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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] [What about the content of this article? (0)] [Affiliation(s)] [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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2
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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. Eur Heart J Acute Cardiovasc 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] [What about the content of this article? (0)] [Affiliation(s)] [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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3
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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 Fail 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] [What about the content of this article? (0)] [Affiliation(s)] [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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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 Adv 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] [What about the content of this article? (0)] [Affiliation(s)] [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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5
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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6
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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. Eur Heart J Qual Care Clin 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] [What about the content of this article? (0)] [Affiliation(s)] [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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7
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Fagundes A, Berg DD, Park JG, Baird-Zars VM, Newby LK, Barsness GW, Miller PE, van Diepen S, Katz JN, Phreaner N, Roswell RO, Menon V, Daniels LB, Morrow DA, Bohula EA. Patients With Acute Coronary Syndromes Admitted to Contemporary Cardiac Intensive Care Units: Insights From the CCCTN Registry. Circ Cardiovasc Qual Outcomes 2022; 15:e008652. [DOI: 10.1161/circoutcomes.121.008652] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND:
With the improvement in outcomes for acute coronary syndrome (ACS), the practice of routine admission to cardiac intensive care units (CICUs) is evolving. We aimed to describe the epidemiology of patients with ACS admitted to contemporary CICUs.
METHODS:
Using the CCCTN (Critical Care Cardiology Trials Network) Registry for consecutive medical CICU admissions across 26 advanced CICUs in North America between 2017 and 2020, we identified patients with a primary diagnosis of ACS at CICU admission and compared patient characteristics, resource utilization, and outcomes to patients admitted with a non-ACS diagnosis and across sub-populations of patients with ACS, including by indication for CICU admission.
RESULTS:
Of 10 118 CICU admissions, 29.4% (n=2978) were for a primary diagnosis of ACS, with significant interhospital variability (range, 13.4%–56.6%). Compared with patients admitted with a diagnosis other than ACS, patients with ACS had fewer comorbidities, lower acute severity of illness with less utilization of advanced CICU therapies (41.3% versus 66.1%,
P
<0.0001), and lower CICU mortality (5.4% versus 9.9%,
P
<0.0001). Monitoring alone, without another CICU indication at the time of admission, was the most frequent admission indication in patients with ACS (53.8%); less common indications in patients with ACS included respiratory insufficiency, shock, or the need for vasoactive therapy. Of patients with ACS admitted for monitoring alone, 94.8% did not subsequently require advanced intensive care unit therapies and had a low CICU length of stay (1.5 days [0.9–2.4] versus 2.6 [1.4–5.1],
P
<0.0001) and CICU mortality (0.6% versus 11.0%,
P
<0.0001), compared with patients with ACS with an admission indication beyond monitoring.
CONCLUSIONS:
In a registry of tertiary care CICUs, ACS represent ≈1/3 of all admissions with significant variability across hospitals. More than half of the ACS admissions to the CICU were for routine monitoring alone, with a low rate of complications and mortality. This observation highlights an opportunity for prospective studies to refine triage strategies for lower risk patients with ACS.
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Affiliation(s)
- Antonio Fagundes
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham & Women’s Hospital, Boston MA (A.F., D.D.B., J.-G.P., V.M.B.-Z, D.A.M., E.A.B.)
| | - David D. Berg
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham & Women’s Hospital, Boston MA (A.F., D.D.B., J.-G.P., V.M.B.-Z, D.A.M., E.A.B.)
| | - Jeong-Gun Park
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham & Women’s Hospital, Boston MA (A.F., D.D.B., J.-G.P., V.M.B.-Z, D.A.M., E.A.B.)
| | - Vivian M. Baird-Zars
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham & Women’s Hospital, Boston MA (A.F., D.D.B., J.-G.P., V.M.B.-Z, D.A.M., E.A.B.)
| | - L. Kristin Newby
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (L.K.N., J.N.K)
| | | | - P. Elliott Miller
- Department of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT (P.E.M.)
| | - Sean van Diepen
- Department of Critical Care and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Canada (S.v.D.)
| | - Jason N. Katz
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (L.K.N., J.N.K)
| | - Nicholas Phreaner
- Sulpizio Cardiovascular Center, University of California San Diego, La Jolla (N.P., L.B.D.)
| | | | | | - Lori B. Daniels
- Sulpizio Cardiovascular Center, University of California San Diego, La Jolla (N.P., L.B.D.)
| | - David A. Morrow
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham & Women’s Hospital, Boston MA (A.F., D.D.B., J.-G.P., V.M.B.-Z, D.A.M., E.A.B.)
| | - Erin A. Bohula
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham & Women’s Hospital, Boston MA (A.F., D.D.B., J.-G.P., V.M.B.-Z, D.A.M., E.A.B.)
