Association between Respiratory Failure and Clinical Outcomes in Patients with Acute Heart Failure: Analysis of 5 Pooled Clinical Trials

Arterial hyperoxia and mortality in the cardiac intensive care unit

BACKGROUND

Arterial hyperoxia (hyperoxemia), defined as a high arterial partial pressure of oxygen (PaO2), has been associated with adverse outcomes in critically ill populations, but has not been examined in the cardiac intensive care unit (CICU). We evaluated the association between exposure to hyperoxia on admission with in-hospital mortality in a mixed CICU cohort.

METHODS

We included unique Mayo Clinic CICU patients admitted from 2007 to 2018 with admission PaO2 data (defined as the PaO2 value closest to CICU admission) and no hypoxia (PaO2 < 60mmHg). The admission PaO2 was evaluated as a continuous variable and categorized (60-100 mmHg, 101-150 mmHg, 151-200 mmHg, 201-300 mmHg, >300 mmHg). Logistic regression was used to evaluate predictors of in-hospital mortality before and after multivariable adjustment.

RESULTS

We included 3,368 patients with a median age of 70.3 years; 70.3% received positive-pressure ventilation. The median PaO2 was 99 mmHg, with a distribution as follows: 60-100 mmHg, 51.9%; 101-150 mmHg, 28.6%; 151-200 mmHg, 10.6%; 201-300 mmHg, 6.4%; >300 mmHg, 2.5%. A J-shaped association between admission PaO2 and in-hospital mortality was observed, with a nadir around 100 mmHg. A higher PaO2 was associated with increased in-hospital mortality (adjusted OR 1.17 per 100 mmHg higher, 95% CI 1.01-1.34, p = 0.03). Patients with PaO2 >300 mmHg had higher in-hospital mortality versus PaO2 60-100 mmHg (adjusted OR 2.37, 95% CI 1.41-3.94, p < 0.001).

CONCLUSIONS

Hyperoxia at the time of CICU admission is associated with higher in-hospital mortality, primarily in those with severely elevated PaO2 >300 mmHg.

Outcomes for Mechanically Ventilated Patients With Acute Myocardial Infarction Admitted to Medical vs Cardiac Intensive Care Units

Background

Acute myocardial infarction (AMI) remains a common reason for admission to the intensive care unit (ICU). However, there is limited data comparing outcomes for patients with AMI admitted to specific ICUs.

Objectives

The purpose of this study was to assess clinical outcomes between patients with AMI requiring invasive mechanical ventilation admitted to the medical ICU (MICU) compared to cardiac (CICU).

Methods

We utilized the Vizient Clinical Data Base to identify patients with a primary diagnosis of AMI between October 2015 and December 2019 and requiring invasive mechanical ventilation. Using multivariable logistic regression, we compared clinical outcomes for patients admitted to the MICU vs CICU.

Results

We identified 12,639 patients, 25.2% (n = 3,185) of which were admitted to a MICU and 74.8% (n = 9,454) to a CICU. Patients admitted to a CICU were more likely to present with STEMI (57.0% vs 42.8%), cardiogenic shock (46.0% vs 37.4%), and require mechanical circulatory support and vasoactive medications (all, P < 0.001). Median ventilator days were 4 days in both ICUs and not statistically different after multivariable adjustment (P = 0.81). In-hospital mortality was 42.7% compared to 41.3% for MICU vs CICU admissions, respectively (P = 0.15). After multivariable adjustment, CICU admission was associated with lower in-hospital mortality (OR: 0.85, 95% CI: 0.78-0.93, P = 0.001), which persisted when stratified by cardiogenic shock, cardiac arrest, STEMI, largest hospital size (>750 beds), and teaching hospitals (all, P < 0.05).

Conclusions

Admission to the CICU, as compared to MICU, was associated with lower in-hospital mortality for patients with AMI. These findings may support optimal triage of critically ill patients with AMI.

