providing a comprehensive analysis of the latest evidence and elucidating the underlying mechanisms, this review seeks to establish a foundation for the development of innovative strategies in diabetes management. These strategies have the potential to significantly improve cardiovascular outcomes and enhance overall patient care.
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Affiliation(s)
- Fnu Jyotsna
- Medicine, Dr. B. R. Ambedkar Medical College & Hospital, Mohali, IND
| | - Areeba Ahmed
- Medicine, Fatima Jinnah Medical University, Lahore, PAK
| | - Kamal Kumar
- Medicine, Chandka Medical College, Larkana, PAK
| | - Paramjeet Kaur
- Internal Medicine, Guru Gobind Singh Medical College, Faridkot, IND
| | | | - Sagar Kumar
- Medicine, Chandka Medical College, Larkana, PAK
| | - Ejaz Khan
- Dermatology, All India Institute of Medical Sciences, New Delhi, New Delhi, IND
| | - Bushra Khanam
- Internal Medicine, National Tuberculosis Control Center, Kathmandu, NPL
| | | | | | - Mahima Khatri
- Medicine and Surgery, Dow University of Health Sciences, Karachi, PAK
| | - Satesh Kumar
- Medicine and Surgery, Shaheed Mohtarma Benazir Bhutto Medical College, Karachi, PAK
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33
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Schöler D, Loosen SH, Wirtz TH, Brozat JF, dos Santos Ferreira Grani LA, Luedde T, Heinrichs L, Frank D, Koch A, Roderburg C, Spehlmann ME. Low extracellular vesicle concentrations predict survival in patients with heart failure. Front Cardiovasc Med 2023; 10:1163525. [PMID: 37293281 PMCID: PMC10244507 DOI: 10.3389/fcvm.2023.1163525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 05/11/2023] [Indexed: 06/10/2023] Open
Abstract
Background Heart disease is of worldwide importance due to high morbidity and mortality. Extracellular vesicle (EV) concentration and size represent novel diagnostic and prognostic biomarkers, e.g. in patients with liver cancer, but data on their prognostic relevance in heart disease are lacking. Here, we investigated the role of EV concentration, size and zeta potential in patients with heart disease. Methods Vesicle size distribution, concentration and zeta potential were measured by nanoparticle tracking analysis (NTA) in 28 intensive care unit (ICU) and 20 standard care (SC) patients and 20 healthy controls. Results Patients with any disease had a lower zeta potential compared to the healthy controls. Vesicle size (X50) was significantly higher in ICU patients (245 nm) with heart disease as compared to those patients with heart disease receiving standard care (195 nm), or healthy controls (215 nm) (p = 0.001). Notably, EV concentration was lower in ICU patients with heart disease (4.68 × 1010 particles/ml) compared to SC patients with heart disease (7,62 × 1010 particles/ml) and healthy controls (1.50 × 1011 particles/ml) (p = 0.002). Extracellular vesicle concentration is prognostic for overall survival in patients with heart disease. Overall survival is significantly reduced when the vesicle concentration is below 5.55 × 1010 particles/ml. Median overall survival was only 140 days in patients with vesicle concentrations below 5.55 × 1010 particles/ml compared to 211 days in patients with vesicle concentrations above 5.55 × 1010 particles/ml (p = 0.032). Summary Concentration of EVs is a novel prognostic marker in ICU and SC patients with heart disease.
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Affiliation(s)
- David Schöler
- Clinic for Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Sven H. Loosen
- Clinic for Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Theresa H. Wirtz
- Department of Gastroenterology, Digestive Diseases and Intensive Care Medicine, RWTH Aachen University Hospital, Aachen, Germany
| | - Jonathan F. Brozat
- Department of Gastroenterology, Digestive Diseases and Intensive Care Medicine, RWTH Aachen University Hospital, Aachen, Germany
- Department of Hepatology and Gastroenterology, Charite—Universitätsmedizin Berlin Campus Virchow-Klinikum (CVK) and Campus Charite Mitte (CCM), Berlin, Germany
| | - Lauredana A. dos Santos Ferreira Grani
- Clinic for Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Tom Luedde
- Clinic for Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Lisa Heinrichs
- Clinic for Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Derk Frank
- Internal Medicine III, University Hospital of Schleswig Holstein, Campus Kiel, Kiel, Germany
| | - Alexander Koch
- Department of Gastroenterology, Digestive Diseases and Intensive Care Medicine, RWTH Aachen University Hospital, Aachen, Germany
| | - Christoph Roderburg
- Clinic for Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Martina E. Spehlmann
- Internal Medicine III, University Hospital of Schleswig Holstein, Campus Kiel, Kiel, Germany
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34
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Sacco A, Tavecchia G, Ditali V, Garatti L, Villanova L, Colombo C, Viola G, Scavelli F, Varrenti M, Milani M, Morici N, Tavazzi G, Lissoni B, Forni L, Gorni G, Saporetti G, Oliva F. Effect of a quality-improvement intervention on end-of-life care in cardiac intensive care unit. Eur J Clin Invest 2023:e13982. [PMID: 36912206 DOI: 10.1111/eci.13982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 02/17/2023] [Accepted: 02/27/2023] [Indexed: 03/14/2023]
Affiliation(s)
- Alice Sacco
- "De Gasperis" Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Giovanni Tavecchia
- "De Gasperis" Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | | | - Laura Garatti
- "De Gasperis" Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Luca Villanova
- "De Gasperis" Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Claudia Colombo
- "De Gasperis" Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Giovanna Viola
- "De Gasperis" Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Francesca Scavelli
- "De Gasperis" Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Marisa Varrenti
- "De Gasperis" Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Martina Milani
- "De Gasperis" Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Nuccia Morici
- S. Maria Nascente-Fondazione Don Carlo Gnocchi ONLUS, Milan, Italy
| | - Guido Tavazzi
- Unit of Anaesthesia and Intensive Care, Department of Clinical-Surgical, Diagnostic and Paediatric Sciences, University of Pavia Italy.,Department of Anaesthesia, Intensive Care and Pain Therapy, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Barbara Lissoni
- Clinical Psicology Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Lorena Forni
- Comitato per l'Etica di Fine Vita, Milan, Italy.,School of Law, Università Milano-Bicocca, Milan, Italy
| | - Giovanna Gorni
- Palliative Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Giorgia Saporetti
- Quality and Risk Management, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Fabrizio Oliva
- "De Gasperis" Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
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Metkus TS, Alviar CL, Baird-Zars VM, Barsness GW, Berg DD, Bohula EA, Burke JA, Fordyce CB, Guo J, Katz JN, Keeley EC, Menon V, Miller PE, O’Brien CG, Sinha SS, So D, Ternus BW, Vadhar S, van Diepen S, Morrow DA. Presentation and Outcomes of Patients With Preoperative Critical Illness Undergoing Cardiac Surgery. JACC. ADVANCES 2023; 2:100260. [PMID: 38357248 PMCID: PMC10865183 DOI: 10.1016/j.jacadv.2023.100260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/16/2024]
Abstract
BACKGROUND Little is known about the prevalence and post-surgical outcomes associated with cardiac intensive care unit (CICU) therapeutics among CICU patients referred for cardiac surgery. OBJECTIVES The purpose of this study was to investigate the clinical characteristics and outcomes of CICU patients referred for cardiac surgery from the intensive care unit. METHODS We analyzed characteristics and outcomes of CICU admissions referred from the CICU for cardiac surgery during 2017 to 2020 across 29 centers. The primary outcome was in-hospital mortality. RESULTS Among 10,321 CICU admissions, 887 (8.6%) underwent cardiac surgery, including 406 (46%) coronary artery bypass graftings, 201 (23%) transplants or ventricular assist devices, 171 (19%) valve surgeries, and 109 (12%) other procedures. Common indications for CICU admission included shock (33.5%) and respiratory insufficiency (24.9%). Preoperative CICU therapies included vasoactive therapy in 52.2%, mechanical circulatory support in 35.9%, renal replacement in 8.2%, mechanical ventilation in 35.7%, and 17.5% with high-flow nasal cannula or noninvasive positive pressure ventilation. In-hospital mortality was 11.7% among all CICU admissions and 9.1% among patients treated with cardiac surgery. After multivariable adjustment, pre-op mechanical circulatory support and renal replacement therapy were associated with mortality, while respiratory support and vasoactive therapy were not. CONCLUSIONS Nearly 1 in 12 contemporary CICU patients receive cardiac surgery. Despite high preoperative disease severity, CICU admissions undergoing cardiac surgery had a comparable mortality rate to CICU patients overall; highlighting the ability of clinicians to select higher acuity patients with a reasonable perioperative risk.
