The recent evolution of coronary care units into intensive cardiac care units: the experience of a tertiary center in Florence

Severity of illness assessment with application of the APACHE IV predicted mortality and outcome trends analysis in an academic cardiac intensive care unit

PURPOSE

To assess trends in life support interventions and performance of the automated Acute Physiology and Chronic Health Evaluation (APACHE) IV model at mortality prediction compared with Oxford Acute Severity of Illness Score (OASIS) in a contemporary cardiac intensive care unit (CICU).

METHODS AND MATERIALS

Retrospective analysis of adults (age ≥ 18 years) admitted to CICU from January 1, 2007, through December 31, 2015. Temporal trends were assessed with linear regression. Discrimination of each risk score for hospital mortality was assessed with use of area under the receiver operating characteristic curve (AUROC) values. Calibration was assessed with Hosmer-Lemeshow goodness-of-fit test.

RESULTS

The study analyzed 10,004 patients. CICU and hospital mortality rates were 5.7% and 9.1%. APACHE IV predicted death had an AUROC of 0.82 (0.81-0.84) for hospital death, compared with 0.79 for OASIS (P < .05). Calibration was better for OASIS than APACHE IV. Increases were observed in CICU and hospital lengths of stay (both P < .001), APACHE IV predicted mortality (P = .007), Charlson Comorbidity Index (P < .001), noninvasive ventilation use (P < .001), and noninvasive ventilation days (P = .02).

CONCLUSIONS

Contemporary CICU patients are increasingly ill, observed in upward trends in comorbid conditions and life support interventions. APACHE IV predicted death and OASIS showed good discrimination in predicting death in this population. APACHE IV and OASIS may be useful for benchmarking and quality improvement initiatives in the CICU, the former having better discrimination.

Morbidity pattern and outcome of patients admitted in a coronary care unit: a report from a secondary hospital in southern region, Saudi Arabia

Background: There is limited information about the clinical profile and outcome on patients admitted to a coronary care unit (CCU) in Saudi Arabia is available.

Objective: The aim of this study was to evaluate reasons for admission, clinical characteristics, outcome and predictors of outcome in CCU patients.

Materials and methods: The data of 392 patients admitted to the CCU of a secondary care centre in southern region of Saudi Arabia from 1 January 2017 to 31 December 2017 were collected. Data that were extracted from the patients included demographics, admission diagnosis and outcome.

Results: A total of 392 patients, comprising 305 (77.81%) males and 87 (22.19%) females, were admitted to the CCU. Their mean age was 64.62 ± 15.7. The most common cause of admission was acute coronary syndrome (63.3%), the majority (97.2%) of whom were above 50 years of age (Table 2). Thirty-one patients died. This figure accounted for 7.7% of all the patients admitted to the CCU and 23.4% of the patients that were fully managed in the CCU. The majority of the patients that died were those with cardiac arrest (12 out of 16). Acute coronary syndrome (p = 0.029), cardiac arrest (p = 0.000) and age greater than 50 years (p = 0.000) were associated with death in the study patients. However, cardiac arrest (p = 0.002) and age greater than 50 years (p = 0.017) were independent predictors of death in the study patients.

Conclusion: The reasons for admission to the CCU were acute coronary syndrome, heart failure and cardiac arrest. Mortality among CCU patient was comparable to reports elsewhere. Cardiac arrest and age greater than 50 years were independent predictors of death.