Ventilation strategies in cardiogenic shock: Insights from the AltShock-2 registry

AIMS

To describe the use and the relation to outcome of different ventilation strategies in a contemporary, large, prospective registry of cardiogenic shock patients.

METHODS AND RESULTS

Among 657 patients enrolled from March 2020 to November 2023, 198 (30.1%) received oxygen therapy (OT), 96 (14.6%) underwent non-invasive ventilation (NIV), and 363 (55.3%) underwent invasive mechanical ventilation (iMV). Patients in the iMV group were significantly younger compared to those in the NIV and OT groups (63 vs. 69 years, p < 0.001). There were no significant differences between groups regarding cardiovascular risk factors. Patients with SCAI B and C were more frequently treated with OT and NIV compared to iMV (65.1% and 65.4% vs. 42.6%, respectively, p > 0.001), while the opposite trend was observed in SCAI D patients (12% and 12.2% vs. 30.9%, respectively, p < 0.001). All-cause mortality at 24 h did not differ amongst the three groups. The 60-day mortality rates were 40.2% for the iMV group, 26% for the OT group, and 29.3% for the NIV group (p = 0.005), even after excluding patients with cardiac arrest at presentation. In the multivariate analysis including SCAI stages, NIV was not associated with worse mortality compared to iMV (hazard ratio 1.97, 95% confidence interval 0.85-4.56), even in more severe SCAI stages such as D.

CONCLUSIONS

Compared to previous studies, we observed a rising trend in the utilization of NIV among cardiogenic shock patients, irrespective of aetiology and SCAI stages. In this clinical scenario, NIV emerges as a safe option for appropriately selected patients.

Incidence and risk factors of postoperative pulmonary complications following total hip arthroplasty revision: a retrospective Nationwide Inpatient Sample database study

BACKGROUND

Postoperative pulmonary complications (PPCs) are among the most severe complications following total hip arthroplasty revision (THAR), imposing significant burdens on individuals and society. This study examined the prevalence and risk factors of PPCs following THAR using the NIS database, identifying specific pulmonary complications (SPCs) and their associated risks, including pneumonia, acute respiratory failure (ARF), and pulmonary embolism (PE).

METHODS

The National Inpatient Sample (NIS) database was used for this cross-sectional study. The analysis included patients undergoing THAR based on NIS from 2010 to 2019. Available data include demographic data, diagnostic and procedure codes, total charges, length of stay (LOS), hospital information, insurance information, and discharges.

RESULTS

From the NIS database, a total of 112,735 THAR patients in total were extracted. After THAR surgery, there was a 2.62% overall incidence of PPCs. Patients with PPCs after THAR demonstrated increased LOS, total charges, usage of Medicare, and in-hospital mortality. The following variables have been determined as potential risk factors for PPCs: advanced age, pulmonary circulation disorders, fluid and electrolyte disorders, weight loss, congestive heart failure, metastatic cancer, other neurological disorders (encephalopathy, cerebral edema, multiple sclerosis etc.), coagulopathy, paralysis, chronic pulmonary disease, renal failure, acute heart failure, deep vein thrombosis, acute myocardial infarction, peripheral vascular disease, stroke, continuous trauma ventilation, cardiac arrest, blood transfusion, dislocation of joint, and hemorrhage.

CONCLUSIONS

Our study revealed a 2.62% incidence of PPCs, with pneumonia, ARF, and PE accounting for 1.24%, 1.31%, and 0.41%, respectively. A multitude of risk factors for PPCs were identified, underscoring the importance of preoperative optimization to mitigate PPCs and enhance postoperative outcomes.