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Affiliation(s)
- Thomas S. Metkus
- Divisions of Cardiology and Cardiac Surgery, Departments of Medicine and Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Carlos L. Alviar
- Leon H. Charney Division of Cardiology, NYU Langone Medical Center, New York City, New York, USA
| | - Vivian M. Baird-Zars
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Gregory W. Barsness
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - David D. Berg
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Erin A. Bohula
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - James A. Burke
- Lehigh Valley Heart and Vascular Institute, Allentown, Pennsylvania, USA
| | - Christopher B. Fordyce
- Division of Cardiology and Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jianping Guo
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Jason N. Katz
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Ellen C. Keeley
- Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida, USA
| | - Venu Menon
- Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - P. Elliott Miller
- Department of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Connor G. O’Brien
- Division of Cardiology, Department of Medicine, University of California-San Francisco School of Medicine, San Francisco, California, USA
| | - Shashank S. Sinha
- Inova Heart and Vascular Institute, Inova Fairfax Medical Center, Falls Church, Virginia, USA
| | - Derek So
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Bradley W. Ternus
- Division of Cardiology, Department of Internal Medicine, University of Wisconsin, Madison, Wisconsin, USA
| | - Sagar Vadhar
- Lehigh Valley Heart and Vascular Institute, Allentown, Pennsylvania, USA
| | - Sean van Diepen
- Division of Cardiology, Department of Critical Care Medicine, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - David A. Morrow
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
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Grupper A, Chernomordik F, Herscovici R, Mazin I, Segev A, Beigel R, Matetzky S. The burden of heart failure in cardiac intensive care unit: a prospective 7 years analysis. ESC Heart Fail 2023; 10:1615-1622. [PMID: 36802123 DOI: 10.1002/ehf2.14320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 01/09/2023] [Accepted: 01/31/2023] [Indexed: 02/20/2023] Open
Abstract
AIMS The profiles of patients at cardiac intensive care units (CICU) have evolved towards a patient population with an increasing number of co-morbid medical conditions and acute heart failure (HF). The current study was designed to illustrate the burden of HF patients admitted to CICU, and evaluate patient characteristics, in-hospital course and outcomes of CICU patients with HF compared with patients with acute coronary syndrome (ACS). METHODS AND RESULTS A prospective study including all consecutive patients admitted to the CICU at a tertiary medical centre between 2014 and 2020. The main outcome was a direct comparison between HF and ACS patients in processes of care, resource use, and outcomes during CICU hospitalization. A secondary analysis compared ischaemic versus non-ischaemic HF aetiology. Adjusted analysis evaluated parameters associated with prolonged hospitalization. The cohort included 7674 patients with a total annual CICU admissions of 1028-1145 patients. HF diagnosis patients represented 13-18% of the annual CICU admissions and were significantly older with higher incidence of multiple co-morbidities compared with patients with ACS. HF patients also required more intensive therapies and demonstrated higher incidence of acute complications as compared with ACS patients. Length of stay at the CICU was significantly longer among HF patients compared with patients with ACS (either STEMI or NSTEMI) (6.2 ± 4.3 vs. 4.1 ± 2.5 vs. 3.5 ± 2.1, respectively, P < 0.001). HF patients represented a disproportionately higher amount of total CICU patient days during the study period, as the total length of hospitalization of HF patients was 44-56% out of the total cumulative days in CICU of patients with ACS every year. In hospital mortality rates were also significantly higher among patients with HF compared with STEMI or NSTEMI (4.2% vs. 3.1% vs. 0.7%, respectively, P < 0.001). Despite several differences in baseline characteristics between patients with ischaemic versus non-ischaemic HF, which can be attributed mainly to disease aetiology, hospitalization length and outcomes were similar among the groups regardless of HF aetiology. In multivariable analysis for the risk of prolonged hospitalization in the CICU adjusted to potential significant co-morbidities associated with poor outcomes, HF was found to be an independent and significant parameter associated with the risk of prolonged hospitalization with an OR of 3.5 (95% CI 2.9-4.1, P < 0.001). CONCLUSIONS Patients with HF in CICU have higher severity of illness with a prolonged and complicated hospital course, all of which can substantially increase the burden on clinical resources.
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Affiliation(s)
- Avishay Grupper
- Division of Cardiology, Leviev Center of Cardiovascular medicine, Sheba Medical Center in Tel-Ha'Shomer, Ramat-Gan, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Fernando Chernomordik
- Division of Cardiology, Leviev Center of Cardiovascular medicine, Sheba Medical Center in Tel-Ha'Shomer, Ramat-Gan, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Romana Herscovici
- Division of Cardiology, Leviev Center of Cardiovascular medicine, Sheba Medical Center in Tel-Ha'Shomer, Ramat-Gan, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Israel Mazin
- Division of Cardiology, Leviev Center of Cardiovascular medicine, Sheba Medical Center in Tel-Ha'Shomer, Ramat-Gan, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Amitai Segev
- Division of Cardiology, Leviev Center of Cardiovascular medicine, Sheba Medical Center in Tel-Ha'Shomer, Ramat-Gan, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Roy Beigel
- Division of Cardiology, Leviev Center of Cardiovascular medicine, Sheba Medical Center in Tel-Ha'Shomer, Ramat-Gan, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Shlomi Matetzky
- Division of Cardiology, Leviev Center of Cardiovascular medicine, Sheba Medical Center in Tel-Ha'Shomer, Ramat-Gan, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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37
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Hernandez-Montfort J, Kanwar M, Sinha SS, Garan AR, Blumer V, Kataria R, Whitehead EH, Yin M, Li B, Zhang Y, Thayer KL, Baca P, Dieng F, Harwani NM, Guglin M, Abraham J, Hickey G, Nathan S, Wencker D, Hall S, Schwartzman A, Khalife W, Li S, Mahr C, Kim J, Vorovich E, Pahuja M, Burkhoff D, Kapur NK. Clinical Presentation and In-Hospital Trajectory of Heart Failure and Cardiogenic Shock. JACC. HEART FAILURE 2023; 11:176-187. [PMID: 36342421 DOI: 10.1016/j.jchf.2022.10.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 10/04/2022] [Accepted: 10/11/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Heart failure-related cardiogenic shock (HF-CS) remains an understudied distinct clinical entity. OBJECTIVES The authors sought to profile a large cohort of patients with HF-CS focused on practical application of the SCAI (Society for Cardiovascular Angiography and Interventions) staging system to define baseline and maximal shock severity, in-hospital management with acute mechanical circulatory support (AMCS), and clinical outcomes. METHODS The Cardiogenic Shock Working Group registry includes patients with CS, regardless of etiology, from 17 clinical sites enrolled between 2016 and 2020. Patients with HF-CS (non-acute myocardial infarction) were analyzed and classified based on clinical presentation, outcomes at discharge, and shock severity defined by SCAI stages. RESULTS A total of 1,767 patients with HF-CS were included, of whom 349 (19.8%) had de novo HF-CS (DNHF-CS). Patients were more likely to present in SCAI stage C or D and achieve maximum SCAI stage D. Patients with DNHF-CS were more likely to experience in-hospital death and in- and out-of-hospital cardiac arrest, and they escalated more rapidly to a maximum achieved SCAI stage, compared to patients with acute-on-chronic HF-CS. In-hospital cardiac arrest was associated with greater in-hospital death regardless of clinical presentation (de novo: 63% vs 21%; acute-on-chronic HF-CS: 65% vs 17%; both P < 0.001). Forty-five percent of HF-CS patients were exposed to at least 1 AMCS device throughout hospitalization. CONCLUSIONS In a large contemporary HF-CS cohort, we identified a greater incidence of in-hospital death and cardiac arrest as well as a more rapid escalation to maximum SCAI stage severity among DNHF-CS. AMCS use in HF-CS was common, with significant heterogeneity among device types. (Cardiogenic Shock Working Group Registry [CSWG]; NCT04682483).