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8
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Fagundes A, Berg DD, Bohula EA, Baird-Zars VM, Barnett CF, Carnicelli AP, Chaudhry SP, Guo J, Keeley EC, Kenigsberg BB, Menon V, Miller PE, Newby LK, van Diepen S, Morrow DA, Katz JN. End-of-life care in the cardiac intensive care unit: a contemporary view from the Critical Care Cardiology Trials Network (CCCTN) Registry. Eur Heart J Acute Cardiovasc Care 2022; 11:190-197. [PMID: 34986236 DOI: 10.1093/ehjacc/zuab121] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 12/07/2021] [Accepted: 12/09/2021] [Indexed: 06/14/2023]
Abstract
AIMS Increases in life expectancy, comorbidities, and survival with complex cardiovascular conditions have changed the clinical profile of the patients in cardiac intensive care units (CICUs). In this environment, palliative care (PC) services are increasingly important. However, scarce information is available about the delivery of PC in CICUs. METHODS AND RESULTS The Critical Care Cardiology Trials Network (CCCTN) Registry is a network of tertiary care CICUs in North America. Between 2017 and 2020, up to 26 centres contributed an annual 2-month snapshot of all consecutive medical CICU admissions. We captured code status at admission and the decision for comfort measures only (CMO) before all deaths in the CICU. Of 13 422 patients, 10% died in the CICU and 2.6% were discharged to palliative hospice. Of patients who died in the CICU, 68% were CMO at death. In the CMO group, only 13% were do not resuscitate/do not intubate at admission. The median time from CICU admission to CMO decision was 3.4 days (25th-75th percentiles: 1.2-7.7) and ≥7 days in 27%. Time from CMO decision to death was <24 h in 88%, with a median of 3.8 h (25th-75th 1.0-10.3). Before a CMO decision, 78% received mechanical ventilation and 26% mechanical circulatory support. A PC provider team participated in the care of 41% of patients who died. CONCLUSIONS In a contemporary CICU registry, comfort measures preceded death in two-thirds of cases, frequently without PC involvement. The high utilization of advanced intensive care unit therapies and lengthy times to a CMO decision highlight a potential opportunity for early engagement of PC teams in CICU.
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Affiliation(s)
- Antonio Fagundes
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham & Women's Hospital, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA
| | - David D Berg
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham & Women's Hospital, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA
| | - Erin A Bohula
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham & Women's Hospital, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA
| | - Vivian M Baird-Zars
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham & Women's Hospital, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA
| | - Christopher F Barnett
- Medstar Heart and Vascular Institute, Medstar Washington Hospital Center, Washington, DC, USA
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Anthony P Carnicelli
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | | | - Jianping Guo
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham & Women's Hospital, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA
| | - Ellen C Keeley
- Division of Cardiology, University of Florida, Gainesville, FL, USA
| | - Benjamin B Kenigsberg
- Medstar Heart and Vascular Institute, Medstar Washington Hospital Center, Washington, DC, USA
| | - Venu Menon
- Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - P Elliott Miller
- Department of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - L Kristin Newby
- Divison of Cardiology, Duke University School of Medicine, Durham, NC, USA
| | - Sean van Diepen
- Division of Cardiology, Department of Critical Care Medicine, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - David A Morrow
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham & Women's Hospital, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA
| | - Jason N Katz
- Divison of Cardiology, Duke University School of Medicine, Durham, NC, USA
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9
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Patel SM, Jentzer JC, Alviar CL, Baird-Zars VM, Barsness GW, Berg DD, Bohula EA, Daniels LB, DeFilippis AP, Keeley EC, Kontos MC, Lawler PR, Miller PE, Park JG, Roswell RO, Solomon MA, van Diepen S, Katz JN, Morrow DA. A pragmatic lab-based tool for risk assessment in cardiac critical care: data from the Critical Care Cardiology Trials Network (CCCTN) Registry. Eur Heart J Acute Cardiovasc Care 2022; 11:252-257. [PMID: 35134860 PMCID: PMC9123931 DOI: 10.1093/ehjacc/zuac012] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 12/11/2021] [Accepted: 01/24/2022] [Indexed: 02/05/2023]
Abstract
AIMS Contemporary cardiac intensive care unit (CICU) outcomes remain highly heterogeneous. As such, a risk-stratification tool using readily available lab data at time of CICU admission may help inform clinical decision-making. METHODS AND RESULTS The primary derivation cohort included 4352 consecutive CICU admissions across 25 tertiary care CICUs included in the Critical Care Cardiology Trials Network (CCCTN) Registry. Candidate lab indicators were assessed using multivariable logistic regression. An integer risk score incorporating the top independent lab indicators associated with in-hospital mortality was developed. External validation was performed in a separate CICU cohort of 9716 patients from the Mayo Clinic (Rochester, MN, USA). On multivariable analysis, lower pH [odds ratio (OR) 1.96, 95% confidence interval (CI) 1.72-2.24], higher lactate (OR 1.40, 95% CI 1.22-1.62), lower estimated glomerular filtration rate (OR 1.26, 95% CI 1.10-1.45), and lower platelets (OR 1.18, 95% CI 1.05-1.32) were the top four independent lab indicators associated with higher in-hospital mortality. Incorporated into the CCCTN Lab-Based Risk Score, these four lab indicators identified a 20-fold gradient in mortality risk with very good discrimination (C-index 0.82, 95% CI 0.80-0.84) in the derivation cohort. Validation of the risk score in a separate cohort of 3888 patients from the Registry demonstrated good performance (C-index of 0.82; 95% CI 0.80-0.84). Performance remained consistent in the external validation cohort (C-index 0.79, 95% CI 0.77-0.80). Calibration was very good in both validation cohorts (r = 0.99). CONCLUSION A simple integer risk score utilizing readily available lab indicators at time of CICU admission may accurately stratify in-hospital mortality risk.