Noninvasive Ventilation in the Cardiac Intensive Care Unit

Over the last several decades, the cardiac intensive care unit (CICU) has seen an increase in the complexity of the patient population and etiologies requiring CICU admission. Currently, respiratory failure is the most common reason for admission to the contemporary CICU. As a result, noninvasive ventilation (NIV), including noninvasive positive-pressure ventilation and high-flow nasal cannula, has been increasingly utilized in the management of patients admitted to the CICU. In this review, we detail the different NIV modalities and summarize the evidence supporting their use in conditions frequently encountered in the CICU. We describe the unique pathophysiologic interactions between positive pressure ventilation and left and/or right ventricular dysfunction. Additionally, we discuss the evidence and strategies for utilization of NIV as a method to reduce extubation failure in patients who required invasive mechanical ventilation. Lastly, we examine unique considerations for managing respiratory failure in certain, high-risk patient populations such as those with right ventricular failure, severe valvular disease, and adult congenital heart disease. Overall, it is critical for clinicians who practice in the CICU to be experts with the application, risks, benefits, and modalities of NIV in cardiac patients with respiratory failure.

The association between serum albumin and long length of stay of patients with acute heart failure: A retrospective study based on the MIMIC-IV database

BACKGROUND

The purpose of this article is to assess the relationship between serum albumin level and long length of stay (LOS) of inpatients with acute heart failure (AHF) in the intensive care unit (ICU).

METHODS

We retrospectively analyzed data of 2280 patients with AHF from the medical information mart for intensive care IV (the MIMIC-IV) database. Multivariate logistic regression was performed to evaluate the association between serum albumin and long LOS, and the development of the predictive model was based on independent predictors of long LOS.

RESULTS

According to the statistical results, A negative linear relationship was presented between albumin and long LOS of AHF patients in the ICU (P for trend <0.001), and serum albumin could predict long LOS (AUC 0.649, 95%CI 0.616-0.683, P <0.001). Based on independent predictors, including respiratory failure (OR 1.672, 95%CI 1.289-2.169, P<0.001), WBC (OR 1.046, 95%CI 1.031-1.061, P<0.001), creatinine (OR 1.221, 95%CI 1.098-1.257, P<0.001), glucose (OR 1.010, 95%CI 1.007-1.012, P<0.001), lactic acid (OR 1.269, 95%CI 1.167-1.381, P<0.001), and albumin (OR 0.559, 95%CI 0.450-0.695, P<0.001), identified by multivariable logistic regression analysis, we developed the nomogram to predict the probability of long LOS of AHF patients in the ICU. The nomogram accurately predicted the probability of long LOS (AUC 0.740, 95%CI 0.712-0.768, P<0.001). The calibration suggested the predictive probability was highly consistent with the actual probability of long LOS. Decision curve analysis (DCA) also suggested that the nomogram was applicable in the clinic.

CONCLUSION

Serum albumin level was negatively associated with LOS among AHF patients. The predictive model based on serum albumin has predictive value for evaluating the length of stay in AHF patients.

Management of Cardiogenic Shock Unrelated to Acute Myocardial Infarction

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.

Liberation From Mechanical Ventilation in the Cardiac Intensive Care Unit

The prevalence of respiratory failure is increasing in the contemporary cardiac intensive care unit (CICU) and is associated with a significant increase in morbidity and mortality. For patients that survive their initial respiratory decompensation, liberation from invasive mechanical ventilation (IMV) and the decision to extubate requires careful clinical assessment and planning. Therefore, it is essential for the CICU clinician to know how to assess and manage the various stages of IMV liberation, including ventilator weaning, evaluation of extubation readiness, and provide post-extubation care. In this review, we provide a comprehensive approach to liberation from IMV in the CICU, including cardiopulmonary interactions relative to withdrawal from positive pressure ventilation, evaluation of readiness for and assessment of spontaneous breathing trials, sedation management to optimize extubation, strategies for patients at a high risk for extubation failure, and tracheostomy in the cardiovascular patient.

Mechanical ventilation in patients with cardiogenic pulmonary edema: a sub-analysis of the LUNG SAFE study

BACKGROUND

Patients with acute respiratory failure caused by cardiogenic pulmonary edema (CPE) may require mechanical ventilation that can cause further lung damage. Our aim was to determine the impact of ventilatory settings on CPE mortality.