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Affiliation(s)
| | - Manreet Kanwar
- Cardiovascular Institute at Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Shashank S Sinha
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, Virginia, USA
| | - A Reshad Garan
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Vanessa Blumer
- Duke University Medical Center, Durham, North Carolina, USA
| | - Rachna Kataria
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Michael Yin
- The CardioVascular Center, Tufts Medical Center, Boston, Massachusetts, USA
| | - Borui Li
- The CardioVascular Center, Tufts Medical Center, Boston, Massachusetts, USA
| | - Yijing Zhang
- The CardioVascular Center, Tufts Medical Center, Boston, Massachusetts, USA
| | - Katherine L Thayer
- The CardioVascular Center, Tufts Medical Center, Boston, Massachusetts, USA
| | - Paulina Baca
- The CardioVascular Center, Tufts Medical Center, Boston, Massachusetts, USA
| | - Fatou Dieng
- The CardioVascular Center, Tufts Medical Center, Boston, Massachusetts, USA
| | - Neil M Harwani
- The CardioVascular Center, Tufts Medical Center, Boston, Massachusetts, USA
| | - Maya Guglin
- Indiana University Health Advanced Heart and Lung Care, Indianapolis, Indiana, USA
| | | | - Gavin Hickey
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | | | - Detlef Wencker
- Baylor Scott and White Health, Advanced Heart Disease Program, Temple, Texas, USA
| | - Shelley Hall
- Baylor Scott and White Advanced Heart Failure Clinic, Dallas, Texas, USA
| | | | - Wissam Khalife
- University of Texas Medical Branch, Galveston, Texas, USA
| | - Song Li
- University of Washington Medical Center, Seattle, Washington, USA
| | - Claudius Mahr
- University of Washington Medical Center, Seattle, Washington, USA
| | - Ju Kim
- Houston Methodist Research Institute, Houston, Texas, USA
| | | | - Mohit Pahuja
- Medstar Heart and Vascular Institute, Georgetown University, Washington, DC, USA
| | | | - Navin K Kapur
- The CardioVascular Center, Tufts Medical Center, Boston, Massachusetts, USA.
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38
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Carnicelli AP, Keane R, Brown KM, Loriaux DB, Kendsersky P, Alviar CL, Arps K, Berg DD, Bohula EA, Burke JA, Dixson JA, Gerber DA, Goldfarb M, Granger CB, Guo J, Harrison RW, Kontos M, Lawler PR, Miller PE, Nativi-Nicolau J, Newby LK, Racharla L, Roswell RO, Shah KS, Sinha SS, Solomon MA, Teuteberg J, Wong G, van Diepen S, Katz JN, Morrow DA. Characteristics, therapies, and outcomes of In-Hospital vs Out-of-Hospital cardiac arrest in patients presenting to cardiac intensive care units: From the critical care Cardiology trials network (CCCTN). Resuscitation 2023; 183:109664. [PMID: 36521683 PMCID: PMC9899313 DOI: 10.1016/j.resuscitation.2022.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 11/19/2022] [Accepted: 12/05/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Cardiac arrest (CA) is a common reason for admission to the cardiac intensive care unit (CICU), though the relative burden of morbidity, mortality, and resource use between admissions with in-hospital (IH) and out-of-hospital (OH) CA is unknown. We compared characteristics, care patterns, and outcomes of admissions to contemporary CICUs after IHCA or OHCA. METHODS The Critical Care Cardiology Trials Network is a multicenter network of tertiary CICUs in the US and Canada. Participating centers contributed data from consecutive admissions during 2-month annual snapshots from 2017 to 2021. We analyzed characteristics and outcomes of admissions by IHCA vs OHCA. RESULTS We analyzed 2,075 admissions across 29 centers (50.3% IHCA, 49.7% OHCA). Admissions with IHCA were older (median 66 vs 62 years), more commonly had coronary disease (38.3% vs 29.7%), atrial fibrillation (26.7% vs 15.6%), and heart failure (36.3% vs 22.1%), and were less commonly comatose on CICU arrival (34.2% vs 71.7%), p < 0.001 for all. IHCA admissions had lower lactate (median 4.3 vs 5.9) but greater utilization of invasive hemodynamics (34.3% vs 23.6%), mechanical circulatory support (28.4% vs 16.8%), and renal replacement therapy (15.5% vs 9.4%); p < 0.001 for all. Comatose IHCA patients underwent targeted temperature management less frequently than OHCA patients (63.3% vs 84.9%, p < 0.001). IHCA admissions had lower unadjusted CICU (30.8% vs 39.0%, p < 0.001) and in-hospital mortality (36.1% vs 44.1%, p < 0.001). CONCLUSION Despite a greater burden of comorbidities, CICU admissions after IHCA have lower lactate, greater invasive therapy utilization, and lower crude mortality than admissions after OHCA.
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Affiliation(s)
- Anthony P Carnicelli
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA.