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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 and Harvard Medical School, 60 Fenwood Rd, Suite 7022, Boston, MA 02115, USA
| | - Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Carlos L Alviar
- Division of Cardiology, Department of Medicine, NYU Langone Medical Center, New York, NY, 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, 60 Fenwood Rd, Suite 7022, Boston, MA 02115, 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, 60 Fenwood Rd, Suite 7022, Boston, MA 02115, 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, 60 Fenwood Rd, Suite 7022, Boston, MA 02115, USA
| | - Lori B Daniels
- Sulpizio Cardiovascular Center, University of California San Diego, La Jolla, CA, USA
| | - Andrew P DeFilippis
- Division of Cardiology, Department of Medicine, Vanderbilt University, Nashville, TN, USA
| | - Ellen C Keeley
- Division of Cardiology, Department of Medicine, University of Florida, Gainesville, FL, USA
| | - Michael C Kontos
- Division of Cardiology, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, 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 Elliott Miller
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, 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, 60 Fenwood Rd, Suite 7022, Boston, MA 02115, 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
| | - Sean van Diepen
- Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, AB, Canada,Division of Cardiology, Department of Critical Care, University of Alberta, Edmonton, AB, Canada
| | - Jason N Katz
- Division of Cardiology, Department of Medicine, Duke University, Durham, NC, 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, 60 Fenwood Rd, Suite 7022, Boston, MA 02115, USA,Corresponding author. Tel: +1 617 278 0181, Fax: +1 617 734 7329,
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10
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Berg DD, Alviar CL, Bhatt AS, Baird-Zars VM, Barnett CF, Daniels LB, Defilippis AP, Fagundes A, Katrapati P, Kenigsberg BB, Guo J, Keller N, Lopes MS, Mody A, Papolos AI, Phreaner N, Sedighi R, Sinha SS, Toomu S, Varshney AS, Morrow DA, Bohula EA. Epidemiology of Acute Heart Failure in Critically Ill Patients with COVID-19: An Analysis from the Critical Care Cardiology Trials Network. J Card Fail 2022; 28:675-681. [PMID: 35051622 PMCID: PMC8762923 DOI: 10.1016/j.cardfail.2021.12.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 12/08/2021] [Accepted: 12/23/2021] [Indexed: 01/18/2023]
Abstract
Background Acute heart failure (HF) is an important complication of coronavirus disease 2019 (COVID-19) and has been hypothesized to relate to inflammatory activation. Methods We evaluated consecutive intensive care unit (ICU) admissions for COVID-19 across 6 centers in the Critical Care Cardiology Trials Network, identifying patients with vs without acute HF. Acute HF was subclassified as de novo vs acute-on-chronic, based on the absence or presence of prior HF. Clinical features, biomarker profiles and outcomes were compared. Results Of 901 admissions to an ICU due to COVID-19, 80 (8.9%) had acute HF, including 18 (2.0%) with classic cardiogenic shock (CS) and 37 (4.1%) with vasodilatory CS. The majority (n = 45) were de novo HF presentations. Compared to patients without acute HF, those with acute HF had higher cardiac troponin and natriuretic peptide levels and similar inflammatory biomarkers; patients with de novo HF had the highest cardiac troponin levels. Notably, among patients critically ill with COVID-19, illness severity (median Sequential Organ Failure Assessment, 8 [IQR, 5–10] vs 6 [4–9]; P = 0.025) and mortality rates (43.8% vs 32.4%; P = 0.040) were modestly higher in patients with vs those without acute HF. Conclusions Among patients critically ill with COVID-19, acute HF is distinguished more by biomarkers of myocardial injury and hemodynamic stress than by biomarkers of inflammation.
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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
| | - Carlos L Alviar
- The Leon H. Charney Division of Cardiovascular Medicine, New York University Langone Medical Center, New York, New York
| | - Ankeet S Bhatt
- 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
| | - Christopher F Barnett
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California; Medstar Heart and Vascular Institute, Medstar Washington Hospital Center, Washington, D.C
| | - Lori B Daniels
- Division of Cardiovascular Medicine, Department of Medicine, University of California San Diego, La Jolla, California
| | - Andrew P Defilippis
- Division of Cardiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Antonio Fagundes
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Praneeth Katrapati
- Division of Cardiovascular Medicine, Department of Medicine, University of Louisville, Louisville, Kentucky
| | - Benjamin B Kenigsberg
- Medstar Heart and Vascular Institute, Medstar Washington Hospital Center, Washington, D.C
| | - Jianping Guo
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Norma Keller
- The Leon H. Charney Division of Cardiovascular Medicine, New York University Langone Medical Center, New York, New York
| | - Mathew S Lopes
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Anika Mody
- Division of Cardiovascular Medicine, Department of Medicine, University of California San Diego, La Jolla, California