METHODS

Patients from the LUNG SAFE cohort, a multicenter prospective cohort study of patients undergoing mechanical ventilation, were studied. Relationships between ventilatory parameters and outcomes (ICU discharge/hospital mortality) were assessed using latent mixture analysis and a marginal structural model.

RESULTS

From 4499 patients, 391 meeting CPE criteria (median age 70 [interquartile range 59-78], 40% female) were included. ICU and hospital mortality were 34% and 40%, respectively. ICU survivors were younger (67 [57-77] vs 74 [64-80] years, p < 0.001) and had lower driving (12 [8-16] vs 15 [11-17] cmH2O, p < 0.001), plateau (20 [15-23] vs 22 [19-26] cmH2O, p < 0.001) and peak (21 [17-27] vs 26 [20-32] cmH2O, p < 0.001) pressures. Latent mixture analysis of patients receiving invasive mechanical ventilation on ICU day 1 revealed a subgroup ventilated with high pressures with lower probability of being discharged alive from the ICU (hazard ratio [HR] 0.79 [95% confidence interval 0.60-1.05], p = 0.103) and increased hospital mortality (HR 1.65 [1.16-2.36], p = 0.005). In a marginal structural model, driving pressures in the first week (HR 1.12 [1.06-1.18], p < 0.001) and tidal volume after day 7 (HR 0.69 [0.52-0.93], p = 0.015) were related to survival.

CONCLUSIONS

Higher airway pressures in invasively ventilated patients with CPE are related to mortality. These patients may be exposed to an increased risk of ventilator-induced lung injury. Trial registration Clinicaltrials.gov NCT02010073.

First 24-h Sardjito Cardiovascular Intensive Care (SCIENCE) admission risk score to predict mortality in cardiovascular intensive care unit (CICU)

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.

Relation of Ischemic Heart Disease to Outcomes in Patients With Acute Respiratory Distress Syndrome

Patients with ischemic heart disease (IHD) are often excluded from acute respiratory distress syndrome (ARDS) clinical trials. As a result, little is known about the impact of IHD in this population. We sought to assess the association between IHD and clinical outcomes in patients with ARDS. Participants from 4 ARDS randomized controlled trials with shared study criteria, definitions, and end points were included. Using multivariable logistic regression, we assessed for the association between IHD and a primary outcome of 60-day mortality. Secondary outcomes included 90-day mortality, 28-day ventilator-free days, and 28-day organ failure. Among 1,909 patients, 102 had a history of IHD (5.4%). Patients with IHD were more likely to be older and male (p <0.05). Noncardiac co-morbidities, severity of illness, and other markers of ARDS severity were not statistically different (all, p >0.05). Patients with IHD had a higher 60-day (39.2% vs 23.3%, p <0.001) and 90-day (40.2% vs 24.0%, p <0.001) mortality, and experienced more frequent renal (45.1% vs 32.0%, p = 0.006) and hepatic (35.3% vs 25.2%, p = 0.023) failure. After multivariable adjustment, 60-day (odds ratio [OR] 1.76; 95% confidence interval [CI]: 1.07 to 2.89, p = 0.025) and 90-day (OR 1.74; 95% CI: 1.06 to 2.85, p = 0.028) mortality remained higher. IHD was associated with 10% fewer ventilator-free days (incidence rate ratio 0.90; 95% CI: 0.85 to 0.96, p = 0.001). In conclusion, co-morbid IHD was associated with higher mortality and fewer ventilator-free days in patients with ARDS. Future studies are needed to identify predictors of mortality and improve treatment paradigms in this critically ill subgroup of patients.

Staffing models in the cardiac intensive care unit

PURPOSE OF REVIEW

The modern cardiac intensive care unit (CICU) has evolved into a high-intensity unit that cares for critically ill patients. Despite this transformation, changes to the staffing model and organizational structure in these specialized units have only recently begun to meet these challenges. We describe the most recent evidence which will inform future CICU staffing models.