| | - Ryan Keane
- Division of Cardiology, Department of Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Kelly M Brown
- Duke University Hospital, Division of Cardiology, Durham, NC, USA
| | - Daniel B Loriaux
- Duke University Hospital, Division of Cardiology, Durham, NC, USA
| | - Payton Kendsersky
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Carlos L Alviar
- Leon H Charney Division of Cardiology, Bellevue Hospital Center, New York University School of Medicine, New York, NY, USA
| | - Kelly Arps
- Duke University Hospital, Division of Cardiology, Durham, NC, USA
| | - David D Berg
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Erin A Bohula
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Jeffrey A Dixson
- Duke University Hospital, Division of Cardiology, Durham, NC, USA
| | - Daniel A Gerber
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Michael Goldfarb
- Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | | | - Jianping Guo
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Michael Kontos
- Division of Cardiology, Department of Medicine, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Patrick R Lawler
- Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada
| | - P Elliott Miller
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Jose Nativi-Nicolau
- Division of Cardiology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - L Kristin Newby
- Duke University Hospital, Division of Cardiology, Durham, NC, USA
| | | | - Robert O Roswell
- Lennox Hill Hospital, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Kevin S Shah
- Division of Cardiology, Department of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Shashank S Sinha
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA, USA
| | - Michael A Solomon
- Critical Care Medicine Department, National Institutes of Health Clinical Center and Cardiovascular Branch, National Heart, Lung, and Blood Institute of the National Institutes of Health, Bethesda, MD, USA
| | - Jeffrey Teuteberg
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Graham Wong
- Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sean van Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Alberta, Canada
| | - Jason N Katz
- Duke University Hospital, Division of Cardiology, Durham, NC, USA
| | - David A Morrow
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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39
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Management of Cardiogenic Shock Unrelated to Acute Myocardial Infarction. Can J Cardiol 2023; 39:406-419. [PMID: 36731605 DOI: 10.1016/j.cjca.2023.01.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 01/18/2023] [Accepted: 01/19/2023] [Indexed: 02/01/2023] Open
Abstract
Cardiogenic shock is an extreme manifestation of acute decompensated heart failure. Cardiogenic shock is often caused by-and has traditionally been studied in the setting of-acute myocardial infarction (AMI CS); however, there is increasing incidence and recognition of cardiogenic shock not associated with acute myocardial infarction (non-AMI CS) as a distinct entity. Despite decades of study and technologic advancements, cardiogenic shock mortality remains as high as 50%, regardless of etiology. New approaches to shock phenotyping and classification have emerged, with a focus on appropriately matching patient physiology to a growing list of available interventions. Further study is needed to determine whether these efforts will lead to more nuanced use of mechanical circulatory support and improved patient outcomes, especially in non-AMI CS. In the meantime, models of care incorporating multidisciplinary decision making, such as shock teams, may improve patient selection and outcomes.
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40
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Cherbi M, Roubille F, Lamblin N, Bonello L, Leurent G, Levy B, Elbaz M, Champion S, Lim P, Schneider F, Cariou A, Khachab H, Bourenne J, Seronde MF, Schurtz G, Harbaoui B, Vanzetto G, Quentin C, Delabranche X, Aissaoui N, Combaret N, Tomasevic D, Marchandot B, Lattuca B, Henry P, Gerbaud E, Bonnefoy E, Puymirat E, Maury P, Delmas C. One-year outcomes in cardiogenic shock triggered by ventricular arrhythmia: An analysis of the FRENSHOCK multicenter prospective registry. Front Cardiovasc Med 2023; 10:1092904. [PMID: 36776263 PMCID: PMC9909601 DOI: 10.3389/fcvm.2023.1092904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 01/09/2023] [Indexed: 01/28/2023] Open
Abstract
Background Cardiogenic shock (CS) is a life-threatening condition carrying poor prognosis, potentially triggered by ventricular arrhythmia (VA). Whether the occurrence of VA as trigger of CS worsens the prognosis compared to non-VA triggers remains unclear. The aim of this study was to evaluate 1-year outcomes [mortality, heart transplantation, ventricular assist devices (VAD)] between VA-triggered and non-VA-triggered CS. Methods FRENSHOCK is a prospective multicenter registry including 772 CS patients from 49 centers. One to three triggers can be identified in the registry (ischemic, mechanical complications, ventricular/supraventricular arrhythmia, bradycardia, iatrogenesis, infection, non-compliance). Baseline characteristics, management and 1-year outcomes were analyzed according to the VA-trigger in the CS population. Results Within 769 CS patients included, 94 were VA-triggered (12.2%) and were compared to others. At 1 year, although there was no mortality difference [42.6 vs. 45.3%, HR 0.94 (0.67-1.30), p = 0.7], VA-triggered CS resulted in more heart transplantations and VAD (17 vs. 9%, p = 0.02). Into VA-triggered CS group, though there was no 1-year mortality difference between ischemic and non-ischemic cardiomyopathies [42.5 vs. 42.6%, HR 0.97 (0.52-1.81), p = 0.92], non-ischemic cardiomyopathy led to more heart transplantations and VAD (25.9 vs. 5%, p = 0.02). Conclusion VA-triggered CS did not show higher mortality compared to other triggers but resulted in more heart transplantation and VAD at 1 year, especially in non-ischemic cardiomyopathy, suggesting the need for earlier evaluation by advanced heart failure specialized team for a possible indication of mechanical circulatory support or heart transplantation. Clinical trial registration https://clinicaltrials.gov, identifier NCT02703038.
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Affiliation(s)
- Miloud Cherbi
- Intensive Cardiac Care Unit, Rangueil University Hospital, Toulouse, France,Institute of Metabolic and Cardiovascular Diseases (I2MC), UMR-1048, National Institute of Health and Medical Research (INSERM), Toulouse, France
| | - François Roubille
- PhyMedExp, Université de Montpellier, INSERM, CNRS, Cardiology Department, INI-CRT, CHU de Montpellier, Montpellier, France
| | - Nicolas Lamblin
- Department of Cardiology, Urgences et Soins Intensifs de Cardiologie, CHU Lille, University of Lille, Inserm U1167, Lille, France
| | - Laurent Bonello
- Aix-Marseille Université, Marseille, France,Intensive Care Unit, Department of Cardiology, Assistance Publique-Hôpitaux de Marseille, Hôpital Nord, Marseille, France,Mediterranean Association for Research and Studies in Cardiology (MARS Cardio), Marseille, France
| | - Guillaume Leurent
- Department of Cardiology, CHU Rennes, Inserm, LTSI-UMR 1099, Univ Rennes 1, Rennes, France
| | - Bruno Levy
- CHRU Nancy, Réanimation Médicale Brabois, Nancy, France
| | - Meyer Elbaz
- Intensive Cardiac Care Unit, Rangueil University Hospital, Toulouse, France,Institute of Metabolic and Cardiovascular Diseases (I2MC), UMR-1048, National Institute of Health and Medical Research (INSERM), Toulouse, France
| | | | - Pascal Lim
- Université Paris Est-Créteil, INSERM, IMRB, Créteil, France,AP-HP, Hôpital Universitaire Henri-Mondor, Service de Cardiologie, Créteil, France
| | - Francis Schneider
- Médecine Intensive-Réanimation, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Alain Cariou
- Medical Intensive Care Unit, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Centre–Université de Paris, Medical School, Paris, France
| | - Hadi Khachab
- Intensive Cardiac Care Unit, Department of Cardiology, CH d’Aix-en-Provence, Aix-en-Provence, France
| | - Jeremy Bourenne
- Aix-Marseille Université, Service de Réanimation des Urgences, CHU La Timone 2, Marseille, France
| | | | - Guillaume Schurtz
- Department of Cardiology, Urgences et Soins Intensifs de Cardiologie, CHU Lille, University of Lille, Inserm U1167, Lille, France
| | - Brahim Harbaoui
- Cardiology Department, Hôpital Croix-Rousse and Hôpital Lyon Sud, Hospices Civils de Lyon, Lyon, France,Department of Cardiology, University of Lyon, CREATIS UMR5220, INSERM U1044, INSA-15, Lyon, France
| | - Gerald Vanzetto
- Department of Cardiology, Hôpital de Grenoble, Grenoble, France
| | - Charlotte Quentin
- Service de Réanimation Polyvalente, Centre Hospitalier Broussais, 1 Rue de la Marne, Saint-Malo, France
| | - Xavier Delabranche