| | - Alexander I Papolos
- Medstar Heart and Vascular Institute, Medstar Washington Hospital Center, Washington, D.C
| | - Nicholas Phreaner
- Division of Cardiovascular Medicine, Department of Medicine, University of California San Diego, La Jolla, California
| | - Romteen Sedighi
- Division of Cardiovascular Medicine, Department of Medicine, University of California San Diego, La Jolla, California
| | - Shashank S Sinha
- Inova Heart and Vascular Institute, Inova Fairfax Medical Center, Falls Church, Virginia
| | - Sandeep Toomu
- Division of Cardiovascular Medicine, Department of Medicine, University of California San Diego, La Jolla, California
| | - Anubodh S Varshney
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - David A Morrow
- 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
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11
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Bhatt AS, Berg DD, Bohula EA, Alviar CL, Baird-Zars VM, Barnett CF, Burke JA, Carnicelli AP, Chaudhry SP, Daniels LB, Fang JC, Fordyce CB, Gerber DA, Guo J, Jentzer JC, Katz JN, Keller N, Kontos MC, Lawler PR, Menon V, Metkus TS, Nativi-Nicolau J, Phreaner N, Roswell RO, Sinha SS, Jeffrey Snell R, Solomon MA, Van Diepen S, Morrow DA. De Novo vs Acute-on-Chronic Presentations of Heart Failure-Related Cardiogenic Shock: Insights from the Critical Care Cardiology Trials Network Registry. J Card Fail 2021; 27:1073-1081. [PMID: 34625127 DOI: 10.1016/j.cardfail.2021.08.014] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 08/27/2021] [Accepted: 08/27/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Heart failure-related cardiogenic shock (HF-CS) accounts for an increasing proportion of cases of CS in contemporary cardiac intensive care units. Whether the chronicity of HF identifies distinct clinical profiles of HF-CS is unknown. METHODS AND RESULTS We evaluated admissions to cardiac intensive care units for HF-CS in 28 centers using data from the Critical Care Cardiology Trials Network registry (2017-2020). HF-CS was defined as CS due to ventricular failure in the absence of acute myocardial infarction and was classified as de novo vs acute-on-chronic based on the absence or presence of a prior diagnosis of HF, respectively. Clinical features, resource use, and outcomes were compared among groups. Of 1405 admissions with HF-CS, 370 had de novo HF-CS (26.3%), and 1035 had acute-on-chronic HF-CS (73.7%). Patients with de novo HF-CS had a lower prevalence of hypertension, diabetes, coronary artery disease, atrial fibrillation, and chronic kidney disease (all P < 0.01). Median Sequential Organ Failure Assessment (SOFA) scores were higher in those with de novo HF-CS (8; 25th-75th: 5-11) vs acute-on-chronic HF-CS (6; 25th-75th: 4-9, P < 0.01), as was the proportion of Society of Cardiovascular Angiography and Intervention (SCAI) shock stage E (46.1% vs 26.1%, P < 0.01). After adjustment for clinical covariates and preceding cardiac arrest, the risk of in-hospital mortality was higher in patients with de novo HF-CS than in those with acute-on-chronic HF-CS (adjusted hazard ratio 1.36, 95% confidence interval 1.05-1.75, P = 0.02). CONCLUSIONS Despite having fewer comorbidities, patients with de novo HF-CS had more severe shock presentations and worse in-hospital outcomes. Whether HF disease chronicity is associated with time-dependent compensatory adaptations, unique pathobiological features and responses to treatment in patients presenting with HF-CS warrants further investigation.
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Affiliation(s)
- Ankeet S Bhatt
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - 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
| | - 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
| | | | - 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
| | | | - James A Burke
- Lehigh Valley Health Network, Allentown, Pennsylvania
| | | | | | - Lori B Daniels
- Sulpizio Cardiovascular Center, University of California San Diego, La Jolla, California
| | | | - Christopher B Fordyce
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Daniel A Gerber
- Cardiovascular Division, Department of Medicine, Stanford University, Stanford, California
| | - 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
| | - Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Jason N Katz
- Division of Cardiology, Duke University, Durham, North Carolina
| | - Norma Keller
- New York University Langone Health, New York, New York
| | - Michael C Kontos
- Division of Cardiology, Virginia Commonwealth University, Richmond, Virginia
| | - Patrick R Lawler
- Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Ontario, Canada
| | - Venu Menon
- Cleveland Clinic Coordinating Center for Clinical Research, Department of Cardiovascular Medicine, Cleveland, Ohio
| | - Thomas S Metkus
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Nicholas Phreaner
- Sulpizio Cardiovascular Center, University of California San Diego, La Jolla, California
| | | | - Shashank S Sinha
- Inova Heart and Vascular Institute, Inova Fairfax Medical Center, Falls Church, Virginia
| | | | - 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
| | - Sean Van Diepen
- Department of Critical Care and Division of Cardiology, 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.