The Difficult Evolution of Intensive Cardiac Care Units: An Overview of the BLITZ-3 Registry and Other Italian Surveys

Coronary care units, initially developed to treat acute myocardial infarction, have moved to the care of a broader population of acute cardiac patients and are currently defined as Intensive Cardiac Care Units (ICCUs). However, very limited data are available on such evolution. Since 2008, in Italy, several surveys have been designed to assess ICCUs' activities. The largest and most comprehensive of these, the BLITZ-3 Registry, observed that patients admitted are mainly elderly males and suffer from several comorbidities. Direct admission to ICCUs through the Emergency Medical System was rather rare. Acute coronary syndromes (ACS) account for more than half of the discharge diagnoses. However, numbers of acute heart failure (AHF) admissions are substantial. Interestingly, age, resources availability, and networking have a strong influence on ICCUs' epidemiology and activities. In fact, while patients with ACS concentrate in ICCUs with interventional capabilities, older patients with AHF or non-ACS, non-AHF cardiac diseases prevail in peripheral ICCUs. In conclusion, although ACS is still the core business of ICCUs, aging, comorbidities, increasing numbers of non-ACS, technological improvements, and resources availability have had substantial effects on epidemiology and activities of ICCUs. The Italian surveys confirm these changes and call for a substantial update of ICCUs' organization and competences.

Description of acute cardiac care in 2014: A French nation-wide database on 277,845 admissions in 270 ICCUs

BACKGROUND

The Intensive Cardiac Care Unit (ICCU) has greatly evolved for decades: it no longer includes only patients with coronary artery disease (CAD). The clinical characteristics and pathological profiles of patients have markedly changed. Detailed data on the topic are critically lacking.

METHODS

We present here a French nation-wide administrative database with an exhaustive description of patients admitted to ICCU throughout a whole year (2014).

RESULTS

A total of 277,845 patients in 270 centers were admitted to ICCUs at least once in 2014 (exhaustive data). Median age was 71years (IQR: 59-81) and the patients were primarily male (63%). Mean ICCU stay was 2.0days (1.0-4.0). CAD patients (49.0%) represented the major group admitted, followed by patients with arrhythmias (15.2%) and heart failure (HF) (10.0%). Patients admitted with acute CAD were significantly younger (mean age 67.4 y), had better outcomes (mortality 4.0%), and shorter hospital stays (mean stay 6.7 d). Patients with HF were significantly older (mean age 75.2 y), with longer hospital stays (mean stay 12.0 d), and poorer outcomes (mortality 10.5%).

CONCLUSION

We present here the largest contemporary administrative database on patients admitted to ICCUs in a developed country. CAD (mainly acute coronary syndromes) remains the primary cause of admission but the population is, by far, more complex than generally considered.

Impact of a Multidisciplinary Team Approach Including an Intensivist on the Outcomes of Critically Ill Patients in the Cardiac Care Unit

OBJECTIVE

To investigate the impact of integrating a medical intensivist into a cardiac care unit (CCU) multidisciplinary team on the outcomes of CCU patients.

PATIENTS AND METHODS

We conducted a retrospective cohort study of 2239 CCU admissions between July 1, 2011, and July 1, 2013, which constituted patients admitted in the 12 months before and 12 months after the introduction of intensivists into the CCU multidisciplinary team. This team included a cardiologist, a medical intensivist, medical house staff, nurses, a pharmacist, a dietitian, and physical and respiratory therapists. The primary outcome was CCU mortality. Secondary outcomes included hospital mortality, CCU length of stay, hospital length of stay, and duration of mechanical ventilation.

RESULTS

After the implementation of a multidisciplinary team approach, there was a significant decrease in both adjusted CCU mortality (3.5% vs 5.9%; P=.01) and hospital mortality (4.4% vs 11.1%; P<.01). A similar impact was observed on adjusted mean CCU length of stay (2.5±2.0 vs 2.9±2.0 days; P<.01), adjusted mean hospital length of stay (7.0±4.5 vs 7.5±4.5 days; P<.01), and adjusted mean ventilation duration (2.0±1.0 vs 4.3±2.5 days; P<.01).

CONCLUSION

The implementation of a multidisciplinary team approach in which an intensivist and a cardiologist comanage the critical care of CCU patients is feasible and may result in better patient outcomes.

Long-term assessment of coronary care unit patient profile and outcomes: analyses of the 12-years patient records

BACKGROUND/AIM

The aim of this study was to determine the patient profile, treatment, and outcomes of a coronary care unit (CCU) by retrospective screening of 12-year patient records.