- Réanimation Chirurgicale Polyvalente, Pôle Anesthésie–Réanimation Chirurgicale–Médecine Péri-opératoire, Les Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil 1, Porte de l’Hôpital, Strasbourg, France
| | - Nadia Aissaoui
- Intensive Cardiac Care Unit, Department of Cardiology, CH d’Aix-en-Provence, Aix-en-Provence, France
| | - Nicolas Combaret
- Department of Cardiology, CHU Clermont-Ferrand, CNRS, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Danka Tomasevic
- Intensive Cardiac Care Unit, Lyon Brom University Hospital, Lyon, France
| | - Benjamin Marchandot
- Université de Strasbourg, Pôle d’Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, Strasbourg, France
| | - Benoit Lattuca
- Department of Cardiology, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | - Patrick Henry
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Lariboisière, Department of Cardiology, Paris, France
| | - Edouard Gerbaud
- Intensive Cardiac Care Unit and Interventional Cardiology, Hôpital Cardiologique du Haut Lévêque, Pessac, France,Bordeaux Cardio-Thoracic Research Centre, U1045, Bordeaux University, Hôpital Xavier Arnozan, Pessac, France
| | - Eric Bonnefoy
- Intensive Cardiac Care Unit, Lyon Brom University Hospital, Lyon, France
| | - Etienne Puymirat
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Européen Georges Pompidou, Department of Cardiology, Paris, France,Université de Paris, Paris, France
| | - Philippe Maury
- Intensive Cardiac Care Unit, Rangueil University Hospital, Toulouse, France,Institute of Metabolic and Cardiovascular Diseases (I2MC), UMR-1048, National Institute of Health and Medical Research (INSERM), Toulouse, France
| | - Clément Delmas
- Intensive Cardiac Care Unit, Rangueil University Hospital, Toulouse, France,Institute of Metabolic and Cardiovascular Diseases (I2MC), UMR-1048, National Institute of Health and Medical Research (INSERM), Toulouse, France,REICATRA, Institut Saint Jacques, CHU de Toulouse, Toulouse, France,*Correspondence: Clément Delmas, ,
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41
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Patel SM, Berg DD, Bohula EA, Baird-Zars VM, Barnett CF, Barsness GW, Chaudhry SP, Daniels LB, van Diepen S, Ghafghazi S, Goldfarb MJ, Jentzer JC, Katz JN, Kenigsberg BB, Lawler PR, Miller PE, Papolos AI, Park JG, Potter BJ, Prasad R, Singam NSV, Sinha SS, Solomon MA, Teuteberg JJ, Morrow DA. Clinician and Algorithmic Application of the 2019 and 2022 Society of Cardiovascular Angiography and Intervention Shock Stages in the Critical Care Cardiology Trials Network Registry. Circ Heart Fail 2023; 16:e009714. [PMID: 36458542 PMCID: PMC9851990 DOI: 10.1161/circheartfailure.122.009714] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Accepted: 09/20/2022] [Indexed: 12/04/2022]
Abstract
BACKGROUND Algorithmic application of the 2019 Society of Cardiovascular Angiography and Intervention (SCAI) shock stages effectively stratifies mortality risk for patients with cardiogenic shock. However, clinician assessment of SCAI staging may differ. Moreover, the implications of the 2022 SCAI criteria update remain incompletely defined. METHODS The Critical Care Cardiology Trials Network is a multicenter registry of cardiac intensive care units (CICUs). Between 2019 and 2021, participating centers (n=32) contributed at least a 2-month snapshot of consecutive medical CICU admissions. In-hospital mortality was assessed across 3 separate staging methods: clinician assessment, Critical Care Cardiology Trials Network algorithmic application of the 2019 SCAI criteria, and a revision of the Critical Care Cardiology Trials Network application using the 2022 SCAI criteria. RESULTS Of 9612 admissions, 1340 (13.9%) presented with cardiogenic shock with in-hospital mortality of 35.2%. Both clinician and algorithm-based staging using the 2019 SCAI criteria identified a stepwise gradient of mortality risk (stage C-E: 19.0% to 83.7% and 14.6% to 52.2%, respectively; Ptrend<0.001 for each). Clinician assignment of SCAI stages identified higher risk patients compared with algorithm-based assignment (stage D: 49.9% versus 29.3%; stage E: 83.7% versus 52.2%). Algorithmic application of the 2022 SCAI criteria, with incorporation of the vasoactive-inotropic score, more closely approximated clinician staging (mortality for stage C-E: 21.9% to 70.5%; Ptrend<0.001). CONCLUSIONS Both clinician and algorithm-based application of the 2019 SCAI stages identify a stepwise gradient of mortality risk, although clinician-staging may better allocate higher risk patients into advanced SCAI stages. Updated algorithmic staging using the 2022 SCAI criteria and vasoactive-inotropic score further refines risk stratification.
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Affiliation(s)
- Siddharth M. Patel
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - David D. Berg
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Erin A. Bohula
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Vivian M. Baird-Zars
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher F. Barnett
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Gregory W. Barsness
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Lori B. Daniels
- Division of Cardiovascular Medicine, Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Sean van Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Shahab Ghafghazi
- Cardiovascular Medicine, University of Louisville, Louisville, Kentucky, USA
| | | | - Jacob C. Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jason N. Katz
- Division of Cardiology, Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Benjamin B. Kenigsberg
- Departments of Cardiology and Critical Care, MedStar Washington Hospital Center, Washington, DC, USA
| | - Patrick R. Lawler
- Peter Munk Cardiac Centre at Toronto General Hospital, Division of Cardiology and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - P. Elliot Miller
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Alexander I. Papolos
- Departments of Cardiology and Critical Care, MedStar Washington Hospital Center, Washington, DC, USA
| | - Jeong-Gun Park
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Brian J. Potter
- Centre Hospitalier de l’Université de Montréal (CHUM) Research Center and Cardiovascular Center, Montreal, QC, Canada
| | | | - N. Sarma V. Singam
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Shashank S. Sinha
- Inova Heart and Vascular Institute, Inova Fairfax Medical Center, Falls Church, Virginia, USA
| | - Michael A. Solomon
- Critical Care Medicine Department, National Institutes of Health Clinical Center and Cardiovascular Branch, National Heart, Lung, and Blood Institute of the National Institutes of Health, Bethesda, Maryland, USA
| | - Jeffrey J. Teuteberg
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California, USA
| | - David A. Morrow
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Sinha SS, Bohula EA, Diepen SVAN, Leonardi S, Mebazaa A, Proudfoot AG, Sionis A, Chia YW, Zampieri FG, Lopes RD, Katz JN. The Intersection Between Heart Failure and Critical Care Cardiology: An International Perspective on Structure, Staffing, and Design Considerations. J Card Fail 2022; 28:1703-1716. [PMID: 35843489 DOI: 10.1016/j.cardfail.2022.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 06/16/2022] [Accepted: 06/24/2022] [Indexed: 10/17/2022]
Abstract
The overall patient population in contemporary cardiac intensive care units (CICUs) has only increased with respect to patient acuity, complexity, and illness severity. The current population has more cardiac and noncardiac comorbidities, a higher prevalence of multiorgan injury, and consumes more critical care resources than previously. Patients with heart failure (HF) now occupy a large portion of contemporary tertiary or quaternary care CICU beds around the world. In this review, we discuss the core issues that relate to the care of critically ill patients with HF, including global perspectives on the organization, designation, and collaboration of CICUs regionally and across institutions, as well as unique models for provisioning care for patients with HF within a health care setting. The latter includes a discussion of traditional and emerging models, specialized HF units, the makeup and implementation of multidisciplinary team-based decision-making, and cardiac critical care admission and triage practices. This article illustrates the ways in which critically ill patients with HF have helped to shape contemporary CICUs throughout the world and explores how these very patients will similarly help to inform the future maturation of these specialized critical care units. Finally, we will critically examine broad, contemporary, international models of HF and cardiac critical care delivery in North America, Europe, South America, and Asia, and conclude with opportunities for the further investigation and generation of evidence for care delivery.