RECENT FINDINGS

In the United States, the majority of CICUs are open as opposed to closed units, yet recent data suggests that transition to a closed staffing model is associated with a decrease in mortality. These reductions in mortality in closed CICUs are most pronounced in the most critically ill populations, such as patients with mechanical circulatory support, cardiac arrest, and respiratory failure. In addition, one study has shown that transition to a cardiac intensivist staffed CICU was associated with a reduction in mortality. Finally, multidisciplinary and protocolized teams imbedded within the CICU, specifically 'shock teams,' have recently been developed and may reduce mortality in this particularly sick patient population.

SUMMARY

Although the preponderance of data suggests improved outcomes with a closed, intensivist staffed CICU model, future multicenter studies are needed to better define the ideal staffing models for the contemporary CICU.

The Impact of Noninvasive Ventilator Assisted Ventilation Nursing Combined with Mechanical Vibration on the Level of Heart Failure Indexes in ICU Patients with Acute Heart Failure

The acute attack of acute heart failure or the continuous deterioration of cardiac function leads to a series of changes such as reduced cardiac contractility, increased cardiac load, and a sudden drop of acute cardiac output, which eventually cause pulmonary circulation congestion and acute dyspnea due to acute pulmonary congestion. To observe the impact of noninvasive ventilator-assisted ventilation nursing combined with mechanical vibration on the level of heart failure indexes in intensive care unit (ICU) patients with acute heart failure, 120 patients with acute heart failure who were treated in the ICU ward of our hospital from September 2018 to March 2021 were selected, and the qualified subjects were divided into two groups according to the 1 : 1 principle by a simple random method. 120 patients were given conventional symptomatic treatment and noninvasive ventilator-assisted ventilation. The control group received conventional nursing intervention, and the observation group was given noninvasive ventilator-assisted ventilation nursing and mechanical vibration intervention. The respiratory system indexes, heart rate, blood pressure, central venous pressure, N-terminal B-type natriuretic peptide precursor (NT-proBNP), cardiac troponin T (cTnT), and cardiac function indexes of the two groups of patients are recorded, and the prognosis of the two groups is compared. After intervention, the partial pressure of oxygen (PaO2) and blood oxygen saturation (SpO2) in the two groups were higher than those before intervention, while the partial pressure of carbon dioxide (PaCO2), respiration (RR), heart rate, blood pressure, and central venous pressure were lower than those before intervention (P < 0.05). Compared with the control group, PaO2, SpO2, systolic blood pressure, diastolic blood pressure, and central venous pressure of the observation group after intervention were significantly higher, while PaCO2, RR, and heart rate were significantly lower (P < 0.05). Compared with the control group, the LVEF of the observation group after intervention was significantly higher, while NT-proBNP, cTnT, LVESD, and LVEDD were markedly lower (P < 0.05). The ventilation time and ICU hospitalization time in the observation group were shorter than those in the control group, and the pulmonary infection rate was lower than in the control group. The remission time of infection in patients with pulmonary infection was shorter than that in the control group. When comparing the 28d mortality rate with the control group, the difference was not statistically significant (P > 0.05). Noninvasive ventilator-assisted ventilation nursing combined with mechanical vibration can improve hypoxemia symptoms and heart function, stabilize hemodynamics, shorten the course of disease and reduce the occurrence of lung infections for those patients with acute heart failure in the ICU.

Heart Failure-Related Cardiogenic Shock: Pathophysiology, Evaluation and Management Considerations: Review of Heart Failure-Related Cardiogenic Shock

Despite increasing prevalence in critical care units, cardiogenic shock related to HF (HF-CS) is incompletely understood and distinct from acute myocardial infarction related CS. This review highlights the pathophysiology, evaluation, and contemporary management of HF-CS.