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12
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Varshney AS, Berg DD, Katz JN, Baird-Zars VM, Bohula EA, Carnicelli AP, Chaudhry SP, Guo J, Lawler PR, Nativi-Nicolau J, Sinha SS, Teuteberg JJ, van Diepen S, Morrow DA. Use of Temporary Mechanical Circulatory Support for Management of Cardiogenic Shock Before and After the United Network for Organ Sharing Donor Heart Allocation System Changes. JAMA Cardiol 2021; 5:703-708. [PMID: 32293644 DOI: 10.1001/jamacardio.2020.0692] [Citation(s) in RCA: 81] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance The new United Network for Organ Sharing (UNOS) donor heart allocation system gives priority to patients supported with nondischargeable mechanical circulatory support (MCS) devices while awaiting heart transplant. Whether there has been a change in temporary MCS use in cardiac intensive care units (CICUs) since the implementation of this policy is unknown. Objectives To examine whether the UNOS donor heart allocation system revision in October 2018 was associated with changes in temporary MCS use in CICUs and whether temporary MCS use differed between US transplant centers and US nontransplant centers and Canadian centers. Design, Setting, and Participants In this cohort study, 14 centers from the Critical Care Cardiology Trials Network (CCCTN), a multicenter network of tertiary CICUs in North America, contributed 2-month snapshots of consecutive medical CICU admissions between September 1, 2017, and September 1, 2018 (prerevision period), and October 1, 2018, and September 1, 2019 (postrevision period). CICUs were classified as US transplant centers (n = 7) or other CICUs (US nontransplant centers or Canadian centers; n = 7). Exposure Revision to the UNOS donor heart allocation system. Main Outcomes and Measures Treatment with temporary MCS (intra-aortic balloon pump, microaxial intracardiac ventricular assist device, percutaneous centrifugal ventricular assist device, venoarterial extracorporeal membrane oxygenation, or surgically implanted, nondischargeable MCS device) during hospital admission. Results A total of 384 admissions for acute, decompensated, heart failure-related cardiogenic shock (ADHF-CS) were included, among which 248 (64.6%) were to US transplant centers; 126 admissions (51%) were in the prerevision period and 122 (49%) were in the postrevision period. The mean (SD) patient age was 61.2 (14.6) years; 246 patients (64.1%) were male. The proportion of admissions with ADHF-CS managed with temporary MCS at US transplant centers significantly increased from 25.4% (32 of 126 admissions) before to 42.6% (52 of 122 admissions) after the UNOS allocation system changes (P = .004). In other CICUs, the proportion did not significantly change (24.5% [13 of 53 admissions] to 24.1% [20 of 83 admissions]; P = .95). After multivariable adjustment, patients admitted to US transplant centers in the postrevision period were more likely to receive temporary MCS compared with those admitted in the prerevision period (adjusted odds ratio, 2.19; 95% CI, 1.13-4.24; P = .02). Conclusions and Relevance In the year after implementation of the new UNOS donor heart allocation system, temporary MCS use in patients admitted with ADHF-CS increased in US transplant centers but not in other CICUs. Whether this shift in practice will affect outcomes of patients with ADHF-CS or organ distribution should be evaluated.
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Affiliation(s)
- Anubodh S Varshney
- Levine Cardiac Intensive Care Unit, Thrombolysis in Myocardial Infarction (TIMI) Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - David D Berg
- Levine Cardiac Intensive Care Unit, Thrombolysis in Myocardial Infarction (TIMI) Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jason N Katz
- Division of Cardiology, Center for Heart and Vascular Care, University of North Carolina, Chapel Hill.,Division of Pulmonary and Critical Care Medicine, Center for Heart and Vascular Care, University of North Carolina, Chapel Hill.,Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Vivian M Baird-Zars
- Levine Cardiac Intensive Care Unit, Thrombolysis in Myocardial Infarction (TIMI) Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Erin A Bohula
- Levine Cardiac Intensive Care Unit, Thrombolysis in Myocardial Infarction (TIMI) Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Anthony P Carnicelli
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | | | - Jianping Guo
- Levine Cardiac Intensive Care Unit, Thrombolysis in Myocardial Infarction (TIMI) Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Patrick R Lawler
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada.,Interdepartmental Division of Critical Care Medicine, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Jose Nativi-Nicolau
- Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City
| | - Shashank S Sinha
- Inova Heart and Vascular Institute, Inova Fairfax Medical Center, Falls Church, Virginia
| | - Jeffrey J Teuteberg
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Sean van Diepen
- Department of Critical Care, University of Alberta, Edmonton, Alberta, Canada.,Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - David A Morrow
- Levine Cardiac Intensive Care Unit, Thrombolysis in Myocardial Infarction (TIMI) Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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13
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Bohula EA, Katz JN, van Diepen S, Alviar CL, Baird-Zars VM, Park JG, Barnett CF, Bhattal G, Barsness GW, Burke JA, Cremer PC, Cruz J, Daniels LB, DeFilippis A, Granger CB, Hollenberg S, Horowitz JM, Keller N, Kontos MC, Lawler PR, Menon V, Metkus TS, Ng J, Orgel R, Overgaard CB, Phreaner N, Roswell RO, Schulman SP, Snell RJ, Solomon MA, Ternus B, Tymchak W, Vikram F, Morrow DA. Demographics, Care Patterns, and Outcomes of Patients Admitted to Cardiac Intensive Care Units: The Critical Care Cardiology Trials Network Prospective North American Multicenter Registry of Cardiac Critical Illness. JAMA Cardiol 2020; 4:928-935. [PMID: 31339509 DOI: 10.1001/jamacardio.2019.2467] [Citation(s) in RCA: 125] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Importance Single-center and claims-based studies have described substantial changes in the landscape of care in the cardiac intensive care unit (CICU). Professional societies have recommended research to guide evidence-based CICU redesigns. Objective To characterize patients admitted to contemporary, advanced CICUs. Design, Setting, and Participants This study established the Critical Care Cardiology Trials Network (CCCTN), an investigator-initiated multicenter network of 16 advanced, tertiary CICUs in the United States and Canada. For 2 months in each CICU, data for consecutive admissions were submitted to the central data coordinating center (TIMI Study Group). The data were collected and analyzed between September 2017 and 2018. Main Outcomes and Measures Demographics, diagnoses, management, and outcomes. Results Of 3049 participants, 1132 (37.1%) were women, 797 (31.4%) were individuals of color, and the median age was 65 years (25th and 75th percentiles, 55-75 years). Between September 2017 and September 2018, 3310 admissions were included, among which 2557 (77.3%) were for primary cardiac problems, 337 (10.2%) for postprocedural care, 253 (7.7%) for mixed general and cardiac problems, and 163 (4.9%) for overflow from general medical ICUs. When restricted to the initial 2 months of medical CICU admissions for each site, the primary analysis population included 3049 admissions with a high burden of noncardiovascular comorbidities. The top 2 CICU admission diagnoses were acute coronary syndrome (969 [31.8%]) and heart failure (567 [18.6%]); however, the proportion of acute coronary syndrome was highly variable across centers (15%-57%). The primary indications for CICU care included respiratory insufficiency (814 [26.7%]), shock (643 [21.1%]), unstable arrhythmia (521 [17.1%]), and cardiac arrest (265 [8.7%]). Advanced CICU therapies or monitoring were required for 1776 patients (58.2%), including intravenous vasoactive medications (1105 [36.2%]), invasive hemodynamic monitoring (938 [30.8%]), and mechanical ventilation (652 [21.4%]). The overall CICU mortality rate was 8.3% (95% CI, 7.3%-9.3%). The CICU indications that were associated with the highest mortality rates were cardiac arrest (101 [38.1%]), cardiogenic shock (140 [30.6%]), and the need for renal replacement therapy (51 [34.5%]). Notably, patients admitted solely for postprocedural observation or frequent monitoring had a mortality rate of 0.2% to 0.4%. Conclusions and Relevance In a contemporary network of tertiary care CICUs, respiratory failure and shock predominated indications for admission and carried a poor prognosis. While patterns of practice varied considerably between centers, a substantial, low-risk population was identified. Multicenter collaborative networks, such as the CCCTN, could be used to help redesign cardiac critical care and to test new therapeutic strategies.