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Affiliation(s)
- Shashank S Sinha
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, Virginia
| | - Erin A Bohula
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sean VAN Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Sergio Leonardi
- Fondazione IRCCS Policlinico San Matteo, Pavia and University of Pavia, Pavia, Italy
| | - Alexandre Mebazaa
- Université de Paris, Inserm 942 MASCOT, APHP Hôpitaux Universitaires Saint-Louis-Lariboisière, Paris, France
| | - Alastair G Proudfoot
- Perioperative Medicine Department, Barts Heart Centre, St Bartholomew's Hospital, London, UK; Clinic For Anaesthesiology & Intensive Care, Charité-Universitätsmedizin Berlin corporate member of Freie Universität Berlin and Humboldt Univesität zu, Berlin, Germany
| | - Alessandro Sionis
- Intensive Cardiac Care Unit, Cardiology Department, Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBER-CV), Madrid, Spain
| | - Yew Woon Chia
- Cardiac Intensive Care Unit, Department of Cardiology, Tan Tock Seng Hospital, Singapore
| | - Fernando G Zampieri
- HCor Research Institute, São Paulo, Brazil Intensive Care Unit, Federal University of São Paulo, Brazil
| | - Renato D Lopes
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina; Brazilian Clinical Research Institute (BCRI), Sao Paulo, Brazil
| | - Jason N Katz
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
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Cardiovascular Critical Care Training: A Collaboration between Intensivists and Cardiologists. ATS Sch 2022; 3:522-534. [PMID: 36726709 PMCID: PMC9885994 DOI: 10.34197/ats-scholar.2022-0087ps] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 10/21/2022] [Indexed: 11/13/2022] Open
Abstract
With growing patient complexity, the cardiovascular intensive care unit (CICU) of today has evolved substantially from the coronary care unit (CCU) of decades ago. The growing burden of noncardiac critical illness and highly specialized acute cardiovascular disease requires a degree of expertise beyond that afforded through a general cardiology training program. Therefore, the American Heart Association (AHA) has proposed a CICU staffing model to include dedicated cardiac intensivists; in the present day, "dual-trained" physicians are extremely sparse. Guidance on designing critical care fellowships for cardiologists is limited but will require collaboration between cardiologists and medical intensivists. Here, we review the evolution of the CICU, describe training pathways, and offer guidance on creating a cardiology critical care training program.
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44
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Grabert J, Velten M. [The OPTIMAL trial on tranexamic acid in cardiac surgery-Does a lot help a lot?]. DIE ANAESTHESIOLOGIE 2022; 71:965-966. [PMID: 36307734 PMCID: PMC9729118 DOI: 10.1007/s00101-022-01216-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 10/10/2022] [Indexed: 06/16/2023]
Affiliation(s)
- J Grabert
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Bonn, Venusberg-Campus 1, 53127, Bonn, Deutschland.
| | - M Velten
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Bonn, Venusberg-Campus 1, 53127, Bonn, Deutschland
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45
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Bruno RR, Wolff G, Kelm M, Jung C. Pharmacological treatment of cardiogenic shock - A state of the art review. Pharmacol Ther 2022; 240:108230. [PMID: 35697151 DOI: 10.1016/j.pharmthera.2022.108230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 05/30/2022] [Accepted: 06/07/2022] [Indexed: 12/14/2022]
Abstract
Cardiogenic shock is a clinical syndrome of impaired tissue perfusion caused by primary cardiac dysfunction and inadequate cardiac output. It represents one of the most lethal clinical conditions in intensive care medicine with mortality >40%. Management of different clinical presentations of cardiogenic shock includes guidance of cardiac preload, afterload, heart rate and contractility by differential pharmacological modulation of volume, systemic and pulmonary vascular resistance and cardiac output besides reversing the triggering cause. Data from large registries and randomized controlled trials on optimal diagnostic guidance as well as choice of pharmacological agents has accrued significantly in recent years. This state-of-the-art review summarizes the basic concepts of cardiogenic shock, the diagnostic work-up and currently available evidence and guideline recommendations on pharmacological treatment of cardiogenic shock.
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Affiliation(s)
- Raphael Romano Bruno
- Heinrich-Heine-University Duesseldorf, Medical Faculty, Department of Cardiology, Pulmonology and Vascular Medicine, Duesseldorf, Germany
| | - Georg Wolff
- Heinrich-Heine-University Duesseldorf, Medical Faculty, Department of Cardiology, Pulmonology and Vascular Medicine, Duesseldorf, Germany
| | - Malte Kelm
- Heinrich-Heine-University Duesseldorf, Medical Faculty, Department of Cardiology, Pulmonology and Vascular Medicine, Duesseldorf, Germany; Cardiovascular Research Institute Düsseldorf (CARID), Duesseldorf, Germany
| | - Christian Jung
- Heinrich-Heine-University Duesseldorf, Medical Faculty, Department of Cardiology, Pulmonology and Vascular Medicine, Duesseldorf, Germany.
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46
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Waskowski J, Michel MC, Steffen R, Messmer AS, Pfortmueller CA. Fluid overload and mortality in critically ill patients with severe heart failure and cardiogenic shock-An observational cohort study. Front Med (Lausanne) 2022; 9:1040055. [PMID: 36465945 PMCID: PMC9712448 DOI: 10.3389/fmed.2022.1040055] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 11/03/2022] [Indexed: 06/03/2024] Open
Abstract
OBJECTIVE Patients with heart failure (HF) and cardiogenic shock are especially prone to the negative effects of fluid overload (FO); however, fluid resuscitation in respective patients is sometimes necessary resulting in FO. We aimed to study the association of FO at ICU discharge with 30-day mortality in patients admitted to the ICU due to severe heart failure and/or cardiogenic shock. METHODS Retrospective, single-center cohort study. Patients with admission diagnoses of severe HF and/or cardiogenic shock were eligible. The following exclusion criteria were applied: (I) patients younger than 16 years, (II) patients admitted to our intermediate care unit, and (III) patients with incomplete data to determine FO at ICU discharge. We used a cumulative weight-adjusted definition of fluid balance and defined more than 5% as FO. The data were analyzed by univariate and adjusted univariate logistic regression. RESULTS We included 2,158 patients in our analysis. 185 patients (8.6%) were fluid overloaded at ICU discharge. The mean FO in the FO group was 7.2% [interquartile range (IQR) 5.8-10%]. In patients with FO at ICU discharge, 30-day mortality was 22.7% compared to 11.7% in non-FO patients (p < 0.001). In adjusted univariate logistic regression, we did not observe any association of FO at discharge with 30-day mortality [odds ratio (OR) 1.48; 95% confidence interval (CI) 0.81-2.71, p = 0.2]. No association between FO and 30-day mortality was found in the subgroups with HF only or cardiogenic shock (all p > 0.05). Baseline lactate (adjusted OR 1.27; 95% CI 1.13-1.42; p < 0.001) and cardiac surgery at admission (adjusted OR 1.94; 95% CI 1.0-3.76; p = 0.05) were the main associated factors with FO at ICU discharge. CONCLUSION In patients admitted to the ICU due to severe HF and/or cardiogenic shock, FO at ICU discharge seems not to be associated with 30-day mortality.