MATERIALS AND METHODS

The data of 13,463 patients admitted to the CCU of a tertiary referral hospital between 1 January 1997 and 30 June 2008 were collected. The patients were assessed with respect to demographics, admission diagnosis, treatment, and outcomes.

RESULTS

The mean age of patients was 61 ± 13 years (66.7%, male). While the diagnosis of acute coronary syndrome (ACS) accounted for 65%, the rate of ST elevation myocardial infarction (STEMI) was 43.4%. Thrombolytic therapy was administered to 48.7% of the patients with STEMI. Systolic heart failure was the most frequent disease (11.9%) among the non-ACS diagnoses. The mortality rate of the CCU was 12.7% on average; it increased gradually after 2005 when the CCU became a general intensive care unit.

CONCLUSION

This study is one of the largest comprehensive analyses of patient profile and outcomes of a CCU. Despite advances in the diagnosis and treatment of cardiac emergencies, the mortality rate of the CCU was high. Serving as a general intensive care unit, the absence of a coronary angiography laboratory and lower use of thrombolytic therapy for STEMI might be responsible factors.

Evaluation of rationality in prescribing, adherence to treatment guidelines, and direct cost of treatment in intensive cardiac care unit: A prospective observational study

BACKGROUND

Cardiovascular diseases (CVDs) remain the most common cause of sudden death. Hence, appropriate drug therapy in intensive cardiac care unit (ICCU) is crucial in managing cardiovascular emergencies and to decrease morbidity and mortality.

OBJECTIVE

To evaluate prescribing pattern of drugs and direct cost of therapy in patients admitted in ICCU.

MATERIALS AND METHODS

Patients admitted in ICCU of a tertiary care teaching hospital were enrolled. Demographic data, clinical history, and complete drug therapy received during their stay in ICCU were noted. Data were analyzed for drug utilization pattern and direct cost of treatment calculated using patient's hospital and pharmacy bills. Rationality of therapy was evaluated based on American College of Cardiology/American Heart Association (ACC/AHA) guidelines.

RESULT

Data of 170 patients were collected over 2 months. Mean age of patients was 54.67 ± 13.42 years. Male to female ratio was 2.33:1. Most common comorbid condition was hypertension 76 (44.7%). Most common diagnosis was acute coronary syndrome (ACS) 49.4%. Mean stay in ICCU was 4.42 ± 1.9 days. Mean number of drugs prescribed per patient was 11.43 ± 2.85. Antiplatelet drugs were the most frequently prescribed drug group (86.5%). Mean cost of pharmacotherapy per patient was '2701.24 ± 3111.94. Mean direct cost of treatment per patient was '10564.74 ± 14968.70. Parenteral drugs constituted 42% of total drugs and 90% of total cost of pharmacotherapy. Cost of pharmacotherapy was positively correlated with number of drugs (P = 0.000) and duration of stay (P = 0.027).

CONCLUSION

Antiplatelet drugs were the most frequently prescribed drug group. Mean number of drugs per encounter were high, which contributed to the higher cost of pharmacotherapy. ACC/AHA guidelines were followed in majority of the cases.

Epidemiology and patterns of care of patients admitted to Italian Intensive Cardiac Care units: the BLITZ-3 registry

BACKGROUND

Intensive cardiac care units (ICCUs) have shifted from the observation of patients with myocardial infarction to the care of different acute cardiac diseases. However, few data on such an evolution are available.