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Affiliation(s)
- 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
| | - Jason N Katz
- University of North Carolina at Chapel Hill, Chapel Hill
| | - Sean van Diepen
- Division of Cardiology, Department of Critical Care Medicine, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | | | - 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
| | - 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
| | | | | | | | - James A Burke
- Lehigh Valley Health Network, Allentown, Pennsylvania
| | | | | | - Lori B Daniels
- Sulpizio Cardiovascular Center, University of California San Diego, La Jolla
| | | | | | | | | | | | | | - Patrick R Lawler
- Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Venu Menon
- Cleveland Clinic Foundation, Cleveland, Ohio
| | | | - Jason Ng
- New York University Langone Health, New York
| | - Ryan Orgel
- University of North Carolina at Chapel Hill, Chapel Hill
| | - Christopher B Overgaard
- Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Nicholas Phreaner
- Sulpizio Cardiovascular Center, University of California San Diego, La Jolla
| | | | | | | | - Michael A Solomon
- Clinical Center and Cardiology Branch, Critical Care Medicine Department, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | | | - Wayne Tymchak
- Division of Cardiology, Department of Critical Care Medicine, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Fnu Vikram
- Lehigh Valley Health Network, Allentown, Pennsylvania
| | - 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
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14
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Varshney A, Berg D, Bohula EA, Baird-Zars VM, Katz J, Diepen SV, Morrow DA. TEMPORARY MECHANICAL CIRCULATORY SUPPORT USE IN TERTIARY CARDIAC INTENSIVE CARE UNITS BEFORE AND AFTER THE UNOS HEART TRANSPLANTATION ALLOCATION SYSTEM UPDATE: INSIGHTS FROM THE CRITICAL CARE CARDIOLOGY TRIALS NETWORK (CCCTN) REGISTRY. J Am Coll Cardiol 2020. [DOI: 10.1016/s0735-1097(20)31286-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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15
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Berg DD, Barnett CF, Kenigsberg BB, Papolos A, Alviar CL, Baird-Zars VM, Barsness GW, Bohula EA, Brennan J, Burke JA, Carnicelli AP, Chaudhry SP, Cremer PC, Daniels LB, DeFilippis AP, Gerber DA, Granger CB, Hollenberg S, Horowitz JM, Gladden JD, Katz JN, Keeley EC, Keller N, Kontos MC, Lawler PR, Menon V, Metkus TS, Miller PE, Nativi-Nicolau J, Newby LK, Park JG, Phreaner N, Roswell RO, Schulman SP, Sinha SS, Snell RJ, Solomon MA, Teuteberg JJ, Tymchak W, van Diepen S, Morrow DA. Clinical Practice Patterns in Temporary Mechanical Circulatory Support for Shock in the Critical Care Cardiology Trials Network (CCCTN) Registry. Circ Heart Fail 2019; 12:e006635. [PMID: 31707801 DOI: 10.1161/circheartfailure.119.006635] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Temporary mechanical circulatory support (MCS) devices provide hemodynamic assistance for shock refractory to pharmacological treatment. Most registries have focused on single devices or specific etiologies of shock, limiting data regarding overall practice patterns with temporary MCS in cardiac intensive care units. METHODS The CCCTN (Critical Care Cardiology Trials Network) is a multicenter network of tertiary CICUs in North America. Between September 2017 and September 2018, each center (n=16) contributed a 2-month snapshot of consecutive medical CICU admissions. RESULTS Of the 270 admissions using temporary MCS, 33% had acute myocardial infarction-related cardiogenic shock (CS), 31% had CS not related to acute myocardial infarction, 11% had mixed shock, and 22% had an indication other than shock. Among all 585 admissions with CS or mixed shock, 34% used temporary MCS during the CICU stay with substantial variation between centers (range: 17%-50%). The most common temporary MCS devices were intraaortic balloon pumps (72%), Impella (17%), and veno-arterial extracorporeal membrane oxygenation (11%), although intraaortic balloon pump use also varied between centers (range: 40%-100%). Patients managed with intraaortic balloon pump versus other forms of MCS (advanced MCS) had lower Sequential Organ Failure Assessment scores and less severe metabolic derangements. Illness severity was similar at high- versus low-MCS utilizing centers and at centers with more advanced MCS use. CONCLUSIONS There is wide variation in the use of temporary MCS among patients with shock in tertiary CICUs. While hospital-level variation in temporary MCS device selection is not explained by differences in illness severity, patient-level variation appears to be related, at least in part, to illness severity.