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Affiliation(s)
- Jan Waskowski
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Wang CH, Chen WS, Liu MH, Lee CY, Wang MY, Liang CY, Chu CM, Wu HP, Chen WH. Stress Hyperphenylalaninemia Is Associated With Mortality in Cardiac ICU: Clinical Factors, Genetic Variants, and Pteridines. Crit Care Med 2022; 50:1577-1587. [PMID: 35916411 PMCID: PMC9555827 DOI: 10.1097/ccm.0000000000005640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Hyperphenylalaninemia predicts poor outcomes in patients with cardiovascular disease. However, the prognostic value and factors associated with stress hyperphenylalaninemia (SHP) were unknown in critical patients in the cardiac ICU. DESIGN Prospective observational study. SETTING Single-center, cardiac ICU in Taiwan. PATIENTS Patients over 20 years old with Acute Physiology And Chronic Health Evaluation II scores greater than or equal to 15 and/or ventilatory support in the cardiac ICU. INTERVENTIONS We measured plasma phenylalanine levels serially during patients' stays in the ICU to investigate their prognostic value for 90-day mortality. Gene array was performed to identify genetic polymorphisms associated with SHP (phenylalanine level ≥ 11.2 μmol/dL) and to develop a Genetic Risk Score (GRS). We analyzed the associations between SHP and clinical factors and genetic variants and identified the correlation between pteridines and genetic variants. MEASUREMENTS AND MAIN RESULTS The study enrolled 497 patients. Increased phenylalanine concentration was independently associated with increased mortality risk. Patients with SHP had a higher mortality risk compared with those without SHP (log rank = 41.13; p < 0.001). SHP was associated with hepatic and renal dysfunction and with genetic polymorphisms on the pathway of tetrahydrobiopterin (BH4) synthesis (CBR1 and AKR1C3) and recycling (PCBD2). Higher GRSs were associated with lower BH4 bioavailability in response to stress ( p < 0.05). In patients without SHP at baseline, those with GRSs gretaer than or equal to 2 had a higher frequency of developing SHP during the ICU stay (31.5% vs 16.1%; p = 0.001) and a higher mortality risk ( p = 0.004) compared with those with GRSs less than 2. In patients with SHP at baseline, genetic variants did not provide additional prognostic value. CONCLUSIONS SHP in patients admitted to the ICU was associated with a worse prognosis. In patients without SHP, genetic polymorphisms associated with SHP measured using a GRS of greater than or equal to 2 was associated with the subsequent SHP and higher mortality risk.
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Affiliation(s)
- Chao-Hung Wang
- Heart Failure Research Center, Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Keelung, Taiwan., School of Medicine, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Wei-Siang Chen
- Heart Failure Research Center, Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Keelung, Taiwan., Intensive Care Unit, Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Min-Hui Liu
- Heart Failure Research Center, Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Keelung, Taiwan., Department of Nursing, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Chi-Ying Lee
- Department of Medical Science, Institute of Bioinformatics and Structural Biology, National Tsing Hua University, Hsinchu, Taiwan
| | - Mei-Ying Wang
- Heart Failure Research Center, Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Keelung, Taiwan., Intensive Care Unit, Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Chung-Yu Liang
- Heart Failure Research Center, Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Keelung, Taiwan., Intensive Care Unit, Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Chien-Ming Chu
- Division of pulmonary, critical care and sleep medicine, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Huang-Ping Wu
- Division of pulmonary, critical care and sleep medicine, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Wen-Hsin Chen
- Heart Failure Research Center, Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Keelung, Taiwan., Intensive Care Unit, Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Keelung, Taiwan
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48
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Bagaswoto HP, Ardelia YP, Setianto BY. First 24-h Sardjito Cardiovascular Intensive Care (SCIENCE) admission risk score to predict mortality in cardiovascular intensive care unit (CICU). Indian Heart J 2022; 74:513-518. [PMID: 36370802 PMCID: PMC9773286 DOI: 10.1016/j.ihj.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 11/05/2022] [Accepted: 11/06/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The application of prognostic scoring systems to identify risk of death within 24 h of CICU admission has significant consequences for clinical decision-making. Previous score of parameters collected after 24 h was considered too late to predict mortality. As a result, we attempted to develop a CICU admission risk score to predict hospital mortality using indicators collected within 24 h. METHODS Data were obtained from SCIENCE registry from January 1, 2021 to December 21, 2021. Outcomes of 657 patients (mean age 58.91 ± 12.8 years) were recorded retrospectively. Demography, risk factors, comorbidities, vital signs, laboratory and echocardiography data at 24-h of patient admitted to CICU were analysed by multivariate logistic regression to create two models of scoring system (probability and cut-off model) to predict in-hospital mortality of any cause. RESULTS From a total of 657 patients, the hospital mortality was 15%. The significant predictors of mortality were male, acute heart failure, hemodynamic instability, pneumonia, baseline creatinine ≥1.5 mg/dL, TAPSE <17 mm, and the use of mechanical ventilator within first 24-h of CICU admission. Based on Receiver Operating Characteristic (ROC) curve analysis a cut off of ≥3 is considered to be a high risk of in-hospital mortality (sensitivity 75% and specificity 65%). CONCLUSION The initial 24-h SCIENCE admission risk rating system can be used to predict in-hospital mortality in patients admitted to the CICU with a high degree of sensitivity and specificity.
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Affiliation(s)
- Hendry Purnasidha Bagaswoto
- Cardiologist at Cardiology and Vascular Medicine Department of Medical, Public Health, and Nursing Faculty Universitas Gadjah Mada, Yogyakarta, 55281, Indonesia.
| | - Yuwinda Prima Ardelia
- Resident of Cardiology and Vascular Medicine Department of Medical, Public Health, and Nursing Faculty Universitas Gadjah Mada, Indonesia.
| | - Budi Yuli Setianto
- Cardiologist at Cardiology and Vascular Medicine Department of Medical, Public Health, and Nursing Faculty Universitas Gadjah Mada, Yogyakarta, 55281, Indonesia.
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Metkus TS, Baird-Zars VM, Alfonso CE, Alviar CL, Barnett CF, Barsness GW, Berg DD, Bertic M, Bohula EA, Burke J, Burstein B, Chaudhry SP, Cooper HA, Daniels LB, Fordyce CB, Ghafghazi S, Goldfarb M, Katz JN, Keeley EC, Keller NM, Kenigsberg B, Kontos MC, Kwon Y, Lawler PR, Leibner E, Liu S, Menon V, Miller PE, Newby LK, O'Brien CG, Papolos AI, Pierce MJ, Prasad R, Pisani B, Potter BJ, Roswell RO, Sinha SS, Shah KS, Smith TD, Snell RJ, So D, Solomon MA, Ternus BW, Teuteberg JJ, van Diepen S, Zakaria S, Morrow DA. Critical Care Cardiology Trials Network (CCCTN): a cohort profile. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2022; 8:703-708. [PMID: 36029517 PMCID: PMC9603535 DOI: 10.1093/ehjqcco/qcac055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 08/23/2022] [Accepted: 08/25/2022] [Indexed: 11/12/2022]
Abstract
AIMS The aims of the Critical Care Cardiology Trials Network (CCCTN) are to develop a registry to investigate the epidemiology of cardiac critical illness and to establish a multicentre research network to conduct randomised clinical trials (RCTs) in patients with cardiac critical illness. METHODS AND RESULTS The CCCTN was founded in 2017 with 16 centres and has grown to a research network of over 40 academic and clinical centres in the United States and Canada. Each centre enters data for consecutive cardiac intensive care unit (CICU) admissions for at least 2 months of each calendar year. More than 20 000 unique CICU admissions are now included in the CCCTN Registry. To date, scientific observations from the CCCTN Registry include description of variations in care, the epidemiology and outcomes of all CICU patients, as well as subsets of patients with specific disease states, such as shock, heart failure, renal dysfunction, and respiratory failure. The CCCTN has also characterised utilization patterns, including use of mechanical circulatory support in response to changes in the heart transplantation allocation system, and the use and impact of multidisciplinary shock teams. Over years of multicentre collaboration, the CCCTN has established a robust research network to facilitate multicentre registry-based randomised trials in patients with cardiac critical illness. CONCLUSION The CCCTN is a large, prospective registry dedicated to describing processes-of-care and expanding clinical knowledge in cardiac critical illness. The CCCTN will serve as an investigational platform from which to conduct randomised controlled trials in this important patient population.