METHODS AND RESULTS

From 7 to 20 April 2008, 6986 consecutive patients admitted to 81% of Italian ICCUs were prospectively enrolled. Patients observed were mainly elderly men (median age 72 years) with several co-morbidities. Most of them were triaged to ICCU from the emergency room, but 15% of admissions were transfer-in from other hospitals. Several diagnostic and therapeutic procedures were applied (78% had echocardiography and 35% coronary angiography) during the ICCU stay [median length 4 days, interquartile range (IQR) 2-5]. The discharge diagnosis was ST-elevation acute coronary syndrome (ACS) in 21%, non-ST-elevation ACS in 31%, acute heart failure (AHF) in 14% and other acute non-ACS, non-AHF cardiac diseases in 34%. Of those with ST-elevation ACS, 60% received reperfusion (15% fibrinolysis and 45% primary percutaneous coronary intervention). The overall in-ICCU crude mortality was 3.3%.

CONCLUSION

The BLITZ-3 survey provides a unique snapshot of current epidemiology and patterns of care of patients admitted to ICCUs. Although ACS still remains the most frequent admission diagnosis, the number of non-ACS patients is substantial. However, the correct standard of care for these non-ACS patients has to be defined.

Primary percutaneous coronary intervention in comatose survivors of cardiac arrest with ST-elevation acute myocardial infarction: a single-center experience in Florence

OBJECTIVE

Primary percutaneous coronary intervention is currently known as the most effective reperfusion strategy in patients with ST-elevation myocardial infarction. There are no formal recommendations from the American Heart Association/American College of Cardiology and European Society of Cardiology guidelines regarding the treatment of comatose patients with signs of ST-elevation myocardial infarction after reestablishment of spontaneous circulation.

METHODS

We assessed prognosis in 31 consecutive comatose ST-elevation myocardial infarction patients admitted to our intensive cardiac care unit after early percutaneous coronary intervention from 1 January 2005 to 30 June 2006.

RESULTS

During intensive cardiac care unit stay, eight patients died (8/23, 34.7%). In comparison between patients who died and those who survived, the former were older (P = 0.049), showed a higher incidence of chronic obstructive pulmonary disease and had a shorter intensive cardiac care unit length of stay (P = 0.001). No differences were detectable in the two subgroups regarding angiographic characteristics. The incidence of thrombolysis in myocardial infarction grade 3 postpercutaneous coronary intervention was higher in patients who survived (P = 0.0437). Patients who died showed higher latency times, both symptoms-to-basic life support and symptoms-emergency-team (P = 0.0171 and 0.0116, respectively). Patients who survived showed a higher ejection fraction than those who died, as well as lower values of peak troponin I, leukocytes and glycemia (P = 0.01, 0.001 and 0.05, respectively).

CONCLUSION

According to our data, comatose survivors undoubtedly present a high-risk subgroup of ST-elevation myocardial infarction population in which percutaneous coronary intervention shows a procedural efficacy similar to conscious ST-elevation myocardial infarction patients and whose prognosis seems to be related both to infarct size and to neurological status. Further studies need to be performed in this high-risk subgroup investigating the effects of mild hypothermia (mainly on the neurological outcome) as well as the feasibility, safety and outcome of assistance device.

Uric acid in the acute phase of ST elevation myocardial infarction submitted to primary PCI: its prognostic role and relation with inflammatory markers: a single center experience

BACKGROUND AND METHODS

Scarce data are available on the prognostic role of uric acid (UA ) in patients with ST elevation myocardial infarction (STEMI). We aimed at assessing the relation between uric acid, measured on Intensive Cardiac Care Unit (ICCU) admission, and mortality at short term follow-up in 466 consecutive STEMI patients submitted to percutaneous coronary intervention (PCI), as well as its relation with inflammatory markers (C-reactive protein, CRP-fibrinogen, erythrocyte sedimentation rate ESR).

RESULTS

Higher UA were detectable in the 21.5%.. In-hospital mortality was higher in patients with elevated UA (p<0.01 O.R. (95% C.I.): 3.9 (1.5-10.2)). At backward stepwise regression analysis UA resulted an independent predictor for in-hospital mortality (OR 1.82, 95%CI 1.15-2.86; p=0.01).

CONCLUSION

Our data strongly suggest that in the acute phase of STEMI patients submitted to PCI, uric acid holds a prognostic role for in-hospital mortality.