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Affiliation(s)
- 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 (D.D.B., V.M.B.-Z., E.A.B., J.-G.P., D.A.M.)
| | - Christopher F Barnett
- Medstar Heart and Vascular Institute, Medstar Washington Hospital Center, Washington DC (C.F.B., B.B.K., A.P.)
| | - Benjamin B Kenigsberg
- Medstar Heart and Vascular Institute, Medstar Washington Hospital Center, Washington DC (C.F.B., B.B.K., A.P.)
| | - Alexander Papolos
- Medstar Heart and Vascular Institute, Medstar Washington Hospital Center, Washington DC (C.F.B., B.B.K., A.P.)
| | - Carlos L Alviar
- Leon H. Charney Division of Cardiology, New York University School of Medicine (C.L.A., J.M.H., N.K.)
| | - 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 (D.D.B., V.M.B.-Z., E.A.B., J.-G.P., D.A.M.)
| | - Gregory W Barsness
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (G.W.B., J.D.G.)
| | - 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 (D.D.B., V.M.B.-Z., E.A.B., J.-G.P., D.A.M.)
| | - Joseph Brennan
- Department of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT (J.B., P.E.M.)
| | - James A Burke
- Lehigh Valley Health Network, Allentown, PA (J.A.B.)
| | - Anthony P Carnicelli
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (A.P.C., C.B.G., L.K.N.)
| | | | - Paul C Cremer
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, OH (P.C.C.)
| | - Lori B Daniels
- Sulpizio Cardiovascular Center, University of California San Diego, La Jolla (L.B.D., N.P.)
| | | | - Daniel A Gerber
- Department of Medicine, Stanford University School of Medicine, CA (D.A.G., J.J.T.)
| | - Christopher B Granger
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (A.P.C., C.B.G., L.K.N.)
| | - Steven Hollenberg
- Department of Cardiovascular Disease, Cooper University Hospital, Camden, NJ (S.H.)
| | - James M Horowitz
- Leon H. Charney Division of Cardiology, New York University School of Medicine (C.L.A., J.M.H., N.K.)
| | - James D Gladden
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (G.W.B., J.D.G.)
| | - Jason N Katz
- Divisions of Cardiology and Pulmonary and Critical Care Medicine, University of North Carolina, Center for Heart and Vascular Care, Chapel Hill (J.N.K.)
| | - Ellen C Keeley
- Division of Cardiology, University of Florida, Gainesville (E.C.K.)
| | - Norma Keller
- Leon H. Charney Division of Cardiology, New York University School of Medicine (C.L.A., J.M.H., N.K.)
| | - Michael C Kontos
- Division of Cardiology, Virginia Commonwealth University, Richmond (M.C.K.)
| | - Patrick R Lawler
- Division of Cardiology and Interdepartmental Division of Critical Care Medicine, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, ON (P.R.L.)
| | - Venu Menon
- Department of Cardiology, St Vincent Hospital, Indianapolis, IN (S.-P.C., V.M.)
| | - Thomas S Metkus
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD (T.S.M., S.P.S.)
| | - P Elliott Miller
- Department of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT (J.B., P.E.M.)
| | - Jose Nativi-Nicolau
- Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City (J.N.-N.)
| | - L Kristin Newby
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (A.P.C., C.B.G., L.K.N.)
| | - 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, MA (D.D.B., V.M.B.-Z., E.A.B., J.-G.P., D.A.M.)
| | - Nicholas Phreaner
- Sulpizio Cardiovascular Center, University of California San Diego, La Jolla (L.B.D., N.P.)
| | | | - Steven P Schulman
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD (T.S.M., S.P.S.)
| | - Shashank S Sinha
- Inova Heart and Vascular Institute, Inova Fairfax Medical Center, Falls Church, VA (S.S.S.)
| | | | - 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 (M.A.S.)
| | - Jeffrey J Teuteberg
- Department of Medicine, Stanford University School of Medicine, CA (D.A.G., J.J.T.)
| | - Wayne Tymchak
- Department of Critical Care and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Canada (W.T., S.v.D.)
| | - Sean van Diepen
- Department of Critical Care and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Canada (W.T., S.v.D.)
| | - 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 (D.D.B., V.M.B.-Z., E.A.B., J.-G.P., D.A.M.)