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Affiliation(s)
- Thomas S Metkus
- Divisions of Cardiology and Cardiac Surgery, Departments of Medicine and Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Vivian M Baird-Zars
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - Carlos E Alfonso
- Division of Cardiology, Department of Medicine; University of Miami Hospital & Clinics, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Carlos L Alviar
- Leon H. Charney Division of Cardiology, NYU Langone Medical Center, New York 10016 NY, USA
| | - Christopher F Barnett
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, CA 94143, USA
| | - Gregory W Barsness
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55902, USA
| | - David D Berg
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - Mia Bertic
- University of Toronto Etobicoke,Toronto ON, Canada
| | - Erin A Bohula
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - James Burke
- Lehigh Valley Heart Institute, Allentown, PA 18103, USA
| | | | | | - Howard A Cooper
- Westchester Medical Center and New York Medical College, Valhalla NY 10901, USA
| | - Lori B Daniels
- Division of Cardiovascular Medicine La Jolla, UCSD, San Diego, CA 92037, USA
| | - Christopher B Fordyce
- UBC Centre for Cardiovascular Innovation, Cardiovascular Health Program, UBC Centre for Health Evaluation & Outcomes Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Shahab Ghafghazi
- Division of Cardiovascular Medicine, University of Louisville, Louisville, KY 40202, USA
| | - Michael Goldfarb
- Division of Cardiology, Jewish General Hospital, McGill University, Montréal, QC, Canada
| | - Jason N Katz
- Division of Cardiology, Duke University School of Medicine, Durham, NC 27710, USA
| | - Ellen C Keeley
- Division of Cardiology, Department of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Norma M Keller
- Department of Medicine at NYU Grossman School of Medicine, Bellevue Hospital, New York NY 10016, USA
| | - Benjamin Kenigsberg
- Departments of Cardiology and Critical Care Medicine, MedStar Washington Hospital Center, Washington DC, WA 20010, USA
| | - Michael C Kontos
- Division of Cardiology, Virginia Commonwealth University, Richmond, VA 23219, USA
| | - Younghoon Kwon
- Division of Cardiology, University of Washington, Seattle, WA 98104, USA
| | - Patrick R Lawler
- Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto ON, Canada
| | - Evan Leibner
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, New York, NY 10029, USA
| | - Shuangbo Liu
- Max Rady College of Medicine St. Boniface Hospital Winnipeg, Manitoba, Canada
| | - Venu Menon
- Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - P Elliott Miller
- Department of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT 06510, USA
| | - L Kristin Newby
- Divison of Cardiology, Duke University School of Medicine, Durham, NC 27710, USA
| | - Connor G O'Brien
- Department of Medicine, Division of Cardiology, University of California-San Francisco School of Medicine, San Francisco, CA 94143, USA
| | - Alexander I Papolos
- Departments of Cardiology and Critical Care Medicine, MedStar Washington Hospital Center, Washington DC, WA 20010, USA
| | - Matthew J Pierce
- Department of Cardiology, Zucker School of Medicine at Hofstra/Northwell, Long Island, NY 11549, USA
| | - Rajnish Prasad
- Wellstar Cardiovascular Medicine, Marietta, GA 30060, USA
| | | | - Brian J Potter
- Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | | | - Shashank S Sinha
- Inova Heart and Vascular Institute, Inova Fairfax Medical Center, Falls Church, VA 22042, USA
| | - Kevin S Shah
- University of Utah Health Sciences Center, Salt Lake City, UT 84132, USA
| | - Timothy D Smith
- The Christ Hospital and Lindner Institute for Research and Education Cincinnati, OH 45219, USA
| | | | - Derek So
- University of Ottawa Heart Institute, Ottawa, ON, Canada
| | | | - Bradley W Ternus
- Division of Cardiology, Department of Internal Medicine, University of Wisconsin, Madison, WI 53792, USA
| | - Jeffrey J Teuteberg
- Division of Cardiovascular Medicine, Stanford University Medical Center, Palo Alto, CA 94305, USA
| | - Sean van Diepen
- Division of Cardiology, Department of Critical Care Medicine, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Sammy Zakaria
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - David A Morrow
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA
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Brusca SB, Galiatsatos P, Warner S, Li X, Powell-Wiley TM, Kadri SS, Solomon MA. Outcomes of Patients With Primary Cardiac Diagnoses Admitted to Cardiac vs Noncardiac Intensive Care Units. JACC. ADVANCES 2022; 1:100114. [PMID: 36466046 PMCID: PMC9718493 DOI: 10.1016/j.jacadv.2022.100114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
BACKGROUND Demographics in cardiac intensive care units (CICUs) have evolved, with increased prevalence of noncardiac critical illnesses. OBJECTIVES This study compares outcomes of patients with primary cardiac diagnoses admitted to CICUs vs those of patients with primary cardiac diagnoses admitted to noncardiac ICUs. METHODS The Cerner Health Facts Database was queried to identify adults with primary cardiac diagnoses admitted to ICUs within 48 hours of presentation between 2009 and 2014. Only hospitals with multiple ICUs including a CICU were studied. Information on ICU staffing was not available. A univariate analysis of ICU type (model 1) and multivariate analyses incorporating patient- and hospital-level variables (model 2) and concurrent, noncardiac, ICU-level diagnoses (model 3) were utilized to assess the impact of ICU type on inpatient mortality. RESULTS Of 16,163 encounters across 14 hospitals, 8,499 (52.6%) were admitted to CICUs and 7,664 (47.4%) to noncardiac ICUs. Univariate analysis (model 1) demonstrated increased mortality in noncardiac ICUs compared to CICUs (odds ratio [OR]: 1.47, 95% CI: 1.32-1.64; P < 0.0001). This risk dissipated (OR: 1.04, 95% CI: 0.91-1.18; P = 0.56) after controlling for patient- and hospital-level variables (model 2). Inclusion of concurrent, noncardiac, ICU-level diagnoses (model 3) lead to a reversal with decreased mortality in noncardiac ICUs (OR: 0.86, 95% CI: 0.76-0.98; P = 0.03). CONCLUSIONS In this historical cohort study evaluating CICU outcomes prior to the evolution of proposed staffing and care model modernization, survival of cardiac patients with concurrent, noncardiac critical illnesses may have been better with the expertise available in general system ICUs. These results may support contemporary efforts to increase the capacity to manage noncardiac critical illnesses in CICUs.
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Affiliation(s)
- Samuel B. Brusca
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland, USA
- Division of Cardiology, Department of Internal Medicine, University of California, San Francisco, California, USA
| | - Panagis Galiatsatos
- Division of Pulmonary and Critical Care Medicine, The Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Sarah Warner
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland, USA
| | - Xiaobai Li
- Biostatistics and Epidemiology Service, National Institutes of Health Clinical Center, Bethesda, Maryland, USA
| | - Tiffany M. Powell-Wiley
- Cardiovascular Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
- Intramural Research Program, National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, Maryland, USA
| | - Sameer S. Kadri
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland, USA
| | - Michael A. Solomon
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland, USA
- Cardiovascular Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
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