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Berg DD, Bohula EA, van Diepen S, Katz JN, Alviar CL, Baird-Zars VM, Barnett CF, Barsness GW, Burke JA, Cremer PC, Cruz J, Daniels LB, DeFilippis AP, Haleem A, Hollenberg SM, Horowitz JM, Keller N, Kontos MC, Lawler PR, Menon V, Metkus TS, Ng J, Orgel R, Overgaard CB, Park JG, Phreaner N, Roswell RO, Schulman SP, Jeffrey Snell R, Solomon MA, Ternus B, Tymchak W, Vikram F, Morrow DA. Epidemiology of Shock in Contemporary Cardiac Intensive Care Units. Circ Cardiovasc Qual Outcomes 2019; 12:e005618. [PMID: 30879324 PMCID: PMC11032172 DOI: 10.1161/circoutcomes.119.005618] [Citation(s) in RCA: 200] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Accepted: 02/25/2019] [Indexed: 01/01/2023]
Abstract
Background Clinical investigations of shock in cardiac intensive care units (CICUs) have primarily focused on acute myocardial infarction (AMI) complicated by cardiogenic shock (AMICS). Few studies have evaluated the full spectrum of shock in contemporary CICUs. Methods and Results The Critical Care Cardiology Trials Network is a multicenter network of advanced CICUs in North America. Anytime between September 2017 and September 2018, each center (n=16) contributed a 2-month snap-shot of all consecutive medical admissions to the CICU. Data were submitted to the central coordinating center (TIMI Study Group, Boston, MA). Shock was defined as sustained systolic blood pressure <90 mm Hg with end-organ dysfunction ascribed to the hypotension. Shock type was classified by site investigators as cardiogenic, distributive, hypovolemic, or mixed. Among 3049 CICU admissions, 677 (22%) met clinical criteria for shock. Shock type was varied, with 66% assessed as cardiogenic shock (CS), 7% as distributive, 3% as hypovolemic, 20% as mixed, and 4% as unknown. Among patients with CS (n=450), 30% had AMICS, 18% had ischemic cardiomyopathy without AMI, 28% had nonischemic cardiomyopathy, and 17% had a cardiac cause other than primary myocardial dysfunction. Patients with mixed shock had cardiovascular comorbidities similar to patients with CS. The median CICU stay was 4.0 days (interquartile range [IQR], 2.5-8.1 days) for AMICS, 4.3 days (IQR, 2.1-8.5 days) for CS not related to AMI, and 5.8 days (IQR, 2.9-10.0 days) for mixed shock versus 1.9 days (IQR, 1.0-3.6) for patients without shock ( P<0.01 for each). Median Sequential Organ Failure Assessment scores were higher in patients with mixed shock (10; IQR, 6-13) versus AMICS (8; IQR, 5-11) or CS without AMI (7; IQR, 5-11; each P<0.01). In-hospital mortality rates were 36% (95% CI, 28%-45%), 31% (95% CI, 26%-36%), and 39% (95% CI, 31%-48%) in AMICS, CS without AMI, and mixed shock, respectively. Conclusions The epidemiology of shock in contemporary advanced CICUs is varied, and AMICS now represents less than one-third of all CS. Despite advanced therapies, mortality in CS and mixed shock remains high. Investigation of management strategies and new therapies to treat shock in the CICU should take this epidemiology into account.
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Affiliation(s)
- 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 (D.D.B, E.A.B., V.M.B.-Z., J.-G.P., D.A.M.)
| | - 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 (D.D.B, E.A.B., V.M.B.-Z., J.-G.P., D.A.M.)
| | - Sean van Diepen
- Department of Critical Care and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, AB, Canada (S.v.D., W.T.)
| | - Jason N Katz
- Divisions of Cardiology and Pulmonary and Critical Care Medicine, University of North Carolina, Center for Heart and Vascular Care Chapel Hill (J.N.K., R.O.)
| | | | - 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 (D.D.B, E.A.B., V.M.B.-Z., J.-G.P., D.A.M.)
| | | | - Gregory W Barsness
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (G.W.B., B.T.)
| | - James A Burke
- Lehigh Valley Health Network, Allentown, PA (J.A.B., A.H., F.V.)
| | - Paul C Cremer
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, OH (P.C.C., V.M.)
| | - Jennifer Cruz
- Section of Cardiology, Cooper University Hospital, Camden, NJ (J.C., S.H.)
| | - Lori B Daniels
- Sulpizio Cardiovascular Center, University of California San Diego, La Jolla (L.B.D., N.P.)
| | - Andrew P DeFilippis
- Division of Cardiovascular Medicine, Department of Medicine, University of Louisville, KY (A.D.)
| | - Affan Haleem
- Lehigh Valley Health Network, Allentown, PA (J.A.B., A.H., F.V.)
| | | | | | - Norma Keller
- New York University Langone Health (J.M.H., N.K., J.N., R.O.R.)
| | | | - Patrick R Lawler
- Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, ON, Canada (P.R.L., C.B.O.)
| | - Venu Menon
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, OH (P.C.C., V.M.)
| | - Thomas S Metkus
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD (T.S.M., S.P.S.)
| | - Jason Ng
- New York University Langone Health (J.M.H., N.K., J.N., R.O.R.)
| | - Ryan Orgel
- Divisions of Cardiology and Pulmonary and Critical Care Medicine, University of North Carolina, Center for Heart and Vascular Care Chapel Hill (J.N.K., R.O.)
| | - Christopher B Overgaard
- Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, ON, Canada (P.R.L., C.B.O.)
| | - 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, MA (D.D.B, E.A.B., V.M.B.-Z., J.-G.P., D.A.M.)
| | - Nicholas Phreaner
- Sulpizio Cardiovascular Center, University of California San Diego, La Jolla (L.B.D., N.P.)
| | | | - Steven P Schulman
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD (T.S.M., S.P.S.)
| | | | - 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 (M.A.S.)
| | - Bradley Ternus
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (G.W.B., B.T.)
| | - Wayne Tymchak
- Department of Critical Care and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, AB, Canada (S.v.D., W.T.)
| | - Fnu Vikram
- Lehigh Valley Health Network, Allentown, PA (J.A.B., A.H., F.V.)
| | - 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 (D.D.B, E.A.B., V.M.B.-Z., J.-G.P., D.A.M.)
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